Psychosomatics 40:360-363, August 1999
© 1999 The Academy of Psychosomatic Medine
Visual Hallucinations in Mild Dementia
A Rare Occurrence of Lhermitte's Hallucinosis
Raphael J. Leo, M.D., and
Kristin Stievater Ahrens, M.D.
Received January 22, 1998; accepted February 5, 1999. From the Department of Psychiatry, School of Medicine and Biomedical Sciences, State University of New York at Buffalo. Address correspondence and reprint requests to Dr. Leo, Erie County Medical Center, 462 Grider St, Buffalo, New York 14215.
Key Words: Hallucinations • Dementia • Lhermitte's Hallucinosis
The elderly patient, presenting with new-onset visual hallucinations, confronts the consultation-liaison psychiatrist with an array of diagnostic possibilities. A number of psychiatric disorders, along with organic etiologies, must be entertained in the differential diagnosis. We report on a patient with visual hallucinations who was found to have mild cognitive deficits. She did not, however, demonstrate other symptoms or signs suggesting common organic or functional psychiatric disorders.
One syndrome appeared to most aptly apply, based upon clinical and laboratory investigations, that is, Lhermitte's hallucinosis. Originally described in 1922, Lhermitte reported a case of a person experiencing hallucinations of strange animals and costumed humans and children, stemming from lesions affecting the mid-brain and pons.1
Case Report
A 67-year-old, married, white woman, who was mother of seven, with history significant for irritable bowel syndrome, presented for evaluation of depression. She reported experiencing depression for "years," that is, feeling "mostly sad,"although she denied overt tearfulness. She described a general sense of anhedonia. While she denied sleep disturbances, she admitted to concentration disturbances and an unintentional 25-pound weight loss. She denied having thoughts of guilt or worthlessness or thoughts of death/dying or suicide. There was no recent or prior history of manic episodes or delusions. She denied any alcohol or illicit substance use.
The patient complained of "creatures" that come "out of the air," move about her house, and "travel right through the walls without leaving a hole or a mark." The patient described these creatures as about 1-foot in height; they have a head and "face colored as if with charcoal or Halloween makeup." Their bodies were covered with scarves, gowns, or rags. The patient was rather jocular and giddy at times, often making light of such visual phenomena and referring to them as "imitation kids." The patient complained of being bothered by seeing such "children" in her house, viewing them as some sort of "phantom family.". While she appeared to talk about them as if convinced that such images were "real," periodically she would question whether these were the "product of her mind."
On examination the patient was alert, without fluctuation of consciousness. She was attentive, aware of her surroundings. Her speech was rapid but clear and coherent (as per her husband, this was typical for the patient). At times her speech was illogical and rambling. Her affect was notable for giddiness and jocularity when discussing the hallucinations but was otherwise normothymic. There was no evidence of any psychomotor agitation or retardation. Cognitive examination was notable for deficits in short-term recall, deficits in constructional praxis, concrete abstract thinking, and impaired judgment.
Her husband reported that, following a severe headache, the patient's hallucinations began about 2 months before psychiatric evaluation. He reported that she had episodes of double vision and "confused behavior," for example, difficulty turning the correct burners on the stove or taking the wrong direction in their home. Interview with the husband about her activities of daily living and personality yielded a Blessed Dementia Rating Scale of 4, with predominance of difficulties in performance of everyday activities. The patient was not incontinent and did not have difficulties with dressing, eating, or significant personality changes.
Her vision was 20/25 bilaterally by Snellen eye chart. Concerns of headache precipitating a "confusional" state,"double vision," and visual hallucinations prompted neuroopthamalogic evaluation. Temporal artery biopsy was immediately conducted and ruled out the possibility of arteritis. Computed tomography (CT) scan of the head revealed microvascular ischemic changes but no cortical atrophy or mass lesions. Magnetic resonance imaging (MRI) of the brain revealed extensive, bilateral, periventricular white-matter punctate foci at the levels of the corona radiata and centrum semiovale and a large infarct at the level of the left-brachium pontis. These foci were felt to be of microvascular ischemic etiology. Carotid artery ultrasonography demonstrated no significant flow reductions bilaterally. An electroencephalogram revealed no epileptiform discharges.
Neurologic examination found her pupils to be equal, round, and reactive to light and accommodation. A nonpathological endpoint nystagmus was noted. Maddox rod testing demonstrated evidence of a left hyperphasia. By double Maddox rod testing, the patient demonstrated head tilt suggesting a left, fourth cranial-nerve palsy. Fundoscopic examination revealed flat discs, with sharp margins. The maculae were normal appearing bilaterally. No gross hemianopsia was noted on visual-field testing. She had a mild ptosis on the right side. There were no focal sensory or motor abnormalities. The Babinski sign was elicited on the left.
Neuropsychological evaluation was requested. Her performance on Wechsler Adult Intelligence Scale–Revised was suggestive of low-average performance, that is, verbal IQ score of 98 (45th percentile rank), performance IQ score of 77 (6th percentile rank), and a full-scale IQ of 88 (21st percentile rank). She demonstrated significant deficits in the Wisconsin Card Sort, deficits in visual perception, but normal language functioning.
The patient was diagnosed as having a mild dementia, with deficits in memory for recent events, visual spatial judgment, constructional praxis, abstract problem-solving ability with normal orientation, normal new learning and recall, verbal intellect, and language functioning. The diagnosis of Lhermitte's hallucinosis was based upon clinical and radiographic findings.
Discussion
New-onset visual hallucinations in the geriatric patient can pose a perplexing differential diagnosis for the clinician. Diagnosis of functional psychiatric disturbances requires the identification of several psychological symptoms in conjunction with the visual hallucinations. Hence, diagnosis of schizophrenia or other psychotic disorders would require the presence of formal thought disorder, bizarre delusions, bizarre or catatonic behavior, and/or negative symptoms in the context of functional decline. Often, there is a past psychiatric history or familial history of psychotic disorder. Diagnosis of conversion disorder rests upon exclusion of physical causes and establishment of a temporal relationship of the visual hallucinations with psychological conflict or stress. Our patient denied any conflicts or stressors. Furthermore, she displayed no evidence of secondary gains to suggest factitious disorder or malingering, nor did she have a history of somatization.
Isolated visual hallucinations, that is, in the absence of commensurate psychological symptoms, are not characteristic of psychiatric disorders.2 One exception might be the brief visual hallucinations that reportedly occur with widowhood.3,4 However, in such cases, elderly widows demonstrate grief and intense longing in association with the visual images of the deceased spouse. Such images are usually not distressing to the patient, and tend to resolve with appropriate resolution of appropriate grief reactions.3
Visual hallucinations often suggest a broad range of "organic" conditions. For example, visual hallucinations in the context of an altered sensorium is suggestive of delirium; new-onset visual hallucinations temporally related to initiation of or dose increases in medications, for example, carbidopa/levodopa, suggests a medication-induced hallucinosis. Hallucinations can occur in association with the aura of migraine and seizures but often are accompanied by altered states of consciousness and/or postictal phenomena.5
Other conditions associated with the emergence of visual hallucinations include visual disturbances and sensory deprivation. In fact, visual hallucinations have been reported among patients with retinal degeneration, cataracts, and in those with lesions of the optic tracts.6 Although there is disagreement about diagnostic criteria, the eponymous Charles Bonnet syndrome has been ascribed to visual hallucinations arising in the context of diminished peripheral visual acuity with a clear sensorium and preserved intellectual functioning.7–9 Hence, visual hallucinations can arise in patients with opthamologic and neural-visual lesions.2
Our patient clearly demonstrated a mild degree of dementia, but her deficits did not conform to a particular syndrome or localizing pattern. There was some evidence of prominent spatial and constructional deficits, along with some features of frontal lobe dysfunction. While visual hallucinations can accompany dementia, the hallucinations occur in the context of prominent memory disturbances in addition to aphasia, agnosia, apraxia, or other signs of deficits in "higher" cortical functioning. Our patient's deficits did not appear to follow this pattern. The possibility of visual hallucinations predating cognitive deficits in Alzheimer's dementia has been reported.10,11 However, such patients will develop the full spectrum of clinical features characteristic of dementia with time. In the present case, the preservation of memory argued against the diagnosis of Alzheimer's dementia, and there was no decline in her cognitive capabilities with time.
Instead, the report of abrupt onset of hallucinations and transient "confusion" was more suggestive of a vascular process. Visual hallucinations have been reported in cases of vascular dementia.5,12 Such phenomena can occur in association with infarcts in cortical regions as well as noncortical regions. Lesions of the primary occipital striate cortex or surrounding peristriate regions are usually associated with unformed or poorly formed visual hallucinations,5 for example, flashes of light, lines, and disengaged images. Complex visual hallucinations can occur in patients with occipital lobe infarcts,13,14 in addition to those with homonymous field defects due to trauma and mass lesions.15 However, other researchers have suggested that visual hallucinations can occur in patients with lesions along any portion in the visual pathways, resulting in visual loss.16 However, CT scan and MRI of the brain failed to demonstrate lesions in the visual pathways or occipital lobe of our patient.
Infarcts in the region of the midbrain or brainstem have been associated with well-formed images of animals, people, and lilliputian images, much as were reported by our case. Such well-formed hallucinations, in conjunction with brainstem or midbrain lesions, have been referred to as Lhermitte's (or peduncular) hallucinosis. Such hallucinations occur in the context of dementia that is mild in severity. Rather than being distressed about such hallucinations, often such hallucinations are recognized as unreal or result in a silly, inappropriate affect, as was noted in this case. Since the original description by Lhermitte, rare cases of hallucinosis involving traditionally nonvisual areas of the midbrain and pons have been reported.17–20
The pontine lesions reported in the MRI of our patient may be the neuropathologic correlate of her hallucinations. There are a small number of fibers coursing from the superior colliculus and descending ipsilaterally to terminate in the dorsolateral pontine nuclei in the region of the cerebellar peduncle.21 These fibers, along with fibers from the pontine nuclei, can transmit optic impulses to restricted regions of the cerebellum. Hallucinations generally occur with bilateral midbrain or pontine lesions.22 Unilateral lesions, as in our case, have also been associated with reports of visual hallucinations.17 The exact mechanism for the hallucinations with such lesions is unknown. It may be that when "normal" afferent input is decreased, for example, by diminished visual acuity or disruption of normal visual impulses by damaged visual pathways, spontaneous cerebral activity of the visual system is disinhibited or "released," resulting in hallucinations.9,18,23 The elderly patient may be particularly vulnerable to a "release" of images produced by disruptions in normal afferent input.24 However, given that such cases are rare, it may be that cerebral pathology, which can occur with age, may render some geriatric patients vulnerable to the release phenomena accompanying pontine lesions. Certainly in our case, there was evidence of diffuse microvascular ischemic changes noted on CT and MRI.
An attenuation of visual phenomena occurred with correction of the patient's double vision. She was prescribed enteric-coated aspirin (325 mg/day). She was also treated with nortriptyline (50 mg qd) to reduce depressive symptoms and reduce the severity and intensity of her headaches. A trial of risperidone was begun but was inefficacious in reducing the visual hallucinations. Reports of the efficacy of antipsychotic medications helping patients experiencing such visual hallucinations are lacking.25 Psychotherapy was helpful in clarifying these phenomena for the patient, relating them to changes within her brain. She was discouraged to learn about the microvascular ischemia and feared having further lesions with psychological/behavioral sequelae. Treatment was also directed at developing behavioral strategies to improve memory, for example, keeping a calendar and keeping a notebook to facilitate day-to-day activities, keeping appointments, etc. Psychotherapy may be effective in facilitating better understanding of the illness, may diminish associated patient distress or hallucination-related behaviors that can be potentially harmful, and may be effective in treating the complications of the illness (e.g., depression).25
Multiple neurologic disturbances can be associated with new-onset visual hallucinations in the elderly. The consultation-liaison psychiatrist can assist with the workup of possible etiologies, thereby preventing the mismanagement of elderly patients presenting with visual hallucinations. Although rare, the emergence of new-onset visual hallucinations in the elderly, especially with commensurate symptoms suggesting mild dementia, should prompt evaluation for Lhermitte's hallucinosis.
REFERENCES
-
Lhermitte J: Syndrome de la calotte du pedoncule cerebral. Les troubles psycho-sensoriels dans les lesions du mesocephale. Rev Neurol (Paris) 1922; 38:1359–1365
-
Lessell S, Lessell IM, Glaser JS: Topical diagnosis: retrochiasmal visual pathways and higher cortical function, in Clinical Opthamology, Vol 2, edited by Duane TD, Jaiger EA. Philadelphia, PA, JB Lippincott, 1988, pp. 1–24
-
Adair DK, Keshavan MS: The Charles Bonnet syndrome and grief reaction (letter). Am J Psychiatry 1988; 145:895
-
Olson PR, Suddeth JA, Peterson PJ, et al: Hallucinations of widowhood. J Am Geriatr Soc 1985; 33:543–547[Medline]
-
Cummings JL, Miller BL: Visual hallucinations—Clinical occurrence and use in differential diagnosis. West J Med 1987; 146:46–51[Medline]
-
White NJ: Complex visual hallucinations in partial blindness due to eye disease. Br J Psychiatry 1980; 136:284–286[Abstract/Free Full Text]
-
Gold K, Rabins PV: Isolated visual hallucinations and the Charles Bonnet syndrome: a review of the literature and presentation of six cases. Compr Psychiatry 1989; 30:90–98[Medline]
-
Pliskin NH, Kiolbasa TA, Towle VL, et al: Charles Bonnet syndrome: an early marker for dementia? J Am Geriatr Soc 1996; 44:1055–1061
-
Rosenbaum F, Harati Y, Rolak L, et al: Visual hallucinations in sane people: Charles Bonnet syndrome. J Am Geriatr Soc 1987; 35:66–68[Medline]
-
Crystal HA, Wolfson LI, Ewing S: Visual hallucinations as the first symptom of Alzheimer's disease (letter). Am J Psychiatry 1988; 145:1318
-
Haddad PM, Benbow SM: Visual hallucinations as the presenting symptom of senile dementia. Br J Psychiatry 1992; 161:263–265[Abstract/Free Full Text]
-
Cummings JL, Miller B, Hill MA, et al: Neuropsychiatric aspects of multi-infarct dementia and dementia of the Alzheimer type. Arch Neurol 1987; 44:389–393[Abstract/Free Full Text]
-
Kolmel HW: Coloured patterns in hemianopic fields. Brain 1984; 107:155–167[Abstract/Free Full Text]
-
Lance JW: Simple form hallucinations confined to the area of specific visual field defect. Brain 1976; 99:719–734[Free Full Text]
-
Kolmel HW: Complex visual hallucinations in the hemianopic field. J Neurol Neurosurg Psychiatry 1985; 48:29–38[Abstract/Free Full Text]
-
Lepore FE: Spontaneous visual phenomena with visual loss:104 patients with lesions of retinal and neural afferent pathways. Neurology 1990; 40:444–447
-
de la Fuente Fernandez R, Lopez JM, Rey del Corral P, et al: Peduncular hallucinosis and right hemiparkinsonism caused by left mesencephalic infarction (letter). J Neurol Neurosurg Psychiatry 1994; 57:870
-
Feinberg WM, Rapcsak SZ: Peduncular hallucinosis following paramedian thalamic infarction. Neurology 1989; 39:1535–1536
-
McKee AC, Levine DN, Kowall NW, et al: Peduncular hallucinosis associated with isolated infarction of the substantia nigra pars reticulata. Ann Neurol 1990; 27:500–504[Medline]
-
Van Bogaert L: L'hallucinose pedonculaire. Rev Neurol (Paris) 1927; 43:608–617
-
Barr ML, Kiernan JA (eds): Visual system, in The Human Nervous System—An Anatomical Viewpoint, 4th Edition. Philadelphia, PA, Harper & Row, 1983, pp. 294–309
-
Geller TJ, Bellur SN: Peduncular hallucinosis: magnetic resonance imaging confirmation of mesencephalic infarction during life. Ann Neurol 1987; 21:602–604[Medline]
-
West LJ (ed): A general theory of hallucinations and dreams, in Hallucinations. New York, Grune & Stratton, 1962, pp. 273–291
-
Raschka LB, Schlager FM: On the diversity of visual hallucinations. Can J Psychiatry 1982; 27:48–51[Medline]
-
Tueth MJ, Cheong JA, Samander J: The Charles Bonnet syndrome: a type of organic visual hallucinosis. J Geriatr Psychiatry Neurol 1995; 8:1–3
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