Hallucinations: Clinical aspects and management

Harding and colleagues 20 reported a strong correlation between Lewy bodies located in the temporal structures specifically in the amygdala and the parahippocampus and well-formed visual hallucinations. Visual hallucinations also occur in up to half of patients with Parkinson's disease. Posterior cortical atrophy is another neurodegenerative syndrome associated with visual hallucinations and parkinsonian symptoms.

The chief pathologic features of posterior cortical atrophy are neurofibrillary tangles and senile plaques similar to those seen in dementia of the Alzheimer's type but with a distribution limited to the occipital and parietal lobes. Patients with posterior cortical atrophy may present with visual agnosia, anomia, apraxia, and features of Gerstmann syndrome. The Charles Bonnet syndrome CBS involves the occurrence of visual hallucinations in the visually impaired.

Any cause of visual impairment including macular degeneration, glaucoma, cataracts, cerebrovascular disease, and tumors may be associated with CBS.

What Are Visual Hallucinations?

WebMD explains the different types of hallucinations, including hearing voices, visual hallucinations, and smelling an odor that isn't there. A hallucination is a perception in the absence of external stimulus that has qualities of real perception. Hallucinations are vivid, substantial, and are perceived to.

Charles Bonnet syndrome has been thought of as a nonpsychiatric cause of visual hallucinations; while this remains true, there is growing evidence that preexisting dementia or cognitive impairment may predispose a patient to the development of CBS. The visual hallucinations in CBS have been described as clear and detailed; they often involve people, faces, animals, and inanimate objects.

While patients may initially be unaware that these images are indeed hallucinations, one of the hallmarks of CBS is the eventual development of insight regarding their visual hallucinations. The strongest risk factors for CBS include bilateral visual impairment, declining visual acuity, cerebral damage, cognitive defects, social isolation, and sensory deprivation. Antipsychotics and selective serotonin reuptake inhibitors have been used to treat CBS, but there is no clear evidence to support this approach.

Anton's syndrome is a rare condition in which patients with cortical blindness deny that they have visual loss. This presentation has been described as a combination of anosognosia and confabulation. The problem may only be discovered when the patient is found running into or falling over objects while reporting odd or fantastical reasons why they did not see the object with which they collided. The mechanism that underlies Anton's syndrome remains unclear, but it is thought to be related to infarction of the primary visual cortex Brodmann's area 17 with preserved function of the visual association cortices.

These patients may have alterations in emotional reactivity that predispose them to denial. Another hypothesis suggests that there may be a synesthetic translation of the remaining senses into mental images that are perceived by the patient as vision. Visual hallucinations caused by seizures have often been described as simple, brief, and consistent for each patient; they usually consist of small, brightly colored spots or shapes that flash.

Hearing voices

Those that remain isolated in 1 visual field suggest seizure activity that originates on the contralateral side. Complex visual hallucinations due to seizures are thought to require the involvement of the visual association cortex. Since occipital seizures are frequently accompanied by a postictal headache, they may be difficult to distinguish from migraines, creating confusion and the delay of appropriate treatment. While neurologic literature indicates that visual hallucinations associated with seizures are simple, there is a growing body of work that describes complex, formed visual hallucinations as ictal, peri-ictal, and intra-ictal phenomena.

The occurrence of complex visual hallucinations as a symptom of epilepsy can be a point of disagreement between neurologists and psychiatrists. Visual hallucinations associated with migraine headaches can be a classic aura of migraine as well as a less common manifestation such as migraine coma and familial hemiplegic migraine. Variations of this classic picture such as colored patterns also occur.

What Are Hallucinations?

The simple visual hallucinations described above are the most common, but more complex hallucinations can occur in migraine coma and familial hemiplegic migraine. Hadjikhani and colleagues 43 used functional magnetic resonance imaging fMRI to show that migraine aura is likely caused by spreading cortical depression.

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This phenomenon involves a brief period of hyperperfusion followed by a slow spreading wave of hypoperfusion. These events are thought to be due to a neuronal dysfunction rather than to a primary vascular event. Peduncular hallucinosis is characterized by visual hallucinations that arise following an infarct of the midbrain. It was originally described in by Lhermitte and has since been the topic of many case reports. The mechanism has been difficult to pinpoint since the literature features a wide variety of lesions. Lesions may involve the cerebral peduncles, but most often involve the reticular formation or its targets.

Each hallucination may last from minutes to hours, often occurring in the evening. Patients eventually develop insight into their hallucinations, and they may find them interesting or amusing. Hypnagogic hallucinations are visual and auditory perceptions that occur during sleep onset, while hypnopompic hallucinations occur on awakening.

They are usually visual and may be bizarre and dreamlike, but with some preservation of consciousness. It was also shown that patients with insomnia, excessive daytime sleepiness, or mental disorders were more likely to experience hallucinations. Many drugs are labeled as hallucinogens because they alter perceptions, 48 although true hallucinations are perceptions in the absence of any actual stimulus.

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Hallucinogenic drugs including mescaline, psilocybin, and lysergic acid diethylamide [LSD] are agonists of serotonin 5-HT 2A receptors; they do not always produce true hallucinations unless they are used at high doses. The effects also depend to some degree on the mood of the user and the situation in which the drug is used. Other drugs often considered to be hallucinogenic include phencyclidine PCP , ecstasy, atropine, and dopamine agonists.

Tumors that lie along, or compress, the optic path may cause visual hallucinations. In one case series, 13 of 59 patients with temporal lobe tumors experienced visual hallucinations. The majority of these visual hallucinations are thought to be related to seizure activity caused by the tumor. A handful of inborn errors of metabolism may cause visual hallucinations. While these are quite rare, they are nonetheless important to consider because patients with inborn errors of metabolism may present with hallucinations at a time when their disease is treatable and when serious neurologic damage has not yet occurred.

Creutzfeldt-Jakob disease CJD is a fatal progressive neurodegenerative illness caused by central nervous system prion infection. Symptoms of CJD may also include visual hallucinations, especially in the Heidenhain variant of the illness. Visual effects may include color changes, visual field defects, visual agnosia, cortical blindness, metamorphopsia, and micropsia that progresses to the frank visual hallucinations characteristic of the Heidenhain variant.

Given the broad variety of potential etiologies of visual hallucinations outlined previously, it is clear that an accurate diagnosis is required before effective treatment can be initiated.

A thorough history and clinical examination are the most vital elements of a workup for visual hallucinations. Associated symptoms and characteristics of the visual hallucinations themselves may help direct diagnosis Table 1. The elicitation of signs or symptoms of psychosis, inattention, parkinsonism, impaired vision, or headache will narrow the diagnosis and prompt further diagnostic studies. An EEG is potentially the most revealing diagnostic study, since it can not only highlight seizure activity, but also detect delirium with theta-delta slowing , delirium tremens with rapid beta activity , and CJD with occipital periodic non-generalizing complexes.

Since effective treatment of visual hallucinations see Table 2 is entirely dependent on the underlying cause, care should be taken to ensure diagnostic accuracy, especially since treatments that may be beneficial for one cause of visual hallucinations may exacerbate another. For example, benzodiazepines are the treatment of choice for delirium tremens, but they will almost certainly worsen a delirium due to any other cause. These medications are also beneficial for the management of delirium in which hallucinations are thought to be due to release of endogenous dopamine , with intravenous haloperidol having the most evidence for safety and efficacy.

Unfortunately, due to their dopamine-blocking activity, most neuroleptics will significantly exacerbate parkinsonian symptoms in patients with DLB or dementia associated with Parkinson's disease.

What Causes Hallucinations?

This condition causes people with vision problems like macular degeneration , glaucoma , or cataracts to see things. At first, you may not realize it's a hallucination, but eventually, you figure out that what you're seeing isn't real. The seizures that go along with this disorder can make you more likely to have hallucinations. The type you get depends on which part of your brain the seizure affects.

First, your doctor needs to find out what's causing your hallucinations. He'll take your medical history and do a physical exam. He'll ask about your symptoms. You may need tests to help identify the problem. For instance, an EEG , or electroencephalogram , checks for unusual patterns of electrical activity in your brain. It could show if your hallucinations are due to seizures.

You might get an MRI , or magnetic resonance imaging , which uses powerful magnets and radio waves to make pictures of structures inside your body. It can find out if a brain tumor or something else, like an area that's had a small stroke , could be causing your hallucinations.

What causes hallucinations?

Your doctor will treat the condition that's causing the hallucinations. The treatment can include things like:. Your doctor may prescribe pimavanserin Nuplazid. Your doctor will be able to recommend the best form of treatment for you once he or she figures out what is causing your hallucinations. Treatment for your hallucinations will depend entirely on their underlying cause. For example, if you are hallucinating due to severe alcohol withdrawal, your doctor might prescribe medication that slows down your nervous system.

An accurate diagnosis is very important for treating the condition effectively. Counseling might also be part of your treatment plan. This is particularly true if the underlying cause of your hallucinations is a mental health condition. Speaking with a counselor can help you get a better understanding of what is happening to you.


A counselor can also help you develop coping strategies, particularly for when you are feeling scared or paranoid. Recovery from hallucinations depends on the cause. If you are not sleeping enough or you are drinking too much, these behaviors can be adjusted. If your condition is caused by a mental illness, like schizophrenia, taking the right medications can improve your hallucinations significantly.

By seeing a doctor immediately and following a treatment plan, you are more likely to have a positive long-term outcome. Psychosis is a serious mental disorder characterized by thinking and emotions that indicate the person experiencing them has lost contact with reality. Schizophrenia is a serious psychiatric disorder characterized by the person slowly losing contact with reality, often experiencing delusions or hallucinations.

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