Persistent Hallucinations Research Articles

Persistent Hallucinations in a Middle-Aged Man After COVID-19 Infection

Persistent Hallucinations in a Middle-Aged Man After COVID-19 Infection

Usefulness of Low-Dose Olanzapine for Initial and Maintenance Treatments of Very-Late-Onset Schizophrenia-Like Psychosis: A Case Report

In pharmacotherapy for schizophrenia, it is recommended that antipsychotic medications should not be discontinued, and their dosage should not be reduced during the stabilization and maintenance phases. Nevertheless, these drugs also have side effects that can increase extrapyramidal symptoms and mortality in the elderly population. It is yet to be determined whether antipsychotics should be reduced or discontinued in patients with very-late-onset schizophrenia-like psychosis (VLOSLP) during the stabilization and maintenance stages. Therefore, we describe the case of an elderly woman for whom low-dose olanzapine was useful throughout the initial, stabilization, and maintenance phases of VLOSLP. The patient was a 70-year-old woman who had experienced persistent hallucinations and delusions for 3 years. Two years after her diagnosis, except for relapse due to self-discontinuation, she remained in remission of her psychotic symptoms by continuing olanzapine treatment (2.5 mg/day). The standard effective dose of olanzapine was 10 mg/day, and she was able to respond to therapy with a low dose of olanzapine in the initial and subsequent phases of stabilization and maintenance. It is suggested that the discontinuation of antipsychotics should be avoided to avoid recurrence, even if the dose is lower than the standard amount during the stabilization and maintenance phases. Additionally, if the patient progresses to dementia, the treatment approach may vary, and it is imperative to monitor cognitive decline and self-discontinuation of oral medications during the follow-up of VLOSLP.

Charles Bonnet Syndrome with Atypical Features: Case Report

Charles Bonnet syndrome (CBS) is a lesser-known condition characterized by recurring or persistent complex visual hallucinations (VHs) that emerge alongside a preceding decline in visual acuity. Individuals with CBS notably maintain their grasp on reality and possess an understanding of the fictitious nature of their VHs. However, due to a general lack of awareness within the medical community; CBS is often erroneously diagnosed as dementia or new-onset psychosis. This syndrome is linked to age-related macular degeneration, glaucoma, and cataracts. Diagnosing CBS hinges primarily on the patient’s medical history, clinical presentation, information from collateral sources, and a process of exclusion for other potential explanations. Unfortunately, no definitive cure exists for CBS, with treatment primarily centered on offering reassurance and education; nevertheless, persistent hallucinations containing unsettling imagery might require targeted intervention, employing offlabel use of psychotropic medications (such as antipsychotics, antidepressants, and anticonvulsants) to address refractory symptoms. This case report underscores a CBS instance with atypical features, highlighting the diagnostic and therapeutic approach applied to promote accurate identification and treatment.

0556 Prevalence and Incidence of Hypnagogic Hallucinations In A Longitudinal Study Of The American General Population

Abstract Introduction Hypnagogic hallucinations are vivid hallucinations that occur at sleep onset, during the transition between wakefulness and REM sleep. The hallucinations can be visual, auditory, tactile or kinetic and can be terrifying for the individual who experience them. Hypnagogic hallucinations are a common symptom of narcolepsy, a disorder characterized by excessive sleepiness, cataplexy and disturbed sleep. The evolution of hypnagogic hallucinations remains seldomly investigated. There is no data regarding its incidence and its chronicity. This study examines the predictive factors for chronic hypnagogic hallucinations in the general population. Methods This longitudinal study had two waves: 12,218 subjects interviewed by phone during wave 1 (W1); 10,931 during wave 2 (W2) three years later. The sample was representative of the general population based on US Census. Analyses included subjects participating to both waves (N=10,931). Logistic regression models were used to determine the predictive variables for persistent hypnagogic hallucinations. Results At W1, 11.7% (95% CI:11.1%-12.3%) reported having experienced hypnagogic hallucinations in the previous year. At W2, 9.3% (95% CI: 8.8%-9.8%) reported hypnagogic hallucinations. A total of 22.8% of subjects with hypnagogic hallucinations at W1 still reported these hallucinations at W2 (2.1% of the sample). The 3-year incidence was 5.7% (95% CI: 5.3%-6.1%). After adjusting for age, sex, alcohol intake and medical conditions, persistence of hypnagogic hallucinations (i.e., present at both interviews) was predicted by the following factors: persistent pain (RR: 3.2 [95% CI:1.9-35.3] p<0.0001), persistent hypersomnolence (RR: 5.8 [95% CI:3.8-8.8] p<0.0001); persistent sleep paralysis (RR: 2.4 [95% CI:1.3-4.2] p=0.003); and persistent cataplexy-like symptoms (RR: 11.6 [95% CI:6.5-20.6] p<0.0001). Conclusion Hypnagogic hallucinations are frequent in the general population. Its chronicity is predicted mostly by factors associated with narcolepsy such as hypersomnolence, cataplexy and sleep paralysis. Support (If Any)

Cognitive behavioral therapy-based approach for management of persistent hallucinations in treatment-resistant schizophrenia.

Cognitive behavioral therapy-based approach for management of persistent hallucinations in treatment-resistant schizophrenia.

Characteristics and stability of hallucinations and delusions in patients with borderline personality disorder

BackgroundPsychotic features have been part of the description of the borderline personality disorder (BPD) ever since the concept “borderline” was introduced. However, there is still much to learn about the presence and characteristics of delusions and about the stability of both hallucinations and delusions in patients with BPD. MethodsA follow-up study was conducted in 326 BPD outpatients (median time between baseline and follow-up = 3.16 years). Data were collected via telephone (n = 267) and face-to-face interviews (n = 60) including the Comprehensive Assessment of Symptoms and History interview, Positive And Negative Syndrome Scale and the Psychotic Symptom Rating Scale. ResultsThe point prevalence of delusions was 26%, with a median strong delusion conviction. For the group as a whole, the presence and severity of both hallucinations and delusions was found to be stable at follow-up. Participants with persistent hallucinations experienced more comorbid psychiatric disorders, and they differed from those with intermittent or sporadic hallucinations with their hallucinations being characterized by a higher frequency, causing a higher intensity of distress and more disruption in daytime or social activities. ConclusionsDelusions in patients with BPD occur frequently and cause distress. Contrary to tenacious beliefs, hallucinations and delusions in participants with BPD are often present in an intermittent or persistent pattern. Persistent hallucinations can be severe, causing disruption of life. Overall, we advise to refrain from terms such as “pseudo”, or assume transience when encountering psychotic phenomena in patients with BPD, but rather to carefully assess these experiences and initiate a tailor-made treatment plan.

Antipsychotic Behavioral Phenotypes in the Mouse Collaborative Cross Recombinant Inbred Inter-Crosses (RIX).

Schizophrenia is an idiopathic disorder that affects approximately 1% of the human population, and presents with persistent delusions, hallucinations, and disorganized behaviors. Antipsychotics are the standard pharmacological treatment for schizophrenia, but are frequently discontinued by patients due to inefficacy and/or side effects. Chronic treatment with the typical antipsychotic haloperidol causes tardive dyskinesia (TD), which manifests as involuntary and often irreversible orofacial movements in around 30% of patients. Mice treated with haloperidol develop many of the features of TD, including jaw tremors, tongue protrusions, and vacuous chewing movements (VCMs). In this study, we used genetically diverse Collaborative Cross (CC) recombinant inbred inter-cross (RIX) mice to elucidate the genetic basis of antipsychotic-induced adverse drug reactions (ADRs). We performed a battery of behavioral tests in 840 mice from 73 RIX lines (derived from 62 CC strains) treated with haloperidol or placebo in order to monitor the development of ADRs. We used linear mixed models to test for strain and treatment effects. We observed highly significant strain effects for almost all behavioral measurements investigated (P < 0.001). Further, we observed strong strain-by-treatment interactions for most phenotypes, particularly for changes in distance traveled, vertical activity, and extrapyramidal symptoms (EPS). Estimates of overall heritability ranged from 0.21 (change in body weight) to 0.4 (VCMs and change in distance traveled) while the portion attributable to the interactions of treatment and strain ranged from 0.01 (for change in body weight) to 0.15 (for change in EPS). Interestingly, close to 30% of RIX mice exhibited VCMs, a sensitivity to haloperidol exposure, approximately similar to the rate of TD in humans chronically exposed to haloperidol. Understanding the genetic basis for the susceptibility to antipsychotic ADRs may be possible in mouse, and extrapolation to humans could lead to safer therapeutic approaches for schizophrenia.

Instrumental rationality and suicide in schizophrenia: a case for rational suicide?

It is estimated that up to 7500 people develop schizophrenia each year in the UK. Schizophrenia has significant consequences, with 28% of the excess mortality in schizophrenia being attributed to...

T108. ANALYTICAL AND PREDICTIVE VALIDITY OF HALLUCINATIONS IN FIRST PSYCHOTIC EPISODES

BackgroundSome studies of first psychotic episodes have suggested the association between childhood trauma, such as sexual abuse, and the risk of hallucinations.1 Furthermore, other studies indicated that environment can alter the phenomenological presentation of first psychotic episodes.2However, there are no studies about the association between hallucinations in first psychotic episodes and the prognosis of the disease. This is the main objective of this study. We also compared the phenomenological differences between hallucinations in first episode psychosis and persistent hallucinations in patients with chronic psychosis.MethodsNaturalistic, longitudinal follow-up study in a sample of 173 patients of first psychotic episode attending public mental health service in Area 5 of Valencia region (Spain) in a period between 2010–2017.We compared first-episode patients with hallucinations (N=38) with two samples: A) First-episode patients without hallucinations (N=137). B) Chronic patients with persistent hallucinations (N=45) from a previous study.3In the first comparison we used the following variables: sociodemographic data, risk factors (such as cannabis consume and immigration), psychiatric pathology (CIE-10), psicopathology (including clinical scales GAF, CGI and PANSS), number of emercengy visits and number of hospitalization after the first psychotic episode.In the second one, we use the PSYRATS scale to compare both groups.ResultsIn the first comparison, First Episode Psychotic patients with and without hallucinations,we only found significant differences in the number of hospital income, with more hospitalizations in the non hallucinating group (P= 0.001).In the second comparison, First Episode Hallucinations versus Chronic Persistent Hallucinations, significant differences were only found in the duration of the hallucinations, which was much higher in chronic persistent hallucinations group (P= 0.001)DiscussionConsequently, it seems that first psychotic episode patients without hallucinations have more hospitalizations than first-episode patients with hallucinations. Moreover, we can conclude that the duration of voices is higher in chronic patients with persistent hallucinations than in first psychotic episode hallucinations.Both results have practical implications in the prognostic importance of hallucinations in first psychotic episodes.

OBSERVATION ON TRAINING NEURAL NETWORK FOR DIAGNOSING SCHIZOPHRENIA

Artificial neural networks may be deployed to diagnose illnesses including mental illness. One such mental illness is schizophrenia which is characterized by persistent delusions, hallucinations, disorganized speech, highly disorganized or catatonic behaviour and negative symptoms. It is commonly believed that one or two hidden layers in a neural network are sufficient to classify data, and that more hidden layers may be avoided because of longer times taken for the network to converge. However, we demonstrate that beyond a certain size of the hidden layer(s), it is harmful to deploy more than one layer because not only will it take longer for the network parameters to converge, the classification performance deteriorates sharply with more than one hidden layers.

Gulliver's world: Persistent lilliputian hallucinations as manifestation of Charles Bonnet syndrome in a case of cataract and normal pressure hydrocephalus.

Charles Bonnet Syndrome (CBS) typically occurs in elderly people with peripheral vision impairment, or interruptions in the connections from eyes to visual cortex. The heterogeneity of presentations and causal mechanisms warrants clinical caution. In this report, we describe a case of CBS developing in the form of Lilliputian Hallucinations in an elderly gentleman, on the background of cataract and normal pressure hydrocephalus, the complexities arising out of such aetiogenesis, and its management. We emphasize upon the fact that CBS might develop through two concurrent mechanisms in a given individual. Treating one of these would mean persistent symptoms, and failing to recognize these would lead to continued morbidity.

M104. Efficacy of Transcranial Direct Current Stimulation (tDCS) as a Treatment for Persistent Hallucinations in Patients With Schizophrenia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Abstract Hallucinations are common symptoms in schizophrenia occurring in about 60% to 80% of patients. Antipsychotics are effective in 70% to 80% of patients, while the remaining 20% to 30% of patients continue to experience persistent hallucinations despite medication. Transcranial direct current stimulation (tDCS) is a noninvasive neurostimulation technique, which has been studied as a treatment for persistent hallucinations in schizophrenia. Given the growing clinical interest in using tDCS as a treatment for persistent hallucination, we conducted a systematic review and meta-analysis of the efficacy of tDCS for alleviating hallucinations in schizophrenia. Systematic search of Medline, Embase, Cochrane Central Register of Controlled Trials, Evidence-Based Medicine Reviews, and CINAHL for relevant studies was done up to March 16, 2016. Bibliographies of retrieved articles and previous reviews were also included in the search. Eligibility criteria for study selection included randomized controlled trials that compared the efficacy of tDCS with sham stimulation for treating persistent hallucinations in patients with schizophrenia. Two reviewers independently extracted data and assessed study risk of bias. Standard mean differences across trials were pooled. Subgroup analyses were performed, and heterogeneity and potential publication bias were assessed. The GRADE system was used to evaluate the quality of evidence and confidence in the conclusions. Main outcome measure Hallucination severity evaluated by a random effects meta-analysis model. Five eligible randomized sham-controlled trials involving 121 patients were included in the meta-analysis. Most patients were reported to have persistent hallucinations despite adequate antipsychotic treatment. Active tDCS (2 mA stimulation for 20 min) was administered once or twice daily, for 5 to 15 sessions, with cathode over the left temporo-parietal junction and anode over the left dorsolateral prefrontal cortex or right supraorbital ridge. The pooled effects from all trials with an overall “moderate quality” (GRADE) was −0.15 (95% CI −0.55 to 0.25), indicating no beneficial effects of tDCS on persistent hallucination in schizophrenia. The heterogeneity between trials was low ( = 37%) and no serious adverse effects were reported. Based on current moderate-quality evidence, tDCS has no beneficial effects on persistent hallucination in schizophrenia, particularly when administered once daily. Future studies should focus on twice daily stimulations to determine if tDCS is effective for treating persistent hallucinations in schizophrenia.

Efficacy of cognitive behavioural therapy for sleep improvement in patients with persistent delusions and hallucinations (BEST): a prospective, assessor-blind, randomised controlled pilot trial

SummaryBackgroundSleep disturbance occurs in most patients with delusions or hallucinations and should be treated as a clinical problem in its own right. However, cognitive behavioural therapy (CBT)—the best evidence-based treatment for insomnia—has not been tested in this patient population. We aimed to pilot procedures for a randomised trial testing CBT for sleep problems in patients with current psychotic experiences, and to provide a preliminary assessment of potential benefit.MethodsWe did this prospective, assessor-blind, randomised controlled pilot trial (Better Sleep Trial [BEST]) at two mental health centres in the UK. Patients (aged 18–65 years) with persistent distressing delusions or hallucinations in the context of insomnia and a schizophrenia spectrum diagnosis were randomly assigned (1:1), via a web-based randomisation system with minimisation to balance for sex, insomnia severity, and psychotic experiences, to receive either eight sessions of CBT plus standard care (medication and contact with the local clinical team) or standard care alone. Research assessors were masked to group allocation. Assessment of outcome was done at weeks 0, 12 (post-treatment), and 24 (follow-up). The primary efficacy outcomes were insomnia assessed by the Insomnia Severity Index (ISI) and delusions and hallucinations assessed by the Psychotic Symptoms Rating Scale (PSYRATS) at week 12. We did analysis by intention to treat, with an aim to provide confidence interval estimation of treatment effects. This study is registered with ISRCTN, number 33695128.FindingsBetween Dec 14, 2012, and May 22, 2013, and Nov 7, 2013, and Aug 26, 2014, we randomly assigned 50 patients to receive CBT plus standard care (n=24) or standard care alone (n=26). The last assessments were completed on Feb 10, 2015. 48 (96%) patients provided follow-up data. 23 (96%) patients offered CBT took up the intervention. Compared with standard care, CBT led to reductions in insomnia in the large effect size range at week 12 (adjusted mean difference 6·1, 95% CI 3·0–9·2, effect size d=1·9). By week 12, nine (41%) of 22 patients receiving CBT and one (4%) of 25 patients receiving standard care alone no longer had insomnia, with ISI scores lower than the cutoff for insomnia. The treatment effect estimation for CBT covered a range from reducing but also increasing delusions (adjusted mean difference 0·3, 95% CI −2·0 to 2·6) and hallucinations (−1·9, −6·5 to 2·7). Three patients, all in the CBT group, had five adverse events, although none were regarded as related to study treatment.InterpretationOur findings show that CBT for insomnia might be highly effective for improving sleep in patients with persistent delusions or hallucinations. A larger, suitably powered phase 3 study is now needed to provide a precise estimate of the effects of CBT for sleep problems, both on sleep and psychotic experiences.FundingResearch for Patient Benefit Programme, National Institute for Health Research.

Resting-state functional connectivity alterations in the default network of schizophrenia patients with persistent auditory verbal hallucinations

To understand the neural mechanism that underlies treatment resistant auditory verbal hallucinations (AVH), is still an important issue in psychiatric research. Alterations in functional connectivity during rest have been frequently reported in patients with schizophrenia. Though the default mode network (DN) appears to be abnormal in schizophrenia patients, little is known about its role in resistant AVH. We collected resting-state functional magnetic resonance imaging (R-fMRI) data with a 3T scanner from 19 schizophrenia patients with chronic AVH resistant to pharmacological treatment, 14 schizophrenia patients without AVH and 20 healthy controls. Using seed-based correlation analysis, we created spherical seed regions of interest (ROI) to examine functional connectivity of the two DN hub regions (posterior cingulate cortex and anteromedial prefrontal cortex) and the two DN subsystems: dorsomedial prefrontal cortex subsystem and medial temporal lobe subsystem (p<0.0045 corrected). Patients with hallucinations exhibited higher FC between dMPFC ROI and bilateral central opercular cortex, bilateral insular cortex and bilateral precentral gyrus compared to non hallucinating patients and healthy controls. Additionally, patients with hallucinations also exhibited lower FC between vMPFC ROI and bilateral paracingulate and dorsal anterior cingulate cortex. As the anterior cingulate cortex and the insula are two hubs of the salience network, our results suggest cross-network abnormalities between DN and salience system in patients with persistent hallucinations.

A negative pilot study of daily bimodal transcranial direct current stimulation in schizophrenia.

A small number of studies conducted to date have suggested that transcranial direct current stimulation (tDCS) applied to the temporoparietal cortex may reduce auditory hallucinations in patients with schizophrenia. Prefrontal brain stimulation with other methods, has also been shown to potentially improve the negative symptoms of this disorder. To investigate the therapeutic potential of daily bimodal tDCS: anodal stimulation to the prefrontal cortex and cathodal stimulation to the temporoparietal junction in patients with persistent hallucinations and negative symptoms of schizophrenia. We conducted two small randomized double-blind controlled trials comparing bimodal tDCS to sham stimulation. In one study, stimulation was provided unilaterally, in the second study it was provided bilaterally. Neither unilateral nor bilateral tDCS resulted in a substantial change in either hallucinations or negative symptoms. Stimulation was well tolerated without side-effects. Daily tDCS does not appear to have substantial potential in the treatment of hallucinations or negative symptoms and further research should investigate higher doses of stimulation or more frequently applied treatment schedules.

A Case Study on Acupuncture in the Treatment of Schizophrenia

This report describes the use of acupuncture as an add on treatment for a patient with chronic schizophrenia. The 63-year-old woman suffered from persistent hallucinations and even physical pain as a result of the hallucination of a black bird that kept pecking her back. The patient received 12 weekly acupuncture treatments. A clinical diagnostic interview and psychological testing (on sleep quality, depression, and on positive and negative symptoms) were conducted before, immediately after and 3 months after the acupuncture treatment. The results of the diagnostic interview gave important insights into the treatment effects. The patient experienced improved daily functioning and noticed a change in hallucinations. Although the hallucinations still occurred, she felt less disturbed by them. Interestingly, pain decreased markedly. In addition, the results showed that the overall score of the positive and negative symptoms did not change immediately; however, a decrease in symptoms occurred 3 months after acupuncture treatment. Moreover, the patient described an immediate improvement in sleep; this was confirmed by a daytime sleepiness questionnaire. The patient was not able to complete a (longer) test on sleep quality beforehand but did so after the treatment period. Finally, a delayed improvement in the depression scale was found. Although larger clinical intervention studies on acupuncture and schizophrenia are needed, the results of this case study indicate that acupuncture may be beneficial as an add on treatment tool in patients with schizophrenia. 3132.

Classical Neurotransmitters and Neuropeptides Involved in Schizophrenia: How to Choose the Appropriate Antipsychotic Drug?

We summarize the alterations of classical neurotransmitters and neuropeptides, including their specific subreceptors, involved in schizophrenia. The essential susceptibility genes in schizophrenia and their coherence to neurotransmitter alterations are highlighted. In this sense, dopamine and serotonin hyperactivity in the mesolimbic system and the hippocampus is due to a reduced presynaptic inhibition carried out by GABA and glutamate, which is due to the susceptibility genes. A neuronal network in the brain regions involved in schizophrenia is developed in order to derive novel therapeutic approaches. A survey of the mechanisms of action of conventional and newer antipsychotic drug is given. We suggest the appropriate antipsychotic drugs considering the symptoms of schizophrenic and their possible side effects. It is important to examine the susceptibility genes in a cohort of patients in order to find out which patients profit more from antipsychotic drugs: those that exert a stronger D2 antagonistic effect or those that exert a stronger 5HT2A antagonistic effect. One question to be answered is whether refractory symptoms such as persistent acoustic hallucinations could be improved with novel antipsychotic drugs.

Determining the Association of the 5HTTLPR Polymorphism with Delusions and Hallucinations in Lewy Body Dementias

To determine whether the 5HTTLPR serotonin transporter polymorphism is associated with delusions and hallucinations in people with dementia with Lewy bodies (DLB) and Parkinson disease dementia (PDD). Prospective cohort study. A total of 187 individuals, recruited from centres in Norway, Sweden, and the United Kingdom were included in this study; 97 with clinically or neuropathologically diagnosed DLB/PDD and 90 cognitively normal individuals as a comparison group. All participants with dementia underwent serial evaluation of neuropsychiatric symptoms to assess the presence of persistent delusions and hallucinations using the Columbia University Scale for Psychopathology in Alzheimer disease, the Neuropsychiatric Inventory, or the Present Behavioural Examination. Severity of cognitive impairment was measured using the Mini Mental State Examination (MMSE). Individuals were genotyped for the 5HTTLPR polymorphism. Logistic regression demonstrated that homozygosity for the L/L genotype and lower MMSE were associated with an increased risk for delusions (odds ratio: 11.5 and 1.16, respectively). Neither was significantly associated with hallucinations. This study is the first to demonstrate the 5HTTLPR polymorphism is associated with delusions in Lewy body dementias, with important implications regarding the mechanisms underlying this symptom across the AD/DLB/PDD spectrum. Further studies are warranted to investigate this relationship further and examine treatment opportunities.

No association of COMT val158met polymorphism and psychotic symptoms in Lewy body dementias

We sought to determine whether the COMT val158met polymorphism (rs4680) is associated with delusions and hallucinations in people with dementia with Lewy bodies (DLB) and Parkinson's disease dementia (PDD). A total of 218 individuals, recruited from centres in Norway, Sweden and the UK were included in this study; 121 with clinically or neuropathologically diagnosed DLB/PDD and 97 age-matched, cognitively normal controls. All participants with dementia underwent serial evaluation of neuropsychiatric symptoms to assess the presence of persistent delusions and hallucinations using the Columbia University Scale for Psychopathology in Alzheimer's disease, the Neuropsychiatric Inventory or the Present Behavioural Examination. Severity of cognitive impairment was measured using the Mini Mental State Examination (MMSE). Both controls and participants with dementia were genotyped for rs4680. In contrast to previous findings, analysis by logistic regression failed to find any associations between rs4680 and psychotic symptoms. Larger studies in well characterised cohorts are warranted in order to investigate this relationship further.

Functional Hallucinations in Schizophrenia Responding to Adjunctive Sodium Valproate

Functional hallucinations are a rare phenomenon, wherein hallucinations are triggered by a stimulus in the same modality, and co-occur with it. Although hallucinations in schizophrenia are normally treated using antipsychotics, not all patients respond to them. The following is the report of a patient with paranoid schizophrenia who experienced persistent functional hallucinations, triggered by the sound of machines in his factory, in the absence of other psychotic symptoms. These occurred despite adequate doses of risperidone, which had controlled his other symptoms. The addition of sodium valproate, titrated up to 1700 mg/day based on response and tolerability, resulted in a marked improvement in this phenomenon and enabled him to return to work. The implications and possible mechanisms of the patient's response are discussed.