PSYCHOGERIATRICS 2011; 11: 116–118

doi:10.1111/j.1479-8301.2010.00353.x

CASE REPORT

Low-dose aripiprazole resolved complex hallucinations in the left
visual field after right occipital infarction (Charles Bonnet syndrome)
Cheng-Che CHEN1 and Hsing-Cheng LIU2

1
Department of General Psychiatry, Taipei City Psychiatric Center, Taipei City Hospital; 2Department of
Psychiatry, School of Medicine, Taipei Medical University, Taipei, Taiwan

Correspondence: Dr Hsing-Cheng Liu MD, PhD,
Department of General Psychiatry, Taipei City Psychiatric Center, Taipei City Hospital. No.309,
Songde Rd., Xinyi Dist., Taipei City 110, Taiwan.
Email: hcliu@tpech.gov.tw
Received 9 November 2010; revision received 8 December
2010; accepted 15 December 2010.

Abstract
We reported a patient who suffered from complex visual hallucinations with
left homonymous hemianopsia. Brain imaging showed an acute haemorrhage infarct at the right occipital lobe. Charles Bonnet syndrome (CBS) was
suspected and aripiprazole was prescribed at 5 mg daily. After 3 weeks, the
symptoms of hallucinations and anxiety were relieved. Although some CBS
patients might be self-limited without discomfort, low-dose aripiprazole can
be considered as a safe medication for significantly anxious patients with
CBS.
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Key words: antipsychotics, aripiprazole, Charles
Bonnet syndrome, occipital infarction, visual
hallucinations.

INTRODUCTION
Charles Bonnet syndrome (CBS) is a clinical syndrome characterized by visual hallucinations in the
absence of consciousness or cognition change. The
causes of CBS are heterogeneous, including central
and peripheral nervous system lesions and ophthalmological disorders.1,2 Herein we report a female
patient with CBS after a sudden visual infarct at the
right occipital lobe; aripiprazole resolved her anxiety
and visual hallucinations in a short time. Although
some CBS patients might be self-limited without discomfort, low-dose aripiprazole can be considered as
a safe medication for significantly anxious patients
with CBS.

CASE REPORT
Mrs A was a 70-year-old woman who received treatment for hypertension regularly. She had had no diabetes, cerebrovascular disease or visual problems
before. She had a sudden onset of visual hallucinations, with colourful images of snakes and dwarves
rushing over her left visual field. When she tried to
focus on them, these images turned back and then
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disappeared temporarily. The hallucinations were persistent all day long. She knew these images were not
real, but still felt extremely frightened and disturbed.
She came to our clinic 7 days later, asking for immediate relief. On examination, Mrs A’s consciousness
was clear. Left homonymous hemianopsia was noted
on confrontation test. No significant cognitive,
sensory or motor impairments were noted. Her MiniMental State Examination had a score of 30/30. An
electroencephalogram showed intermittent diffuse
theta waves at 6–8 Hz without epileptic discharge.
Brain computed tomography showed recent haemorrhagic infarct at the right occipital lobe, sparing the
primary visual cortex, as shown in Figure 1.
We prescribed quetiapine 12.5 mg/day to alleviate
her visual hallucinations, but she complained of intolerable dizziness. Therefore, we shifted to aripiprazole
5 mg/day in the second week. Her anxious preoccupation was relieved immediately, and the visual hallucinations began to decrease within 14 days. Three
weeks after complete remission of visual hallucinations, aripiprazole was discontinued, and she was free
from the hallucinations thereafter.
© 2011 The Authors
Psychogeriatrics © 2011 Japanese Psychogeriatric Society

Aripiprazole for Charles Bonnet syndrome

Figure 1 Brain computed tomography showed recent haemorrhagic infarct at the right occipital lobe.

DISCUSSION
The present patient showed the characteristics of
CBS including: (i) recurrent, formed, complex, visual
hallucinations of people and animals; (ii) having
insight that the images were not real; (iii) an absence
of delusional ideation; and (iv) no cognitive impairment.3 In the present case, the visual hallucinations
occurred only at the left visual field with homonymous hemianopsia, and occurred immediately after
the right occipital infarction. Most patients with CBS
have experienced hallucinations after acute visual
loss, the visual hallucinations are derived from
de-afferentation along the visual pathway in this
acute period. Then, the neurons of visual association
cortices, which are located in the occipital and
inferior-lateral temporal lobe, attempt to adapt by
supersensitivity to incoming stimuli, which might
trigger visual hallucinations.4 The SPECT study by
Adachi et al. showed hyperperfusion in the lateral
temporal cortex, striatum and thalamus.5 The
dynamic adaptation of the neural network might
explain why visual hallucinations often occur after
the visual loss, and why the hallucinations in some
patients might decrease gradually.6 To our knowledge, this is the first report that aripiprazole might
achieve prompt alleviation of visual hallucinations
© 2011 The Authors
Psychogeriatrics © 2011 Japanese Psychogeriatric Society

experienced in CBS. As the literature shows,
patients without significant sufferings might not
need pharmacological treatment. Visual hallucinations might disappear if the cause of vision is
resolved, such as removal of a cataract.2,6 Education
of their benign nature is often sufficient. However, for
patients who are deeply disturbed by vivid hallucinations, neuroleptic prescription might be justified
to promptly reduce hallucinations and associated
anxious irritability.3 Antipsychotics including risperidone, olanzapine and haloperidol have been
reported to reduce the hallucinations. Anticonvulsants and some antidepressants have also been
given with some improvement.2,3 Aripiprazole
reduced the anxiety in our patient immediately,
whereas the hallucinations were attenuated progressively within 4 weeks. As a modern antipsychotic
drug, aripiprazole acts as a dopamine D2 partial
agonist, a partial agonist at the serotonin 5-HT1A
receptor, and an antagonist at the 5-HT2A receptor. In
a recent study, it was found that the anxiolytic effect
of aripiprazole might be linked to the partial agonist
on the 5-HT1A receptor.7 Compared with other antipsychotics, aripiprazole has a more tolerable sideeffect profile of weight gain, hyperprolactinemia,
sedation and metabolic syndromes.7,8 Aripiprazole
might be a safety option in elderly patients with
CBS.
Although CBS has been described since 1760,
the syndrome is still under-diagnosed.9 The patients
might seek psychiatric, neurological or ophthalmological services. Because the symptoms of CBS are
often self-limited, some physicians might underestimate the necessity of initiating prompt pharmacological treatment when patients are apparently
distressed.2,3 Physicians might consider evaluating
the patients’ subjective suffering, and low-dose aripiprazole might be a reasonable choice to achieve
quick symptomatic relief, without undesirable sideeffects. Further investigations regarding the pathogenesis and treatment are necessary to understand
this unique clinical syndrome.

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H-C Liu and C-C Chen
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© 2011 The Authors
Psychogeriatrics © 2011 Japanese Psychogeriatric Society