Organic hallucinations

[NeuroKlitch]

Would a neuropsychiatrist deal with organic non psychotic hallucinations secondary to TBI , or is that more under the realm of neurology ?


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[Shikima]

Or PM&R with Neurology?

 

[deleted452516]

Not entirely sure what you mean by 'organic,' or 'non-psychotic,' or 'deal with' for that matter.
Without specifying further the nature of the injury or the symptom, hallucinations (perceptions without a stimulus), that develop after a brain injury may be treated by a variety of physicians- primary care doctor, physiatrist, neurologist, psychiatrist, neuropsychiatrist, or others.

 

[Merovinge]

Would a neuropsychiatrist deal with organic non psychotic hallucinations secondary to TBI , or is that more under the realm of neurology ?
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The real answer here is yes. PMR and PCPs are not dealing with this condition, unless there is some huge regional variation in practice. At all institutes I have been at with neuropsychiatry this is absolutely an appropriate consult for them.

 

[splik]

Would a neuropsychiatrist deal with organic non psychotic hallucinations secondary to TBI , or is that more under the realm of neurology ?


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It could be managed be neuropsychiatrist, general psychiatry, neurology, or PMR depending on the etiology. Btw hallucinations are a psychotic symptom. If they are non psychotic then they are hysterical symptoms - called pseudohallucinations

 

[Shikima]

Then I guess one would need a ... hysterectomy!

 

[NeuroKlitch]

Ok, thanks. I ask because I recently learned about Charles Bonnet syndrome, which is hallucinations secondary to the patient's macular degeneration. Was the first i ever heard of something like that. Although there seems to be no treatment, I was wondering if these existed elsewhere, such as in the context of traumatic brain injury, and if they did, if this would fall under the realm of psychiatry, as opposed to something else. Thanks for the answers.

 

[splik]

Ok, thanks. I ask because I recently learned about Charles Bonnet syndrome, which is hallucinations secondary to the patient's macular degeneration. Was the first i ever heard of something like that. Although there seems to be no treatment, I was wondering if these existed elsewhere, such as in the context of traumatic brain injury, and if they did, if this would fall under the realm of psychiatry, as opposed to something else. Thanks for the answers.

No - in Charles Bonnet, the hallucinations aren't secondary to macular degeneration. It refers to visual hallucinations in the context of blindness (of which macular degeneration is the most common cause). It probably release phenomena due to de-afferentation of the visual association areas of the cerebral cortex. (Doesn't explain why most pts with blindness dont have hallucinations though). Another theory is that visual hallucinations cross-cut diagnostic categories and are related to abnormal activity in visual thalamic-cortical pathways. The exception is visual hallucination seen in just one eye, which is related to the anterior visual pathways, and these are sometimes called retrobulbar visual hallucinations.

You don't usually need to treat Charles Bonnet since most of the time the patients know they are hallucinating. Often they have positive hallucinations. I had one patient who had the most ornate hallucinations that were so beautiful they would bring her to tears. When they are distressing, or the patient is cognitively impaired, or becomes frankly psychotic with reasoning biases (jumping to conclusions) then treatment can be indicated. I had one pt with MS who had optic neuritis and had visual hallucinations of his carer having sex with women and he developed delusions about it. That's on the more severe end of Charles Bonnet. about 1/3 of pts have clinically significant charles bonnet (i.e. causing impairment needing treatment). SSRIs are usually treatment of choice. sometimes neuroleptics are used.

 

[NeuroKlitch]

thanks for the clarification. And that is amazing. I'm glad to hear that you are getting exposure to all these interesting patients in neuropsychiatry. That's very exciting and was what I was hoping to hear. Thank you.

 

[splik]

thanks for the clarification. And that is amazing. I'm glad to hear that you are getting exposure to all these interesting patients in neuropsychiatry. That's very exciting and was what I was hoping to hear. Thank you.

Actually the above cases were from before I went into psychiatry! You're much less likely to see people with positive hallucinations in psych.

Also it's not typical for people to come to me because they have hallucinations. We see patients who are getting in trouble. For example (to take the visual hallucination example), one pt I saw was a woman in her 40s who had SI, tried to take gun from police officer to kill herself, was reporting hearing voices and apparently saw a lion at the place she worked (they evacuated lol). She denied having seen the lion when i saw her but when we did the MOCA she recognized the lion and I asked her if she saw him at work and she smiled. She got referred to me cuz no one knew wtf was going on (is this brain disease or psych?) and she was very difficult to manage. Also had started eating trash. Got her to draw a clock and it was clear she unfortunately had bvFTD rather than psychotic depression, confirmed with MRI/PET imaging and genetics.

Another pt was referred to me because his visual hallucinations would lead to violent behavior (like throwing knives and stuff) and neurology couldn't manage and didn't know wtf was causing it. He had no recollection of the hallucinations or violent behavior. I though it was related to his temporal lobe epilepsy (he also had terrible dementia of unknown etiology despite million dollar work up) but as his anticonvulsants were optimized, I d/c'd his neuroleptics and treated like an intermittent explosive disorder.

Another pt was seeing gorillas and alligators in their apartment (there weren't any, we checked) and had attempted suicide previous year after spouse died. had fluent nonsensical speech, new onset vocal and motor tics, coprolalia, howled like an owl, and had clouding of consciousness.

So yes, we see some fascinating pts in neuropsych, but i think it would highly unusual for someone to be referred just because they had hallucinations, and the vast majority of pts with organic hallucinosis are not going to get anywhere near a neuropsychiatrist (or general psychiatrist for that matter), and rightly so.