Diagnosis and Treatment of Psychiatric Comorbidity in a Patient with Charles Bonnet Syndrome

Table 1

Chronological synopsis of signs and symptoms, tentative diagnoses, medication changes, and responses to psychopharmacologic treatment.

Date	Signs and symptoms	Tentative diagnoses and (differential diagnoses)	Psychopharmacologic and nonpsychopharmacologic treatments, if any	Responses to treatments, if any
1970s	Motorcycle collision requiring one week’s hospitalization. No known TBI was diagnosed. Note the large time lag between the collision and the symptoms that follow.	Postconcussive headache
1980s	Severe unilateral headaches	Migraines	Amitriptyline	Partial effective response, but patient discontinued it due to significant weight gain
1990s	Fainting episodes. When the patient stood for a long time, she would tumble down and get up. If she stood quickly, she would lose her vision.	Syncope—appeared to be familial
2007	Thought to be having seizures. These occurred when the patient was lying in bed. She would wake up and shake in the middle of the night. No loss of consciousness.	Epilepsy versus nonepileptic seizures	Levetiracetam	Continued having events where the patient had whole-body shaking, lasting 5 to 10 minutes and also shaking of her right hand, arm, and face. Following events, eyes were closed and she was very tired and slept for several hours. She had at least two of the right-sided events.
2008 Summer	Had an event where she was walking to the bathroom at night and crashed down on the floor; she had raccoon eyes and bruises and was hospitalized	Syncope diagnosed by tilt-table testing; simultaneously noted to be hypertensive	Not started on any medications during that hospitalization but advised to sit at the edge of the bed and stand up slowly.
2008 Fall	First complained of having comprehension difficulties and poor memory, citing difficulties doing the laundry. At times, she was incapable of using a coffee maker that she has used for a long time and her husband confirmed that those events were more frequently occurring. She had not been sleeping very well and had difficulties concentrating. She denied feeling depressed. Physical exam found no cog-wheeling but falling diffusely with positive Romberg's and her eyes closed. She also had difficulties performing tandem gait but was able to walk on her heels and toes.	Pseudodementia versus dissociative state versus adverse effect to treatment with clonazepam	Was on clonazepam during this time
April 2010	VEEG monitoring captured only NES.	NES	None
March 2011	Patient re-presented in outpatient clinic with chief complaint of headaches and did not have any significant NES spells.	Headaches; NES	While she did not have psychiatric care, she initiated both citalopram and clonazepam as prescribed by her primary care physician (PCP).	Continued to have falling episodes, dissociative episodes.
September 2011	Seen in outpatient neurology clinic with chief complaint of headache and worsening depth perception	Headaches; NES	Prescribed topiramate for headaches and considered amitriptyline, although patient was concerned about possibility of weight gain as had happened in the past. The patient was counseled on nonpharmacologic treatments of both anxiety and sleep hygiene.
June 2012	First described having more frequent falls as well as worsened headaches	Headaches; NES	Increased on topiramate and initiated hydroxyzine for moderate headaches and zolmatriptan for more severe headaches.	Did not exhibit significant clinical improvement
March to May 2013	Nightly hallucinations consisting of witnessing other people talking to each other, but never to her directly. These people never talked to her or told her to do things. She denied these as the typical AHs worrisome of primary thought disorders consisting of running commentary about the patient’s own behavior. The AHs were also never present in the absence of VHs. The VHs were nonhostile, but the patient’s emotions associated with them were of fear due to uncertainty of the intentions of the people she was experiencing. However, she “knew that these people weren’t really there” and that when she “turned on the lights, they would disappear.” She also described episodes where she was confused and had wandered about. Although she had been living in the same house for 37 years, it did not feel like the same house to her.	Dissociative episodes, Major Depression with Psychotic Features (schizophrenia)	The patient and her family thought that the hallucinations were associated with nortriptyline, and dosage was reduced to 10 mg PO at night	No significant changes from reduction in nortriptyline
November 2013	Scored PHQ-9 greater than 15 to be considered for evaluation with embedded psychiatric clinician within neurology department. Physical exam did not find any cog-wheeling, rigidity, shuffling gait, or gait instability. MSE revealed appearing younger than her stated age, anxious mood and flat affect, and thought content revealing the belief that “there are migrant French-Canadian workers at home threatening to hurt my family members.” She had seen them at least twice or thrice.; MOCA score of 20/30.	Pseudodementia, (Alzheimer’s, Charles Bonnet syndrome)	Re-did MRI and obtained dementia workup, including B12/folate, and other basic labs, which were all unremarkable.
January 2014	Had constellation of visual hallucinations, cognitive impairment, and history of multiple falls despite not having any clear Parkinsonian features on physical exam. Both the patient and her family were more significantly distressed by especially the AH component of her experiences, described as “little people threatening to do things to me or my family.” Worsening PHQ-9 and GAD-7 scores. MRI was unchanged compared to a year ago.	Major Depression with Psychotic Features, adverse effect of clonazepam, (Lewy-Body dementia, Alzheimer’s, and Primary Thought Disorder)	It was thought at this time that the patient’s distressing symptoms as well as psychotic symptoms could benefit from trial of quetiapine, to which the patient was naïve. Concurrently, we aimed to decrease clonazepam dosage from 3 mg to 2 mg per day over several weeks.
February 2014	“Everybody is noticing the difference with the Seroquel (quetiapine).” No longer had any AVH. Her quetiapine dosage had been titrated to effect to 200 mg PO QHS. Her PHQ-9 and GAD-7 scores were both 0. As a result, the patient stated that since she was doing so well, she declined formal MOCA retesting.	Major Depression with Psychotic Features, in partial remission; medication-induced falls and daytime grogginess and impaired concentration associated with clonazepam	Quetiapine titrated to effect to 200 mg PO QHS.; Patient had also tapered off clonazepam completely.	Both headaches and her memory complaints had also decreased.
April 2014	Described having horrible headaches and having hallucinations again: “I see people in the bathroom dressed in regular clothes, and they just stand there without talking to me.” The patient and her family did not seem to think that her headaches and hallucinations were connected. She also stated that sleep was awful despite taking hydroxyzine, melatonin, and quetiapine concurrently.	Major Depression with Psychotic Features; Charles Bonnet syndrome	Transitioned sertraline to venlafaxine using cross-titration.
May 2014	Headaches were “now gone completely” and her mood symptoms were also improved: “The new medication is a happy pill!” The patient described having minimal auditory and visual hallucinations which were “no longer bothering me.”	Major Depression with Psychotic Features, in remission; migraines, currently in remission; Charles Bonnet syndrome	Patient and family had requested trial of increasing quetiapine from 200 to 300 mg PO at night; titrated venlafaxine up to 225 mg PO daily.	Noticeable improvement with both increases of quetiapine and transition from sertraline to venlafaxine
June 2014	“Things are going very well”: she was no longer waking up in the morning with any headaches and felt comfortable with seeing “little happy faces at night” when either falling asleep or waking up. Given the patient’s historical lack of depth perception and known history of floaters, it was thought that Charles Bonnet syndrome could be considered due to response of patient’s AH to quetiapine but not her visual hallucinations.	Charles Bonnet syndrome; Major Depression with Psychotic Features	At this point, the patient’s venlafaxine dosage was 225 mg PO QDay and quetiapine dosage was between 300 and 400 mg PO at night.; The patient was educated about the possibility that she had Charles Bonnet syndrome in addition to meeting criteria for major depressive disorder with Psychotic Features and she was reassured.
September 2014	Significant improvement in mood symptoms, and clinical exam and family collateral information indicated her Major Depression was in remission. The patient’s medication dosages of venlafaxine 225 mg daily and 400 mg quetiapine at night were stable and did not cause any noticeable adverse effects. The patient was no longer distressed by the VH.	Charles Bonnet syndrome; Major Depression with Psychotic Features in remission	Discussion eventually trying to find the minimally effective dose—especially in the case of quetiapine, due to concerns for potential metabolic and extrapyramidal adverse effects. However, the patient and her family desired continuation of her current medications and dosages given lack of any psychiatric symptoms.