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Visual Hallucinations in Parkinson's Disease

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Visual Hallucinations in Parkinson's Disease J Neurol Neurosurg Psychiatry 2001;70:727–733 727 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.70.6.727 on 1 June 2001. Downloaded from Visual hallucinations in Parkinson’s disease: a review and phenomenological survey J Barnes, A S David Abstract According to the DSM IV criteria,1 a hallucina- Objectives—Between 8% and 40% of pa- tion is “a sensory perception without external tients with Parkinson’s disease undergo- stimulation of the relevant sensory organ” dis- ing long term treatment will have visual tinguishing it from an illusion, in which an hallucinations during the course of their external stimulus is perceived but then misin- illness. There were two main objectives: terpreted. Although separate, the phenomena firstly, to review the literature on Parkin- often overlap, with illusions leading to halluci- son’s disease and summarise those factors nations and vice versa. One of the commonest most often associated with hallucinations; neurological conditions associated with visual secondly, to carry out a clinical compari- hallucinations is Parkinson’s disease. Although son of ambulant patients with Parkinson’s there are reports of visual hallucinations in disease with and without visual hallucina- Parkinson’s disease before the dopamine era,2 tions, and provide a detailed phenomeno- the phenomena have only been noted as a fre- logical analysis of the hallucinations. quent complication of the disorder since Methods—A systematic literature search levodopa treatment was introduced.3 using standard electronic databases of One categorisation of visual hallucinations is published surveys and case-control stud- “simple” versus “complex”. Simple hallucina- ies was undertaken. In parallel, a two stage tions are characterised by the absence of form, questionnaire survey was carried out and are often photopsias such as flashes of light based on members of a local branch of the or colour. Occasionally, geometric shapes are Parkinson’s Disease Society and followed described which move around in space. up with a clinical interview. Complex visual hallucinations are character- Results—The review disclosed common ised by visions that are clearly defined, have factors associated with visual hallucina- specific form, and can include animals, objects, tions in Parkinson’s disease including and humans. These two types tend to be seen greater age and duration of illness, cogni- as having localisation value: simple, pointing to 45 tive impairment, and depression and sleep occipital pathology whereas the complex type 67 disturbances. The survey comprised 21 are presumed to involve the temporal cortex, patients with visual hallucinations and 23 either directly or indirectly through modula- without. The hallucinators had a longer tory connections (as in peduncular hallucino- sis).910 duration and a greater severity of illness, 11 and tended to show more depressed mood In a recent review it was proposed that http://jnnp.bmj.com/ and cognitive impairment. The typical there were three basic mechanisms, which, visual hallucination in these patients is a alone or in combination, underlie complex complex visual image experienced while visual hallucinations with widely diVering they are alert and have their eyes open. causes: irritative processes acting on higher visual centres or pathways; defective visual Department of The image appears without any known Psychology, Oxford trigger or voluntary eVort, is somewhat processing (both peripheral and central); and Brookes University, blurred, and commonly moves. It stays brainstem modulation of thalamocortical con- Gipsy Lane, present for a period of “seconds” or nections. on October 2, 2021 by guest. Protected copyright. Headington, Oxford “minutes”. The content can be variable In this article we review surveys of visual OX3 0BP,UK hallucinations in patients with Parkinson’s dis- J Barnes within and between hallucinators, and ASDavid includes such entities as people, animals, ease and contribute a survey of our own. The buildings, or scenery. These features re- objectives were firstly, to characterise the typi- Division of semble those highlighted in hallucinations cal features of the hallucinations in Parkinson’s Psychological in the visually impaired (Charles Bonnet’s disease and summarise their associations; and Medicine, Section of secondly, to compare these findings to those Cognitive syndrome). Conclusion—A consistent set of factors derived from descriptions of visual hallucina- Neuropsychiatry, GKT tions in other disorders. The aim was to exam- School of Medicine are associated with visual hallucinations and Institute of in Parkinson’s disease. The results of the ine whether the phenomena in diVerent Psychiatry, London phenomenological survey and those of settings have characteristics in common despite SE5 8AF, UK visual hallucinations carried out in other varied causes and whether inferences about J Barnes settings suggest a common physiological their pathophysiology can be made on this basis. Correspondence to: substrate for visual hallucinations but Professor A S David with cognitive factors playing an as yet [email protected] unspecified role. (J Neurol Neurosurg Psychiatry 2001;70:727–733) Literature review Received 15 May 2000 and A systematic literature search using in final form 6 November 2000 Keywords: visual hallucinations; Parkinson’s disease; MEDLINE and EMBASE databases was Accepted 22 November 2000 phenomenology carried out on papers published in English www.jnnp.com 728 people may be responsible for confusion in elderly at length. with sleep disturbances has also been discussed hallucinations. systems together have been implicated in illusions plusPrevalence rates hallucinations, ofPrevalence 11/89 (12.3%) for visual after 1991. maries the results of included studies published oughly reviewed by Cummings. studies includingphenomena. those These beforequalitative criteria 1990 informationnosis (thor- excluded on of Parkinson’s most abnormalterion disease was was some visual information reachedreports on and and how reviews. the The minimum diag- control quality cri- studiesand were “visual”. included, Case butterms series, were not surveys, Parkinson(s) case between and and hallucination(s)/ case- 1966 and December 1999. Search ences in drug history. hallucinators have seldom shownComparisons major di ofMEDICATION hallucinators and non- tively reviewed elsewhere. with Parkinson’s disease and have beenmary exhaus- deficits in visual processing are associated (11.6%) for hallucinations eral be associated with visual hallucinationssuch in as gen- visual impairmentvisual have hallucinations been (table foundconsistent to 1). results Some in features tors terms and of 806The risk review—based comparison on factors a subjects— total for Risk of factors showed 316 hallucina- being labelled as “mad”. view studies, possibly because patients may fear al No hallucinations were provoked. Fernandez levodopa infusions in a placebo controlledhallucinations trial. whopatients were with Parkinson’s given disease high with daily dose “presence”. Aarsland real percepts (illusions)frightening to vague “visions”, feelingsphenomena through of range a distortions from bizarre, of complex, and not simply relate to highof levels of immobility. dopaminergic Hence visualclinical state hallucinations it do was morebetween likely to hallucinations be in periods and medication or sistent. Goetz dopamine agonists) butuse the results of are incon- anticholinergic drugs (and primary reporting is a possible problem, severe hallucinationssight, and and another delusions. 14(9.8%) Under- patients (6%) had hadwith hallucinations more Parkinson’s disease. with Ofmunity retained these, based 23 study in- patients of 235 patients in Norway nations between 8.8% and 44%. veys give prevalence estimates ofples visual of halluci- chronically treated patients. Recent sur- 29 found that when there was an apparent link 21 and in other neurological disorders. 25 11 24 and cholinergic et al 27 Some authors noted increased 28 studied five non-demented 16 et al Anticholinergic agents 20 26 13 23 carried out a com- are typical of sam- The possible link and serotonergic www.jnnp.com 15 12 3 14–19 Table 1 sum- even in inter- or 23/189 The visual 22 V Pri- er- et Table 1 Summary of studies of visual hallucinations in Parkinson’s patients with disease showing clinical associations Association with visual hallucinations Controls/ No of comparison Cognitive Disease severity/ Sleep Study patients group Sample Age Duration Medication dose impairment disability Depression disturbance Comments Fernandez et al 199229 30 20 Random clinical + − − + − − − 8 patients’ VHs associated with oV periods Haeske-Dewick 199515 16 20 Clinic survey: initial mailing + − − + + − (when adjusted for age) ? Not premorbid IQ Klein et al 199731 29 58 Prospective clinical ** − − + − + *Matched for age/duration. MMSE fell over follow up; CT measures not diVerent Sanchez-Ramos et al 55 214 Consecutive clinical + − + + + + (history) + Higher anticholinergic and 199616 bromocriptine in VH-ve group Graham et al 199717 32 97 Clinic survey ? Trend + dopamine + late onset + motor disorder in Less in late onset ? Main analysis early/late onset of agonists only early onset halls v duration matched controls Inzelberg et al 199853 35 76 Consecutive clinical − − + (lifetime) + − + (reported in AH+VH ? Emphasis on combined auditory 10Aud +VH group only) and visual hallucinations Barnes, David Aarsland et al 199920 23 212 Population based + − − + + + + First population
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