Visual Hallucinations: Differential Diagnosis and Treatment
Ryan C. Teeple, B.S., Jason P. Caplan, M.D., and Theodore A. Stern, M.D.
What Are Visual Hallucinations?
Hallucinations, defined as the perception of an object or event (in any of the 5 senses) in the absence of an external stimulus, are experienced by patients with conditions that span several fields (e.g., psychiatry, neurology, and ophthalmology). When noted by nonpsychiatrists, visual hallucinations, one type of sensory misperception, often trigger requests for psychiatric consultation, although visual hallucinations are not pathognomonic of a primary psychiatric illness.
Visual hallucinations have numerous etiologies. Here, we discuss possible mechanisms and offer a differential diagnosis of visual hallucinations, with an emphasis placed on conditions that arise in the context of medical and surgical illness. Treatment typically rests on the underlying etiology, so timely recognition and an understanding of causative mechanisms are crucial.
What Causes Visual Hallucinations?
Numerous hypotheses have been suggested to explain the genesis of visual hallucinations. These have been summarized and categorized by Asaad and Shapiro1: psychophysiologic (i.e., as a disturbance of brain structure), psychobiochemical (as a disturbance of neurotransmitters), and psychodynamic (as an emergence of the unconscious into consciousness). Visual hallucinations can be the result of all 3 processes, given the interplay among disturbances of brain anatomy, brain chemistry, prior experiences, and psychodynamic meaning.
To date, no single neural mechanism has explained all types of visual hallucinations; however, the similarity of visual hallucinations that are associated with seemingly diverse conditions suggests a final common pathway. Manford and Andermann2 summarized 3 pathophysiologic mechanisms thought to account for complex visual hallucinations.
The first mechanism involves irritation (e.g., seizure activity) of cortical centers responsible for visual processing. Irritation of the primary visual cortex (Brodmann's area 17) causes simple elementary visual hallucinations, while irritation of the visual association cortices (Brodmann's areas 18 and 19) causes more complex visual hallucinations.3 These data are supported by both electroencephalographic (EEG) recordings and direct stimulation experiments.2
Lesions that cause deafferentation of the visual system may lead to cortical release phenomenon, including visual hallucinations.4 Normal inputs are thought to be under the control of inhibitory processes that are effectively removed by deafferentation. It has been further suggested that deafferented neurons undergo specific biochemical and molecular changes that lead to an overall increase in excitability (similar to the denervation hypersensitivity seen in phantom limb syndrome experienced by amputees).5
A multitude of lesions can cause this loss of input and inhibit other cognitive functions.6 Of note, visual hallucinations may be induced by prolonged visual deprivation. One study reported visual hallucinations in 10 of 13 healthy subjects blindfolded for a period of 5 days; this finding lends strong support to the idea that the simple loss of normal visual input is sufficient to cause visual hallucinations.7
Finally, due to its role in the maintenance of arousal, the reticular activating system has been implicated in the genesis of visual hallucinations. Lesions of the brainstem have led to visual hallucinations (as in peduncular hallucinosis). Further, visual hallucinations are common in those with certain sleep disorders, and occur more frequently in those who are drowsy. The observation that visual hallucinations occur more frequently in those who are drowsy (even in the absence of frank sleep pathology) suggests that the reticular activating system plays a role in visual hallucinations, although the precise mechanism has not yet been established.
Meer @
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2660156/ en tevens een lange referentielijst met meer artikelen over het onderwerp. Een van deze referenties:
Nichols DE. Hallucinogens. Pharmacol Ther. 2004;101:131–181 is eigenlijk toch wel een must als beginpunt.
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