Complex Visual Hallucinations Research Articles

Improvement of Visual Hallucinations With Donepezil in Charles Bonnet Syndrome Secondary to Vascular Pathology

ABSTRACTThere is a lack of high‐quality evidence for pharmacological treatment options for Charles Bonnet syndrome and guidelines do not recommend any particular pharmacological option. Here, a case is presented of an older age male who developed complex visual hallucinations following stroke and central retinal artery occlusion (one after the other leading to loss of vision in both eyes), thus indicative of CBS secondary to vascular pathology. This case demonstrates a sustained progressive improvement in hallucinations in CBS following the initiation of acetylcholinesterase inhibitor, donepezil.

Resting-state EEG spectral and fractal features in dementia with Lewy bodies with and without visual hallucinations

ObjectiveComplex visual hallucinations (VH) are a core feature of dementia with Lewy bodies (DLB), though they may not occur in all patients. Power spectral density (PSD) analysis of resting-state EEG (rs-EEG) shows associations between some frequency bands (e.g., θ), individual alpha frequency (IAF) and VH. However, new tools that improve early differential diagnosis and symptom-based stratification with higher sensitivity and specificity, even within the DLB population, are desirable. We aimed to assess differences in rs-EEG data between DLB patients with VH (DLB-VH+) and without VH (DLB-VH-), comparing innovative non-linear approaches with more traditional linear ones. MethodsWe retrospectively analyzed rs-EEG recordings of DLB-VH+, DLB-VH-, Alzheimer’s disease patients and age-matched healthy controls. EEG was analyzed using the nonlinear Higuchi’s Fractal Dimension (FD) measure, and the results were compared with those of entropy and standard linear methods based on PSD and IAF. ResultsOnly the FD measure could discriminate between DLB-VH+ and DLB-VH-. ConclusionsIn conclusion, rs-EEG differences between DLB-VH+ and DLB-VH- are better characterized by FD analysis than by a more traditional power spectrum approach. SignificanceThis suggests that the presence of complex VH is associated with less complex brain dynamics at rest, as reflected by the FD measure.

A - 124 A Case of Lewy Body Dementia and Charles Bonnet Syndrome in a Patient with Bilateral Enucleation

Abstract Objective The patient presented with a history of blindness due to bilateral enucleation (age 10 and 23) and visual hallucinations for approximately 2 years. Approximately 30% of visually impaired individuals are affected by Charles Bonnet syndrome, characterized by complex visual hallucinations in visually challenged patients, possibly stemming from the brain’s attempt to fill the visual void. Additionally, she was diagnosed with Lewy Body dementia (LBD) 2 years prior by her neurologist, and she reported challenges with completing instrumental activities of daily living (IADLs). Method The patient was a left-handed 83-year-old woman, with a history of total blindness and bilateral enucleation, who presented with progressive memory loss 3–4 years prior, along with balance/gait disturbances for 1–1.5 years. The patient and her family sought neuropsychological testing to clarify her cognitive functioning in light of her physical and neurologic symptoms. Results Premorbid functioning was estimated in the low average range, with 11 years of education. Due to her total vision loss, neuropsychological evaluation was limited. Her cognitive profile was marked by impairments in immediate memory, delayed memory, recognition, executive functioning, and language. Conclusions In light of the patient’s marked cognitive deficits in memory, attention, and executive functioning, along with visual hallucinations (although also attributed to possible Charles Bonnet syndrome), balance/gait disturbances, fluctuating awareness, autonomic dysfunction (i.e., bladder/bowel control), and sleep changes (i.e., acting out dreams), her presentation is consistent with LBD, in the moderate stage of severity. Given the symptomatology, it raises the possibility the patient may be experiencing Charles Bonnet syndrome along with LBD.

Differentiating Prodromal Dementia with Lewy Bodies from Prodromal Alzheimer's Disease: A Pragmatic Review for Clinicians.

This pragmatic review synthesises the current understanding of prodromal dementia with Lewy bodies (pDLB) and prodromal Alzheimer's disease (pAD), including clinical presentations, neuropsychological profiles, neuropsychiatric symptoms, biomarkers, and indications for disease management. The core clinical features of dementia with Lewy bodies (DLB)-parkinsonism, complex visual hallucinations, cognitive fluctuations, and REM sleep behaviour disorder are common prodromal symptoms. Supportive clinical features of pDLB include severe neuroleptic sensitivity, as well as autonomic and neuropsychiatric symptoms. The neuropsychological profile in mild cognitive impairment attributable to Lewy body pathology (MCI-LB) tends to include impairment in visuospatial skills and executive functioning, distinguishing it from MCI due to AD, which typically presents with impairment in memory. pDLB may present with cognitive impairment, psychiatric symptoms, and/or recurrent episodes of delirium, indicating that it is not necessarily synonymous with MCI-LB. Imaging, fluid and other biomarkers may play a crucial role in differentiating pDLB from pAD. The current MCI-LB criteria recognise low dopamine transporter uptake using positron emission tomography or single photon emission computed tomography (SPECT), loss of REM atonia on polysomnography, and sympathetic cardiac denervation using meta-iodobenzylguanidine SPECT as indicative biomarkers with slowing of dominant frequency on EEG among others as supportive biomarkers. This review also highlights the emergence of fluid and skin-based biomarkers. There is little research evidence for the treatment of pDLB, but pharmacological and non-pharmacological treatments for DLB may be discussed with patients. Non-pharmacological interventions such as diet, exercise, and cognitive stimulation may provide benefit, while evaluation and management of contributing factors like medications and sleep disturbances are vital. There is a need to expand research across diverse patient populations to address existing disparities in clinical trial participation. In conclusion, an early and accurate diagnosis of pDLB or pAD presents an opportunity for tailored interventions, improved healthcare outcomes, and enhanced quality of life for patients and care partners.

Peduncular Hallucinosis: Clinical characteristics, etiology, and a case report

IntroductionVisual hallucinations are a relatively common neurological complaint. Peduncular hallucinosis (PH) stands out as a distinct entity, characterized by complex visual hallucinations resulting from structural lesions in the brainstem or diencephalon.ObjectivesWe aim to provide an overview of the clinical features, etiological factors, and management strategies associated with PH, incorporating a unique case study.MethodsClinical case report and brief literature review.ResultsClinical Characteristics: PH is marked by detailed, colorful, vivid, and occasionally emotionally charged visual hallucinations. These hallucinations encompass people, animals, or objects and may be mistaken for reality. While primarily visual, they may occasionally involve other sensory modalities. Crucially, patients with PH maintain insight, distinguishing it from primary psychotic disorders.Etiological Factors: PH is most commonly associated with structural brainstem lesions, particularly in the midbrain. Potential instigators encompass ischemic strokes, vascular anomalies, tumors and infections. Disruption of the reticular activating system in the brainstem is implicated in the pathogenesis. Advanced imaging techniques have unveiled cases with subtle presentations, broadening our comprehension of PH.Pathogenesis: PH may involve the disturbance of serotonergic inhibitory pathways and the reticular activating system. A plausible link with hypnagogic hallucinations hints at a mechanism related to rapid REM sleep transitions.Case Report: Mr. J., a 30-year-old patient, suffered recurrent mesencephalic strokes attributed to Sneddon’s syndrome, ADA-2 deficiency, and protein C deficiency, leading to malacic lesions in the hemimesencephalon and right hemipons. He experienced complex visual hallucinations, primarily geometric patterns and animals, mainly at night. Importantly, he maintained insight into their hallucinatory nature. Mr. J. also had diplopia, visual impairment, recurrent headaches, and left hemiparesis.Reactive anxiety and depression due to functional loss followed his recurrent strokes. Initially, antipsychotics were used to manage sensory-perceptual disturbances, but were later discontinued due to reduced interference with daily functioning. Antidepressant and psychological therapy was continued throughout the follow-up to address mood symptoms.Conclusions Peduncular hallucinosis is an intriguing phenomenon characterized by complex visual hallucinations. Understanding its clinical features, etiology, and possible mechanisms is essential for accurate diagnosis and management. This case report emphasizes PH’s clinical aspects and the importance of a multidisciplinary approach, including pharmacological intervention and psychological support. Understanding its features, causes, and management is essential for accurate care. Further research is needed to improve our comprehension and optimize treatment strategies.Disclosure of InterestNone Declared

The impact of Charles Bonnet syndrome in patients with age-related macular degeneration

Abstract Introduction: Charles Bonnet syndrome (CBS) is a condition related to patients having complex visual hallucinations and visual loss due to ophthalmologic disease, without cognitive impairment. CBS is an important differential diagnosis of dementia syndromes, and the correct diagnosis has a great impact on the quality of life of those who suffer from the stigma of psychiatric disease. Objective: The objective of the present study is to determine the impact and review symptoms of CBS in patients with visual loss due to age-related macular degeneration (AMD) by using a questionnaire. Method: Sixty patients suffering from AMD were forwarded from the Retina Sector of the Ophthalmology Service of the Hospital do Servidor Público Estadual de São Paulo to the Low Vision Sector for a cognitive assessment questionnaire. Results: Of the 60 patients studied, 10 were diagnosed with CBS, thus representing 16.6% of the incidence of CBS cases in individuals with AMD. Among these 10 cases, males represented 30% versus females who represented 70% of the total. Patients over 80 years old represented 50% of those who were diagnosed with CBS. CBS represents an important co-diagnosis in AMD patients. Conclusion: The research highlights the utility of the cognitive assessment questionnaire as a valuable tool for easily diagnosing the syndrome in patients with AMD. This tool facilitates the identification of the condition, enabling the recommendation of appropriate clinical treatments and the provision of essential psychosocial support.

Our old friend lithium and encephalopathy: a case report

IntroductionLithium is a well-established mood stabilizer used in the management of bipolar disorder, that is generally well-tolerated; however, it is associated with rare but potentially severe neurological side effects. Lithium-induced encephalopathy is characterized by a spectrum of symptoms, ranging from subtle cognitive deficits to severe manifestations such as altered mental status to overt delirium, seizures and coma. Risk factors include advanced age, concomitant medication and underlying renal impairment. This symptoms do not consistentely correlate with lithium concentrations.ObjectivesThis abstract aims to provide an overview of the clinical characteristics, underlying mechanisms, and management of lithium-induced encephalopathy.MethodsWe discuss a case of a 62-years-old woman diagnosed with bipolar disorder under treatment with lithium and olanzapine, without recent changes of posology. She presented to emergency department with subacute and fluctuating neuropsychiatric symptoms, including confusion, disorientation in time and space, complex visual hallucinations, delusional ideas, alteration in memory and logic thinking, dysarthria and dyspraxia. Neuroimaging showed no structural abnormalities, blood tests were normal and serum lithium levels were within the therapeutic range (0.8 mEq/L). Upon discontinuation of lithium, the patient exhibited a gradual resolution of symptoms. We conducted a comprehensive search of medical databases, including PubMed, to identify relevant articles related to lithium encephalopathy published up to September 2023.ResultsThis case challenges the conventionally established threshold of elevated serum lithium levels in the development of encephalopathy. The underlying pathophysiology is complex and multifactorial, with proposed mechanisms including alterations in neurotransmitter balance, oxidative stress, mitochondrial dysfunction and individual susceptibility to idiosyncratic reactions. Early diagnosis is challenging, necessitating a high clinical suspicion, neuroimaging and exclusion of other etiologies. Management strategies involve discontinuation of lithium, even when serum lithium levels are within the therapeutic range, supportive care, and, in severe cases, hemodialysis to reduce lithium levels rapidly.ConclusionsClinicians should maintain a high index of suspicion of lithium-induced encephalopathy, especially in patients presenting with neurological symptoms while on lithium treatment. Early recognition and intervention are essential for minimizing morbidity and preventing potentially irreversible neurological damage. Further research is needed to better understand the precise mechanisms underlying it, risk factors and to refine treatment strategies.Disclosure of InterestNone Declared

Emotional well-being in Charles Bonnet syndrome: exploring associations with negative affect, loneliness and quality of life.

Charles Bonnet syndrome (CBS) is a condition characterised by the occurrence of vivid and complex visual hallucinations in individuals with visual impairment. To explore the relationship between emotional distress and the perceived impact of CBS symptoms on participants' lives. We tested the hypothesis that heightened negative affect was associated with a more negative appraisal of CBS symptoms, increased self-reported loneliness, and poorer quality of life (QOL). Cross-sectional. Participants recruited predominantly via vision-related charities rated their hallucinations and their impact on a Likert scale. Loneliness and negative affect were assessed with the Three-Item Loneliness Scale and Positive and Negative Affect Schedule. Health index (EQ-5D-3L) and vision-related QOL (VF-9) were also assessed. Correlation analysis and multi-variable regression determined the relation between survey responses. The majority of 126 respondents (81%) were aged 65+ years and 84% reported active CBS symptoms. Fifty-five percent of respondents rated impact of CBS as negative and no-one rated the impact as 'very pleasant'. A statistically significant correlation was found between impact of CBS and negative affect (p ⩽ 0.001; rho = -0.34) and impact of CBS and loneliness (p = 0.017; rho = -0.21). The relation between negative affect and CBS impact remained statistically significant when accounting for the impact of loneliness and the relationship between loneliness and CBS effect (p = 0.002, adj R 2 = 0.1). A statistically significant correlation between loneliness and negative affect (p ⩽ 0.001; rho = 0.55) was also found. Respondents experiencing negative emotions were more likely to perceive the impact of CBS symptoms as negative and report greater feelings of loneliness. Negative affect is an important consideration when assessing people with CBS.

Global brain analysis of minor hallucinations in Parkinson's disease using EEG and MRI data.

Visual hallucination is a prevalent psychiatric disorder characterized by the occurrence of false visual perceptions due to misinterpretation in the brain. Individuals with Parkinson's disease often experience both minor and complex visual hallucinations. The underlying mechanism of complex visual hallucinations in Parkinson's patients is commonly attributed to dysfunction in the visual pathway and attention network. However, there is limited research on the mechanism of minor hallucinations. To address this gap, we conducted an experiment involving 13 Parkinson's patients with minor hallucinations, 13 Parkinson's patients without hallucinations, and 13 healthy elderly individuals. We collected and analyzed EEG and MRI data. Furthermore, we utilized EEG data from abnormal brain regions to train a machine learning model to determine whether the abnormal EEG data were associated with minor hallucinations. Our findings revealed that Parkinson's patients with minor hallucinations exhibited excessive activation of cortical excitability, an imbalanced interaction between the attention network and the default network, and disruption in the connection between these networks. These findings is similar to the mechanism observed in complex visual hallucinations. The visual reconstruction of one patient experiencing hallucinations yields results that differ from those observed in subjects without such symptoms. The visual reconstruction results demonstrated significant differences between Parkinson's patients with hallucinations and healthy subjects. This suggests that visual reconstruction techniques may offer a means of evaluating hallucinations.

Neurochemistry and functional connectivity in the brain of people with Charles Bonnet syndrome.

Charles Bonnet syndrome (CBS) is a condition in which people with vision loss experience complex visual hallucinations. These complex visual hallucinations may be caused by increased excitability in the visual cortex that are present in some people with vision loss but not others. We aimed to evaluate the association between γ-aminobutyric acid (GABA) in the visual cortex and CBS. We also tested the relationship among visually evoked responses, functional connectivity, and CBS. This is a prospective, case-controlled, cross-sectional observational study. We applied 3-Tesla magnetic resonance spectroscopy, as well as task-based and resting state (RS) connectivity functional magnetic resonance imaging in six participants with CBS and six controls without CBS. GABA+ was measured in the early visual cortex (EVC) and in the lateral occipital cortex (LOC). Participants also completed visual acuity and cognitive tests, and the North-East Visual Hallucinations Interview. The two groups were well-matched for age, gender, visual acuity and cognitive scores. There was no difference in GABA+ levels between groups in the visual cortex. Most participants showed the expected blood oxygenation level dependent (BOLD) activation to images of objects and the phase-scrambled control. Using a fixed effects analysis, we found that BOLD activation was greater in participants with CBS compared to controls. Analysis of RS connectivity with LOC and EVC showed little difference between groups. A fixed effects analysis showed a correlation between the extent of functional connectivity with LOC and hallucination strength. Overall, our results provide no strong evidence for an association between GABAergic inhibition in the visual cortex and CBS. We only found subtle differences in visual function and connectivity between groups. These findings suggest that the neurochemistry and visual connectivity for people with Charles Bonnet hallucinations are comparable to a sight loss population. Differences between groups may emerge when investigating subtle and transient changes that occur at the time of visual hallucinations.

Clinical Manifestations.

Visual hallucinations (VH) phenomenology in Lewy Body Disease (LBD) is heterogenous, including minor phenomena (passage, presence, illusions) and complex hallucinations. Neural substrates and mechanisms involved are still unclear. Here we investigated grey matter (GM) alterations associated with minor (MVH) and complex VH (CVH). LBD patients (n = 28) with VH and Healthy controls (HC-n = 20) underwent MRI. We administered the North East Visual Hallucinations Interview (NEVHI), a semi-structured interview assessing the phenomenology of VH, their duration and frequency. VH were clustered in MVH and CVH and treated as a patient's trait. First we compared GM volume of LBD and HC. Then, multiple regressions were performed to disclose alterations associated with the duration, frequency and severity of MVH and CVH, including the opposite VH domain, total intracranial volume (TIV) and MMSE as nuisance regressors. We found a decreased GM volume in the bilateral fusiform gyrus (FG), in the left posterior cingulate and in the right inferior frontal gyrus in LBD compared to HC. We also found that CVH duration was negatively associated with GM volume in the left FG. We did not find any association with MVH phenomenology. LBD patients showed GM alterations in ventral-visual-stream, default-mode-network and inhibitory regions compared to HC. Although the LBD versus HC comparison is not specific to VH, the regions identified have been implicated in VH in previous studies suggesting they may represent structural hallmarks of functional alterations in networks contributing to VH. When the association with VH phenomenology was tested, we did not find GM alterations associated with MVH. It is likely that these phenomena might be not associated with structural alterations but with functional alterations within visual networks. CVH were instead associated with decreased GM in FG. The atrophy in the FG may lead to a spontaneous activation of this region that sustain CVH duration, accounting for VH content (D'Antonio et al., 2022). These alterations may represent the predisposing condition to VH in LBD. According to the hodotopic model, VH phenomenology may help identify brain regions implicated and might reveal the substrates for cortical region/network dysfunctions occurring during VH state (ffytche et al., 2008).

Gallstone Ileus; the Radiographic Findings in an Elderly Patient: A Case Report

Since the beginning of the COVID-19 pandemic in December 2019, Ivermectin has been proposed as an alternative for prophylaxis and treatment of COVID-19 infection despite the lack of evidence and clinical trials recommending its use. In this study, we report the case of a 52-year old Filipino male with newly diagnosed diabetes mellitus who developed a subacute history of fever, cough and generalized weakness, causing him to self-medicate with supratherapeutic doses of Ivermectin and thereafter subsequently developed decrease in sensorium, restlessness and complex visual hallucinations. Significant laboratory examinations showed hyperglycemia, mild hyponatremia, positive SARS-CoV2 reverse transcriptase polymerase chain reaction test and bilateral pneumonia on chest radiograph. He was subsequently started on antibiotics, high flow nasal cannula and given two doses of activated charcoal. During the first 24 hours of hospital admission, there was significant improvement in the patient’s sensorium with resolution of restlessness and visual hallucinations. During the rest of the hospitalization, his respiratory symptoms had improved and he was subsequently discharged. Clinical outcome in our patient after administration of activated charcoal and completion of antibiotics showed an overall improvement in symptoms and without any neurologic sequelae.

Phantom vision or psychotic malady? A case report of Charles Bonnet syndrome plus

Charles Bonnet syndrome (CBS) is commonly experienced by elderly individuals after acute or gradual loss of vision. It is characterized by complex and vivid visual release hallucinations with insight into the unreality of visual experiences, which cannot be explained by any other psychiatric or neurodegenerative disorder. Most often these hallucinations are visual only without hallucinations in other sensory modalities. Here, we report an atypical case of CBS in an 80-year-old male who presented with complex visual scenic, auditory, and olfactory hallucinations after visual loss secondary to glaucoma with no insight and no cognitive decline. He further showed improvement in the low-dose antipsychotic and mood stabilizer combination.

Identifying the Toxidrome of Ivermectin Toxicity

Since the beginning of the COVID-19 pandemic in December 2019, Ivermectin has been proposed as an alternative for prophylaxis and treatment of COVID-19 infection despite the lack of evidence and clinical trials recommending its use. In this study, we report the case of a 52-year old Filipino male with newly diagnosed diabetes mellitus who developed a subacute history of fever, cough and generalized weakness, causing him to self-medicate with supratherapeutic doses of Ivermectin and thereafter subsequently developed decrease in sensorium, restlessness and complex visual hallucinations. Significant laboratory examinations showed hyperglycemia, mild hyponatremia, positive SARS-CoV2 reverse transcriptase polymerase chain reaction test and bilateral pneumonia on chest radiograph. He was subsequently started on antibiotics, high flow nasal cannula and given two doses of activated charcoal. During the first 24 hours of hospital admission, there was significant improvement in the patient’s sensorium with resolution of restlessness and visual hallucinations. During the rest of the hospitalization, his respiratory symptoms had improved and he was subsequently discharged. Clinical outcome in our patient after administration of activated charcoal and completion of antibiotics showed an overall improvement in symptoms and without any neurologic sequelae.

Behavioral and neural correlates of pareidolic illusions in dementia with Lewy bodies

IntroductionPareidolia, a form of visual illusions phenomenologically similar to complex visual hallucinations, is a phenomenon that is associated with visual hallucinations in dementia with Lewy bodies (DLB). This study aimed to identify commonalities and differences in behavioral and neural correlates between pareidolic illusions and visual hallucinations in DLB. MethodsForty-three patients with DLB underwent the scene pareidolia test, which evokes and measures pareidolic illusions, and standardized neuropsychological and behavioral assessments. Regional cerebral blood flow (rCBF) was measured by single-photon emission computed tomography. Factor analysis was performed to assess the relationships among pareidolic illusions, cognitive functions, and behavioral symptoms. Partial least squares correlation analysis was used to investigate the relationship between these symptoms and rCBF. ResultsFactor analysis yielded three behavior factors: the first factor (hallucinations/fluctuations) consisted of pareidolic illusions, visual hallucinations, and fluctuating cognition; the second factor (general cognitive function) consisted of general cognitive function and working memory; and the third factor (visual processing) consisted of visual processing and pareidolic illusions. Partial least squares correlation analysis identified two brain-behavior correlation patterns: (1) rCBF reduction in the frontal and perisylvian/periventricular regions was associated with lower general cognitive function and lower visual processing; and (2) rCBF reduction in the bilateral occipitotemporal cortex was associated with more severe hallucinations/fluctuations and lower visual processing. ConclusionsAt the behavioral level, pareidolic illusions are associated with visual hallucinations, fluctuating cognition, and visual processing in DLB. At the neural level, pareidolic illusions may arise from the synergistic effects of global neuropathological changes and occipitotemporal cortical dysfunctions.

Spatial Correspondence of LSD-Induced Variations on Brain Functioning at Rest With Serotonin Receptor Expression

BackgroundLysergic acid diethylamide (LSD) is an atypical psychedelic compound that exerts its effects through pleiotropic actions, mainly involving 1A/2A serotoninergic (5-HT) receptor subtypes. However, the mechanisms by which LSD promotes a reorganization of the brain’s functional activity and connectivity are still partially unknown. MethodsOur study analyzed resting-state functional magnetic resonance imaging data acquired from 15 healthy volunteers undergoing LSD single-dose intake. A voxelwise analysis investigated the alterations of the brain’s intrinsic functional connectivity and local signal amplitude induced by LSD or by a placebo. Quantitative comparisons assessed the spatial overlap between these 2 indices of functional reorganization and the topography of receptor expression obtained from a publicly available collection of in vivo, whole-brain atlases. Finally, linear regression models explored the relationships between changes in resting-state functional magnetic resonance imaging and behavioral aspects of the psychedelic experience. ResultsLSD elicited modifications of the cortical functional architecture that spatially overlapped with the distribution of serotoninergic receptors. Local signal amplitude and functional connectivity increased in regions belonging to the default mode and attention networks associated with high expression of 5-HT2A receptors. These functional changes correlate with the occurrence of simple and complex visual hallucinations. At the same time, a decrease in local signal amplitude and intrinsic connectivity was observed in limbic areas, which are dense with 5-HT1A receptors. ConclusionsThis study provides new insights into the neural processes underlying the brain network reconfiguration induced by LSD. It also identifies a topographical relationship between opposite effects on brain functioning and the spatial distribution of different 5-HT receptors.

An auditory Charles Bonnet Syndrome managed with psychological intervention: A case report

IntroductionCharles Bonnet Syndrome (CBS) is an age-related disorder characterized by complex visual hallucinations in older persons with vision loss and underlying ocular pathology. The management of these symptoms is imprecise and combines psychological measures with psychotropic drugs.Objectivesto discuss the non-pharmacological management of Bonnet syndrome through a case report.MethodsWe report a case of atypical CBS in a 76-year-old male patient presenting with visual and auditory hallucinations that were improved by reassurance.ResultsThe past medical history was significant for diabetic retinopathy, difficulty hearing due to bilateral sensorineural hearing loss. He recognized these visions as unreal and felt distressed by them. No cognitive impairment was observed on several neuropsychological tests. He was reassured of the false nature of the visual experiences after explanations that he had no mental illness and that the problem could disappear. He was taught how to keep the images away by closing his eyes for sometimes and repeated blinking. After six weeks of psychological intervention, the visual experiences had disappeared without using any drugConclusionsIn the management of CBS drug treatments remain partially satisfactory. Nonpharmacological interventions focus on the reduction of the visual pathway deprivation. This therapeutic alternative seems to provide positive benefits.Disclosure of InterestNone Declared

ELECTROCONVULSIVE THERAPY FOR AGITATION IN LEWY BODIES DEMENTIA

IntroductionDementia with Lewy Bodies (DLB) is a primary degenerative dementing syndrome characterized by visual hallucinations, fluctuation in cognition, depressive symptoms and parkinsonism. Literature has shown the utility of electroconvulsive therapy (ECT) in demented patients regarding depressive symptoms and agitation. Nevertheless, the majority of cases described include patients with vascular dementia and Alzheimer’s disease. There are no cases informed concerning ECT in DLB patients with agitation and aggressive behaviors.ObjectivesEvaluate the impact of electroconvulsive therapy (ECT) for agitation in a patient with diagnosis of Lewy Bodies Dementia (DLB).MethodsCase report. 68-year-old male, with no prior neuropsychiatric history, was present for psychiatric evaluation for 5 year history of progressive dementia with fluctuations in cognition, complex visual hallucinations, delusional beliefs, depressive mood, anhedonia, irritability, associated to parkinsonism and increasing autoaggressive behaviors and agitation.An extensive neurologic workup including neuroimaging, EEG and laboratory studies failed to reveal a specific etiology. Neuropsychological testing reveals frontal, attentional, and visuospatial dysfunction. A presumptive diagnosis of DLB was made.Medication trials including donepezil, memantine, lamotrigine, sertraline, quetiapine, risperidone and melatonin failed to manage his depressive, psychotic and behavioral disturbances.ResultsConsidering past medication failures and prominent behavioral disturbances family consented for an acute course of ECT.Initial acute phase consisted of 6 sessions of right unilateral, brief pulse width (0.3 ms) ECT tri-weekly utilizing Mecta Spectrum. Anesthesia was induced with propofol, and received succinylcholine for muscle relaxation. Initial charge was 115 mC (6x seizure threshold), then raised to 192 mC. Seizure duration averaged in 22 seconds. No adverse reactions reported.Clinical outcomes were measured with the CGI-Efficacy Index. Pre-ECT CGI-SI score was 6 (severely ill) and post-ECT CGI-I was 3 (minimally improved).ConclusionsMood and behavioral disturbances are a frequent primary motive consultations in DLB patients. The treatment is challenging due to the sensitivity to antidopaminergic medications evidenced in this type of patients. This case suggests that ECT has an impact in the treatment of agitation and aggression in DLB patients, although further investigation is needed.Disclosure of InterestNone Declared

Charles- Bonnet Syndrome: a case review. The objective of this poster is to contribute a case to the existing series, and thus get closer to the knowledge of this clinical entity.

IntroductionCharles-Bonnet syndrome was described in 1760 by the Swiss philosopher Charles-Bonnet, who reported that his grandfather’s visual hallucinations were due to eye disease rather than mental illness.It is characterized by the presence of visual hallucinations, which are usually complex and structured, in elderly patients with preserved cognitive status, significant deterioration in visual acuity and no evidence of associated psychiatric or neurological disease.ObjectivesThe objective of this poster is to contribute a case to the existing series, and thus get closer to the knowledge of this clinical entity.MethodsTo review the case, a search was made in Pubmed with the terms hallucinations and Charles Bonnet’s Syndrome.ResultsThis is a 76-year-old man, in follow-up by the ophthalmology service in the context of bilateral cataract, which causes severe visual disturbance. He went to our hospital, accompanied by his wife, reporting that for some months he has had complex visual hallucinations of various animals, colors in space, as well as children playing around him. All this generates a lot of anxiety, although the patient makes adequate criticism of them.The neurological examination performed was normal. The CT scan and laboratory tests were also within normal limits. Cognitive impairment was explored using the MMSE scale, which did not show any alteration. In addition, after a psychiatric evaluation, the patient does not meet the criteria for any disorder included in the DSM V. After reviewing the literature and taking into account the clinical picture described, the case is framed within a Charles-Bonnet syndrome.Regarding the therapeutic plan carried out, it was decided to start treatment with Gabapentin up to a maximum dose of 900 mg/day, with a considerable improvement in the hallucinatory symptoms. In addition, given the repercussion at the affective level, especially with a predominance of anxious symptoms, it was decided to start sertraline at a dose of 50 mg/day, with an adequate therapeutic response.ConclusionsCharles-Bonnet syndrome refers to hallucinosis, generally of a visual nature, that appear in patients with a sensory deficit associated with the type of sensory-perceptive alteration. It is important to take it into account in the differential diagnosis of the elderly patient with hallucinosis. There is no established treatment, although neuroleptics, benzodiazepines, antidepressants and antiepileptics are used.Disclosure of InterestNone Declared

Visual Hallucinations in Psychosis: The Curious Absence of the Primary Visual Cortex.

Approximately one-third of patients with a psychotic disorder experience visual hallucinations (VH). While new, more targeted treatment options are warranted, the pathophysiology of VH remains largely unknown. Previous studies hypothesized that VH result from impaired functioning of the vision-related networks and impaired interaction between those networks, including a possible functional disconnection between the primary visual cortex (V1) and higher-order visual processing regions. Testing these hypotheses requires sufficient data on brain activation during actual VH, but such data are extremely scarce. We therefore recruited seven participants with a psychotic disorder who were scanned in a 3 T fMRI scanner while indicating the occurrence of VH by pressing a button. Following the scan session, we interviewed participants about the VH experienced during scanning. We then used the fMRI scans to identify regions with increased or decreased activity during VH periods versus baseline (no VH). In six participants, V1 was not activated during VH, and in one participant V1 showed decreased activation. All participants reported complex VH such as human-like beings, objects and/or animals, during which higher-order visual areas and regions belonging to the vision-related networks on attention and memory were activated. These results indicate that VH are associated with diffuse involvement of the vision-related networks, with the exception of V1. We therefore propose a model for the pathophysiology of psychotic VH in which a dissociation of higher-order visual processing areas from V1 biases conscious perception away from reality and towards internally generated percepts.