Case report of visual hallucinations in anxiety.

Hallucinations rarely occur in individuals with anxiety disorders. This case report describes a 36-year-old male with Social Phobia and Agoraphobia with Panic Attacks who had prominent visual hallucinations that were both distressing and incapacitating. Treatment with sertraline 200 mg/d, clonazepam 1 mg/d, and propranolol 20 mg/day for one month completely resolved both his anxiety and the hallucinations, after which he was able to return to his social and occupational life. The report underscores the fact that visual hallucinations are not always indicators of a psychotic disorder, they may be present across a spectrum of mental disorders. In cases where hallucinations occur in nonpsychotic disorders, treatment of the underlying condition usually simultaneously resolves the associated hallucinations without the need to resort to the use of antipsychotic medication. Detailed analyses of such unusual cases can help improve our understanding of the pathogenesis of psychotic-like symptoms.

1. Case history

A 36-year-old married Hindu male presented to the psychiatry unit based in a tertiary care general hospital in New Delhi, India. He was accompanied by his wife and father, who were the primary informants and caregivers. The patient was referred by the government institute where he was employed because he had difficulty interacting with his colleagues, appeared extremely worried and fearful, frequently trembled, sweated profusely, and isolated himself from others.

As described by the patient and his wife, he had an 8-year history of anxiety and apprehension associated with autonomic complaints of sweating, palpitations, dryness of the mouth, and fidgetiness and tremulousness of the hands. He had difficulty interacting with people at social gatherings, meeting new people, and speaking in front of his colleagues and seniors; but he could interact properly with his friends and family members. He was also afraid of closed spaces such as elevators and stores, and of crowded places such as markets, buses, and subways. His anxiety and autonomic symptoms intensified in these places and circumstances, sometimes to an extent that he would feel that he was about to die from choking, lack of breath or severe palpitations. These problems had worsened in the past 2 months, possibly because he was transferred to another office where he had to deal with new people.

The patient also reported seeing images of a lady that no one else could see during the last 2 months. These clear and distinct images occurred when he was awake and fully conscious and appeared real. He reported seeing them five to ten times a day, for 5 minutes at a time. Sometimes, the image would say some words to him in a language he could not understand. The patient was usually fearful of these images. His father reported that the images appeared when the patient was very anxious, fidgety, and sweating heavily.

The patient had previously had two depressive episodes that lasted for around 3 months each and resolved completely with treatment, one 1 year previously and one 7 years previously. However, no medical records were available about these episodes. There was no family history of significant mental illnesses. The patient had no history suggestive of drug or alcohol abuse, head injury, significant medical illness, or other psychiatric illness. No symptoms suggestive of depression were reported during the current episode.

On mental status examination the patient appeared anxious and fidgety. There was increased psychomotor activity, increased rate of speech, and poor eye contact. He reported visual hallucinations that he believed to be real (i. e. , he had no insight about these symptoms) but his higher mental functions were intact except for inattention and distractibility. His general physical examination was normal except for tachycardia (pulse 120/minute), increased sweating, hand tremors, and a trembling voice. The patient’s test results including blood cell counts, kidney and liver function tests, electrolytes, and blood glucose were all within normal limits. A Magnetic Resonance Imaging scan of the head revealed no significant abnormality.

The patient was admitted for diagnosis and management. An initial assessment of the patient’s symptoms using the Hamilton Anxiety Rating scale (HAM-A) [1] and the 17-item version of the Hamilton Depression Rating Scale (HAM-D) [2] indicated moderateto-severe anxiety (HAM-A score of 26) and mild depression (HAM-D score of 8). Based on criteria in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders(DSM-IV), [3] the patient was given the comorbid diagnoses of Social Phobia and Agoraphobia with Panic Attacks. The patient was started on oral sertraline 50 mg/day, clonazepam 0. 5 mg twice a day, and propranolol 20 mg/day (for his disabling tremors). The dose of sertraline was increased to 200 mg/day after 2 weeks, clonazepam was tapered off within 1 month, and propranolol was stopped after 2 weeks. After 4 weeks of treatment the visual hallucinations resolved completely (without any use of anti-psychotic medications), and there was a significant improvement in the patient’s anxiety symptoms and agoraphobia; the HAM-A scores had dropped to 14 and the HAM-D score had dropped to 4.

2. Discussion

Hallucinations are false perceptions - not sensory distortions or misinterpretations - that occur simultaneously with real perceptions. [4] They can occur in all five basic sensory modalities, but auditory hallucinations are the most common. Visual hallucinations have numerous etiologies, but are mostly commonly observed in organic brain disorders and psychoses. Recent articles and reviews have estimated the point prevalence of visual hallucinations in schizophrenia, [5] bipolar affective disorder, [5] delirium, [6] and dementia with Lewy body. [7] Visual hallucinations have also been reported in up to half of patients with Parkinson’s disease. [8] Organic causes of visual hallucinations may include Charles Bonnett syndrome, Anton syndrome, seizures, migraine, tumor, peduncular hallucinosis, sleep disturbances, drug effects, inborn errors of metabolism, and Creutzfeldt-Jakob disease. [9] In addition to their occurrence in various organic and psychiatric disorders, up to 6% of the general population report visual hallucinations. [10]

Visual hallucinations and other psychotic features are uncommon in anxiety spectrum disorders, though they do occur. A community-based study reported that individuals with anxiety disorders had a much higher likelihood of reporting visual or auditory hallucinations than those with no mental disorder (odds ratios ranging from 5 to 9). [11] There have been case reports of patients with panic disorder who experienced concurrent delusions and auditory hallucinations in which the psychotic symptoms resolved when the panic symptoms were treated with selective serotonin reuptake inhibitors (SSRIs) and benzodiazepines alone, that is, without the need for antipsychotic medication. [12] Another report described 3 patients with Social Anxiety Disorder who had concurrent delusions. [13]

Anxiety symptoms that are sufficiently severe to meet the diagnostic criteria for anxiety spectrum disorders frequently occur in patients with schizophrenia, particularly during the initial phases of the illness, [14] so in individuals with concurrent anxiety and psychotic symptoms it is important that clinicians identify the primary diagnosis. The case reported here presented with moderately severe symptoms of anxiety and concurrent visual hallucinations. No other psychotic features were present (the patient’s insight and selfcare were preserved) and no organic abnormalities that could otherwise explain the occurrence of hallucinations were identified. Based on these findings, we assumed that the hallucinations were associated with the anxiety disorder and treated the primary condition with antianxiety medications without resorting to the use of antipsychotic medications. After 2 weeks of this treatment there was a substantial reduction in the severity of the anxiety symptoms and the hallucinations had stopped completely, confirming our clinical impression that the psychotic phenomenon were secondary to the anxiety disorder.

It has been suggested that psychotic-like experiences are markers for a distinct psychopathological process that occurs on a continuum of severity from isolated episodes to the full clinical diagnosis of a psychotic disorder. [15] Another approach is to consider psychotic-like experiences nonspecific markers that can occur in any type of mental disorder, including anxiety spectrum disorders. Supporting the latter approach, a meta-analysis by van Os and colleagues [16] reported a median prevalence of psychotic-like experiences of 5. 3% in the community and a community-based study by Hanssen and colleagues [17] found that psychoticlike experiences were common in individuals who reported symptoms of depression or anxiety. [16] This case report emphasizes the need for clinicians to distinguish psychotic features observed in individuals with primary anxiety disorders from the more common situation in which anxiety symptoms occur in individuals with primary psychotic disorders. In these situations, presuming that the psychotic symptoms are primary and, thus, treating the patient with antipsychotic medication would be a mistake and could lead to longterm problems for the patient. Moreover, detailed analyses of such unusual cases can help improve our understanding of the pathogenesis of psychotic-like symptoms.