Charles bonnet syndrome, management with simple behavioral technique
About 85-years-old Mr. IA had been managed for bilateral glaucoma at the Eye Clinic of the University of Ilorin Teaching Hospital (UITH), Nigeria for about 7 years. He had been clinically blind (no light perception) without any improvement in his visual acuity and had been on supportive care for more than 3 years. His 71-year-old wife had noticed that he frequently hit imaginary objects with his guide stick (walking stick) for which they had quarreled several times previously. He was subsequently reported to one of the sons, a civil servant in the state capital who then thought that his father might be having a mental disorder, arranged for an appointment at the psychiatric clinic.\nMr. IA's complaint was the perception of images of people in front of him. Even though they were not talking, they were displaying complex bodily movements including dancing, eating, praying (e.g., raising hands, bowing, kneeling, etc., the Muslims way), being a Muslim. These experiences had been ongoing for about 8 weeks before the psychiatric appointment. He, occasionally, could identify people he had known before his eyes problems began. At a particular period he started recognizing his colleagues who died years before and became terrified by these vivid experiences. He had no strange experiences in other sensory modalities; his memory was judged satisfactory by the relations and was, according to them, a “normal old man” apart from the loss of vision and the recent events.\nThe patient did not have other medical complaints. Though hypertensive, the blood pressure was reported to be under good control. All the while the night sleep had been satisfactory and sleep seemed a period of relief from the visual experiences. He did not take alcohol or other substances of abuse. He had no previous history of mental illness.\nOn examination, Mr. IA spoke rationally unhindered by his experiences which he described quite amazingly: Complex visual hallucination in a state of clear consciousness. He was euthymic without any perceptual abnormalities at the time of examination which the patient described as the usual pattern when the objects of his hallucination could disappear momentarily and reappear again. His memory was good and recognized his experiences as “false” though with frightening potential.\nPhysical examinations were essentially normal for his age. Bilateral dry macular degeneration, pale optic disc with cup to disc asymmetry of greater than 0.4 bilaterally were recorded at fundoscopy. Other neurological examinations were satisfactory. Hematological and Biochemical findings were satisfactory.\nHe was reassured of the false nature of the visual experiences after explanations that he had no mental illness and that the problem could disappear. He was taught how to keep the images away by closing his eyes for sometimes and repeated blinking.\nThe relatives were educated on the nature of CBS and the importance of not attributing it to mental illness and not to prejudice the situation to his disadvantage. This behavioral method was explained to the understanding of the patient and his relatives and periodic appointment scheduled to monitor compliance with and effectiveness of the method.\nInitial 2 weekly visits were later reduced to 4 and later 6 weekly. Over these periods there was no improvement in his visual acuity but the visual experiences had disappeared 6 months afterwards without using any drug.