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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 4  |  Issue : 1  |  Page : 87-89

The brain sees what the eyes don't! visual hallucinations in a blind female suffering from schizophrenia


Department of Psychiatry, Seth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India

Date of Submission01-Aug-2019
Date of Decision25-Sep-2019
Date of Acceptance01-Oct-2019
Date of Web Publication30-May-2020

Correspondence Address:
Dr. Amey Yeshwant Angane
402, Dharam Palace, Shantivan, Borivali East, Mumbai - 400 066, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aip.aip_48_19

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  Abstract 


While visual hallucinations are more common in organic disorders, they have also been reported in 27% of patients in schizophrenia with a more severe psychopathological profile and a less favorable prognosis. There is literature on visual hallucinations in psychiatric illnesses, eye diseases, and organic disorders individually, but visual hallucinations in a psychiatric disorder with an eye disease have not been reported. Here, we report a 55-year-old female who developed complete blindness and was diagnosed with retinitis pigmentosa and macular degeneration at 8 years which is a case of schizophrenia for the past 30 years and presented with visual hallucinations for the past 1 year. She was successfully treated with antipsychotic medications.

Keywords: Blindness, retinitis pigmentosa, schizophrenia, visual hallucinations


How to cite this article:
Shah NT, Angane AY. The brain sees what the eyes don't! visual hallucinations in a blind female suffering from schizophrenia. Ann Indian Psychiatry 2020;4:87-9

How to cite this URL:
Shah NT, Angane AY. The brain sees what the eyes don't! visual hallucinations in a blind female suffering from schizophrenia. Ann Indian Psychiatry [serial online] 2020 [cited 2020 Oct 20];4:87-9. Available from: https://www.anip.co.in/text.asp?2020/4/1/87/285503




  Introduction Top


When noted by nonpsychiatrists, visual hallucinations often trigger requests for psychiatric consultation, although visual hallucinations are not pathognomonic of a primary psychiatric illness.[1]

Visual hallucinations have been reported in 27% of patients with schizophrenia and 15% of patients with affective psychosis.[2] They are often life-sized, detailed, and solid with three-dimensional shapes, depth, and distinct edges. The presence of visual hallucinations in psychosis has often been linked to a more severe psychopathological profile and to a less favorable prognosis. While there is enough literature on visual hallucinations in schizophrenia, literature for the same in blind schizophrenic patients is lacking.


  Case Report Top


A 55-year-old divorced female patient working as a telephone operator developed complete blindness at the age of 8 years when she was diagnosed with retinitis pigmentosa and macular degeneration in the ophthalmology outpatient department. She had a familial pattern of similar illness as her siblings also suffered from retinitis pigmentosa. She was initially brought to the psychiatry outpatient department 30 years back post her divorce with complaints of aggressive behavior over parents, suspiciousness that people were talking ill about her and wanted to harm, hearing of voices inaudible to others commenting on her actions, and sleep disturbances and was diagnosed with schizophrenia. She was following up regularly and was well maintained on tablet pimozide 4 mg. It was last year when without any apparent stressor, she presented with complaints of visual hallucinations. She could see her ex-lover's building in which there were men whom she assumed might be his friends. Their faces and figures were clearly visible to her, while some had a dusky complexion and some were fair. She was able to describe these men in terms of their built, clothes, and facial features and expressions. She claimed that she had cameras installed in her eyes through which she could see them. They were trying to entertain her by jumping, dancing, and making her laugh. Gradually, she would try to ignore them, but they would get angry and undress themselves in front of her and try to harm her with a knife to get her attention. They would even follow her at work and in the taxi while commuting. She claimed that these people had installed cameras at work and at home through which they kept an eye on her and would flash lights so bright in her eyes giving her a headache. Among twenty of these friends, there were two who followed her with mangalsutras and wanted to marry her. She could also see them staring at her while bathing. These visual hallucinations were present throughout the day until she fell asleep. Due to these distressing images, she had contemplated committing suicide. Decreased self-care and sleep disturbances were also present. A past medical history revealed that she was a known case of hypertension and hypothyroidism well maintained on medications with a regular checkup. There was a family history of psychosis in her father and maternal cousin sister who were well maintained on the treatment.

Due to a breakthrough episode and nonavailability of tablet pimozide, it was stopped and tablet risperidone 2 mg was added, which was titrated up to 6 mg. Furthermore, tablet haloperidol 5 mg was added and was gradually increased to 15 mg. The patient claimed that there was a significant reduction (around 90%) in visual hallucinations within a month. The patient is still undergoing regular follow-up.


  Discussion Top


Visual hallucinations have numerous etiologies such as narcolepsy-cataplexy syndrome, peduncular hallucinosis, treated idiopathic Parkinson's disease,  Lewy body dementia More Details, migraine coma, Charles Bonnet syndrome, schizophrenia, hallucinogen-induced states, and epilepsy.

Certain clinical characteristics are useful in differentiating schizophrenic from organic visual hallucinations. As in the case reported, the visual hallucinations were present throughout the waking hours and associated with hyperarousal as compared to organic disease, in which they are more often nocturnal and associated with drowsiness.[2] She also had increased paranoia and had a poor insight. The patient was advised magnetic resonance imaging brain, but due to unaffordability, it could not be done. On clinical basis, we therefore ruled out the possibility of organic etiologies.

Regarding visual hallucinations in the blind, the brain reacts to a lack of visual input. As one experiences vision loss, the brain continues to interpret visual data, even without corresponding visual input. Lacking that input, the brain will invent images, and visual brain cells will begin to fire spontaneously to compensate for the lack of visual data.[3] The closest differential diagnosis for visual hallucinations in visually impaired individuals is Charles Bonnet syndrome. As the criteria for diagnosing Charles Bonnet syndrome include the absence of psychiatric disorders,[4] it was ruled out. Furthermore, the visual hallucinations decreased significantly after giving typical antipsychotic medications over a period of 1 month.

While congenital cortical blindness has a protective effect against schizophrenia, there are genes implicated in peripheral blindness (a major cause being retinitis pigmentosa) which show multiple connections to genes implicated in schizophrenia, for example, OTX2.[5] Retinitis pigmentosa, a progressive degeneration of retinal neuroepithelium leading to impairment of visual acuity and fields eventually ending in blindness, has often been found to be accompanied by involvements of other structures, particularly the nervous and endocrine systems. Mental subnormality is a prominent part of most of the retinitis pigmentosa syndromes, the important ones being the Laurence–Moon Biedl syndrome, Refsum's syndrome, Cockayne's syndrome, Hallgren's syndrome, and Usher's syndrome.[6] As our patient was of an average intelligence, it was an advantage for us to take the history and details of the symptoms.


  Conclusion Top


Given the broad variety of potential etiologies of visual hallucinations, 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. Neuroimaging should be done to rule out certain organic causes if required. The subvocal thought hypothesis suggests that true auditory hallucinations would be confined to deaf people who at some point in their lives had heard speech, while the auditory hallucinations of prelingually deaf people lack clear-cut auditory features. Similarly, in our case report, the patient developed blindness 8 years after birth prior to which she had a vision. Therefore, she was able to give her visual hallucinations' precise descriptions. It was not only intriguing for her family members but also the doctors that a blind schizophrenic patient presented with such distressing clear-cut visual images invisible to others.

Acknowledgement

The authors would like to thank

Dr. Ajita S Nayak, Professor and Head of Department, Seth G. S. Medical College and KEM Hospital, Mumbai.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Teeple RC, Caplan JP, Stern TA. Visual hallucinations: Differential diagnosis and treatment. Prim Care Companion J Clin Psychiatry 2009;11:26-32.  Back to cited text no. 1
    
2.
Waters F, Collerton D, Ffytche DH, Jardri R, Pins D, Dudley R, et al. Visual hallucinations in the psychosis spectrum and comparative information from neurodegenerative disorders and eye disease. Schizophr Bull 2014;40 Suppl 4:S233-45.  Back to cited text no. 2
    
3.
Jan T, del Castillo J. Visual hallucinations: Charles Bonnet syndrome. W J Emerg Med. 2012;13:544-7.  Back to cited text no. 3
    
4.
Kester EM. Charles bonnet syndrome: Case presentation and literature review. Optometry 2009;80:360-6.  Back to cited text no. 4
    
5.
Leivada E, Boeckx C. Schizophrenia and cortical blindness: Protective effects and implications for language. Front Hum Neurosci 2014;8:940.  Back to cited text no. 5
    
6.
Shukla GD, Jain BS, Bajpai HS, Mishra DN. Schizophrenia associated with retinitis pigmentosa: A case report. Indian J Psychiatry 1983;25:162-3.  Back to cited text no. 6
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