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CHARLES BONNET CHARLES BONNET SYNDROME SYNDROME Dr. Syed Faheem Shams Dr. Syed Faheem Shams Student of MD (Part-II) Student of MD (Part-II) Department of Psychiatry, Department of Psychiatry, BSMMU BSMMU

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CHARLES BONNET CHARLES BONNET SYNDROMESYNDROME

Dr. Syed Faheem ShamsDr. Syed Faheem ShamsStudent of MD (Part-II) Student of MD (Part-II)

Department of Psychiatry, BSMMUDepartment of Psychiatry, BSMMU

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De Morsier (1938) used this eponym to De Morsier (1938) used this eponym to describe a syndrome of complex V.H in describe a syndrome of complex V.H in mentally normal, but usually visual mentally normal, but usually visual impaired, old people.impaired, old people.

Podoll Podoll et alet al ( 1990) had given an ( 1990) had given an operational definition which requires operational definition which requires

--- the presence of V.H --- the presence of V.H --- --- clear consciousnessclear consciousness --- --- absence of cerebral pathology or absence of cerebral pathology or

psychosispsychosis. . ---Visual impairment is considered a usual ---Visual impairment is considered a usual

but not necessary concomitant. but not necessary concomitant.

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History of Charles Bonnet History of Charles Bonnet SyndromeSyndrome

Swiss naturalist and Swiss naturalist and philosopher Charles Bonnet.philosopher Charles Bonnet.

Described the condition in Described the condition in

1769. He first documented it in 1769. He first documented it in his 89-year-old grandfather his 89-year-old grandfather Charles Lullin, who was nearly Charles Lullin, who was nearly blind from blind from cataractscataracts but but perceived men, women, birds, perceived men, women, birds, carriages, buildings, tapestries, carriages, buildings, tapestries, and scaffolding patternsand scaffolding patterns..

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PREVALENCE RATEPREVALENCE RATE

1-2% ( Berrios & Brook, 1984; Podoll 1-2% ( Berrios & Brook, 1984; Podoll et et alal.,1990)..,1990).

3.5% in old age. 10-15% in visual impaired 3.5% in old age. 10-15% in visual impaired elder patients.elder patients.

a recent Australian study has found the a recent Australian study has found the prevalence to be 17.5%. Two Asian studies, prevalence to be 17.5%. Two Asian studies, however, report a much lower prevalence. however, report a much lower prevalence.

Non-reporting is thought to be as a result of Non-reporting is thought to be as a result of sufferers being afraid to discuss the symptoms sufferers being afraid to discuss the symptoms out of fear that they will be labeled insane.out of fear that they will be labeled insane.

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Causes of Charles Bonnet Causes of Charles Bonnet syndromesyndrome

Little is known about how the brain stores the Little is known about how the brain stores the information it gets from the eyes and how we information it gets from the eyes and how we use this information to help us create the use this information to help us create the pictures we see. There is some research which pictures we see. There is some research which shows that, when we see, the information from shows that, when we see, the information from the eyes actually stops the brain from creating the eyes actually stops the brain from creating its own pictures. When people lose their sight, its own pictures. When people lose their sight, their brains are not receiving as many pictures their brains are not receiving as many pictures as they used to, and sometimes, new fantasy as they used to, and sometimes, new fantasy pictures or old pictures stored in our brains are pictures or old pictures stored in our brains are released and experienced as though they were released and experienced as though they were seen.seen.

(Deafferentation (Deafferentation hypothesis) .hypothesis) .

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When do they occur?When do they occur? These experiences seem to happen when These experiences seem to happen when

there is not much going on, for example there is not much going on, for example when people are sitting alone, somewhere when people are sitting alone, somewhere quiet which is familiar to them or when quiet which is familiar to them or when they are in lying in bed at night.they are in lying in bed at night.

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In particular, central vision loss due to a In particular, central vision loss due to a condition such as condition such as macular degenerationmacular degeneration combined with peripheral vision loss from combined with peripheral vision loss from glaucomaglaucoma may predispose to CBS, may predispose to CBS, although most people with such deficits do although most people with such deficits do not develop the syndrome. The syndrome not develop the syndrome. The syndrome can also develop after can also develop after bilateral optic nerve bilateral optic nerve damage due to methyl alcohol poisoning damage due to methyl alcohol poisoning

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all ages. ( visionaustralia).all ages. ( visionaustralia). common in people with age-related common in people with age-related

macular degeneration. macular degeneration. usually stop within a year to 18 months.usually stop within a year to 18 months.

Age of onsetAge of onset

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Visual Hallucination Visual Hallucination starts suddenly, lasts for only brief periods (seconds or starts suddenly, lasts for only brief periods (seconds or

minutes) and are more common in the evening or at minutes) and are more common in the evening or at night.night.

Transient/ persistentTransient/ persistent well formedwell formed VividVivid 1/3rd are simple photopsia (flashes of light), lines or 1/3rd are simple photopsia (flashes of light), lines or

patterns (like fortification spectra, zigzags, or circles). patterns (like fortification spectra, zigzags, or circles). Complex( animals, people , buildings or scenes)Complex( animals, people , buildings or scenes) Content – variable/ stereotypedContent – variable/ stereotyped aware that these images are not realaware that these images are not real pleasant/ distressing.pleasant/ distressing.

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""Lilliputian hallucinationsLilliputian hallucinations" " (hallucinations in which the (hallucinations in which the

characters or objects are smaller characters or objects are smaller than normal).than normal).

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Insight – Partial or complete.Insight – Partial or complete.Aware that these images are not Aware that these images are not

real.real.

Sometimes can make the image Sometimes can make the image disappear by closing their eyes. disappear by closing their eyes.

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Differential Differential DiagnosisDiagnosis

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DLB’s ( Dementia with Lewy bodies)—DLB’s ( Dementia with Lewy bodies)—

2 features are essential—2 features are essential— progressive cognitive decline with pronounced variations progressive cognitive decline with pronounced variations

in attention and alertness.in attention and alertness. Recurrent V.H – well formed, detailed.Recurrent V.H – well formed, detailed. Spontaneous motor features of ParkinsonismSpontaneous motor features of Parkinsonism Other features – Repeated falls, syncope, transient loss Other features – Repeated falls, syncope, transient loss

of consciousness, neuroleptic sensitivity, Systematized of consciousness, neuroleptic sensitivity, Systematized delusions and hallucinations in other modalitiesdelusions and hallucinations in other modalities

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Acute confusional state( delirium)Acute confusional state( delirium)

onset of clinical features- rapid with fluctuations in severity over onset of clinical features- rapid with fluctuations in severity over minutes and hoursminutes and hours

Impaired level of consciousness with reduced ability to direct, Impaired level of consciousness with reduced ability to direct, sustain and shift attention.sustain and shift attention.

Global impairment of cognition with disorientation.Global impairment of cognition with disorientation. Impairment of recent memory, abstract thinking.Impairment of recent memory, abstract thinking. Disturbance in sleep cycle with nocturnal worsening of symptoms,Disturbance in sleep cycle with nocturnal worsening of symptoms, psychomotor agitationpsychomotor agitation emotional labilityemotional lability perceptual distortions, perceptual distortions, IllusionsIllusions Hallucinations characteristically visualHallucinations characteristically visual Speech- incoherentSpeech- incoherent thought disorders- may be presentthought disorders- may be present

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SchizophreniaSchizophrenia

Complex partial seizureComplex partial seizure

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InvestigationsInvestigations

EXCLUDE ---EXCLUDE ---

Psychosis Psychosis

Impaired sensoriumImpaired sensorium

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Investigations Investigations (contd.)(contd.)

DementiaDementia

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Investigations Investigations (contd.)(contd.)

EpilepsyEpilepsy

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InvestigationsInvestigations(contd.)(contd.)

IntoxicationIntoxication

Metabolic derangementMetabolic derangement Focal neurological illness.Focal neurological illness.

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InvestigationsInvestigations(contd.)(contd.)

Eye testing Eye testing EEG- some abnormalities may be found.EEG- some abnormalities may be found.

( Podol ( Podol et alet al, 1990)., 1990).

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Reassurance. Reassurance. (For those experiencing CBS, (For those experiencing CBS, knowing that they are suffering knowing that they are suffering from this syndrome and not a from this syndrome and not a

mental illness seems to be mental illness seems to be the best the best treatmenttreatment so far, as it improves so far, as it improves

their ability to cope with the their ability to cope with the hallucinations).hallucinations).

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Some common methodsSome common methods

Interrupting vision for a short time by Interrupting vision for a short time by closing the eyes or blinking. closing the eyes or blinking.

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When they occur, try to change things to When they occur, try to change things to see if this will help them disappear. For see if this will help them disappear. For example, if they happen in the dark, try example, if they happen in the dark, try switching a light on or if they happen in the switching a light on or if they happen in the light, try switching the light off. If the light, try switching the light off. If the person is sitting down when they happen, person is sitting down when they happen, try standing up. try standing up.

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Some people find that moving their eyes Some people find that moving their eyes helps (e.g.. from left to right or up and helps (e.g.. from left to right or up and down). down).

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Treatment of visual impairment Treatment of visual impairment whenever possible (e.g. removal of whenever possible (e.g. removal of

cataract).cataract).

AntipsychoticsAntipsychotics – Small dose – to – Small dose – to reduce distressing symptoms. reduce distressing symptoms.

A recent case report suggests A recent case report suggests selective serotonin reuptake inhibitselective serotonin reuptake inhibitorsors

may be helpful. may be helpful.

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PrognosisPrognosis

Resolves within 12-18 months.Resolves within 12-18 months. Vision restore, total blindness -------- V.H Vision restore, total blindness -------- V.H

improves.improves. Some authors suggested that these Some authors suggested that these

patients subsequently develop cerebral patients subsequently develop cerebral cortical pathology such as CVD, and it has cortical pathology such as CVD, and it has been reported as a C/F of Alzheimer’s been reported as a C/F of Alzheimer’s disease.( Crystal et al., 1988). and stroke. disease.( Crystal et al., 1988). and stroke. ( Ball, 1991).( Ball, 1991).

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ConclusionConclusion

When a patient presents with vivid visual When a patient presents with vivid visual hallucinations, a doctor probably considers hallucinations, a doctor probably considers common diagnosis such as delirium, common diagnosis such as delirium, dementia, psychosis, or a drug related dementia, psychosis, or a drug related condition. condition.

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The correct diagnosis of this The correct diagnosis of this distressing but not uncommon distressing but not uncommon

condition is of condition is of utmost importanceutmost importance, , considering the serious implications considering the serious implications

of the alternative diagnoses. . of the alternative diagnoses. . Clinicians must therefore be aware Clinicians must therefore be aware and ask elderly people with visual and ask elderly people with visual

impairment impairment whether they have whether they have hallucinations. hallucinations.

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THANK YOU ALLTHANK YOU ALL