Atypical Charles Bonnet Syndrome
A 72-years-old female was brought to psychiatry outpatient department, relatives reported that for last 1 month, she is complaining, she is not in her home as she often says that she should be taken to her own home. She was not able to move about freely due to her impaired vision, weight and diabetic neuropathy. She had to be helped for activities of daily living due to impaired vision. She would often say that there are people around her whom she does not know. She was also hearing voices of some persons crying and would ask her daughter-in-law about it. She said she could see a few children eating from her plate when she is eating her meals and she would ask them to be removed. She said there are 3-4 children of 6-8 years age who are eating from her plate. She could see monkeys in her room. At times she would say that she is being taken in an ox-cart, she could see the desert and ruins of a building. She would repeatedly say that she can see many persons around her and they should be removed from there, or she should be taken to her own home. She remained irritable due to the presence of unwanted persons around her. At times, she also said that someone has carried out black magic on her, though on examination, it was not a firmly held belief. On mental status examination her cognitive functions were intact. She had auditory and visual hallucinations. She was troubled by auditory and visual hallucinations and lacked insight.\nShe was a diagnosed case of diabetes and hypertension since 1999. She also had diabetic nephropathy and neuropathy. She was on injection Insulin twice a day 18 units and 12 units, morning and evening.\nIn March 2009, she had an ophthalmic examination. She had proliferative diabetic retinopathy and ocular hemorrhage. She had complete vision loss since March 2009 (2 months) and had to be helped for activities of daily living. She was taking tablet alprazolam occasionally for last 1 year. Her appetite was normal, but sleep was disturbed.\nShe was started on Tablet Aripiprazole 10 mg/day, later increased to 15 mg/day. However, there was no improvement after 2 months and in June 2009, tablet Risperidone was started initially 2 mg/day, increased to 4 mg/day. She was also given tablet lorazepam 2 mg/day. There was no improvement in any of her symptoms. A computed tomography scan was suggested but due to her difficulty in walking and obesity, relatives expressed inability to get it done.\nIn June 2010, she had her ophthalmic checkup. She had mature cataract in both eye, it was not possible to examine her retina. A decision was made to perform cataract surgery in both eyes simultaneously, as it was difficult to bring her to hospital repeatedly. After cataract surgery her psychotic symptoms resolved completely within 1 week. Her risperidone was stopped; she remained symptom free until her death in September 2011.