An adaptation disorder patient with accompanied visual hallucinantions and the occipital lobe lesions: A case report Oksipital bölge lezyonu ile eş zamanli ortaya çikan, görsel varsanilarla seyreden bir uyum bozukluǧu olgusu
Klinik Psikofarmakoloji Bulteni, cilt.19, sa.SUPPL. 1, 2009 (SCI-Expanded, Scopus, TRDizin)
- Yayın Türü: Makale / Özet
- Cilt numarası: 19 Sayı: SUPPL. 1
- Basım Tarihi: 2009
- Dergi Adı: Klinik Psikofarmakoloji Bulteni
- Derginin Tarandığı İndeksler: Science Citation Index Expanded (SCI-EXPANDED), Scopus, TR DİZİN (ULAKBİM)
- Anahtar Kelimeler: Adjustment disorders, Occipital lobe lesion, Visual hallucinations
- Sağlık Bilimleri Üniversitesi Adresli: Hayır
Özet
Introduction: Numerous studies that investigate the association of structural abnormalities of brain with psychosis and related disorders become increasingly informative by the contribution of advanced imaging techniques(1). Sometimes symptomatology occurring secondary to structural abnormalities or lesions of brain may direct clinician to a misdiagnosis in cross-sectional assessments. Particularly visual hallucinations secondary to lesions in the occipital lobe such as tumor, ischemia, or hemorrhage may cause confusion in the diagnosis by addition of psychological problems to an existing medical situation(2). Case: The case was a 30 years old, university graduate male that was presented with discomfort, distress, uneasiness, apprehension, quick anger, and aggressiveness accompanied with visual hallucinations including colored bright shapes and shades. In his interview, he disclosed that his father died in an airplane accident when he was young and her sister died in a road accident one month ago. Visual sensations including shadows and colored figures suggested visual hallucinations. Clinical picture was considered as the beginning of a psychotic process. However, subtle neurologic findings in physical examination and reduction in visual field raised the possibility of an organic lesion. Brain MRI revealed an ischemic area localized to left occipital lobe. Patient was referred to GATA Psychiatry Clinic. He was hospitalized by the psychiatry clinic for advanced tests and consulted to neurology and ophthalmology clinics. Detailed ophthalmologic examination revealed that he had a left homonym quadrianopsia. Neurologic examination also confirmed left homonym quadranopsia, and a lesion consistent with subacute infarct was observed in his MRI. Transcranial Doppler examination was positive for emboli. VEP examination showed a right cortical p100 response latency of 102 ms. Left cortical p100 latency was measured as 109.50 ms and its amplitude was lower compared to right and its configuration was disturbed. No embolic focus could be detected. Routine biochemical, hematologic, rheumatologic and microbiologic examinations and laboratory tests were normal. He was followed by the neurology department for late stroke. Fluvoxamine was started at a dose of 150mg/day for anxiety and gradually increased. Acetyl salicylic acid at a dose 300mg/day was given by the neurology department. Patient that had initial score of 22 for Hamilton Anxiety Scale benefited from medical treatment and his symptoms regressed within 4 weeks. At the end of the treatment his score by Hamilton Anxiety Scale was reduced to 12. Patient is now stable and followed by psychiatry and neurology clinic. Discussion: Although presence of difficulty in impulse control, aggressiveness, quick anger in the history of Mr S. and absence of such symptoms in premorbid period along with a clinical picture progressing with visual hallucinations of sudden onset indicate a psychotic process, this was not supported by his psychiatric examination and clinical follow-up. Mr. S was the only child of a mother with obsessive personality. Mother that has lost her husband in an airplane accident and her daughter in a road accident increased her control on her son. She frequently called him in varying times of the day and asked whether he faced any disaster or not. Increased control of mother raised the dependence-independence conflict of Mr. S who already had a dependent personality, and he reflected his reaction that he was unable to express to her upset mother to the individuals within close proximity. Mr. S was experiencing adaptation problem to the new situation. Concurrent occurrence of visual hallucinations has led to confusions in diagnosis and required further investigation of the symptoms in terms of a psychotic disorder. Positive Hoffmann reflex in his neurologic examination and the possibility that visual hallucinations may be associated with visual field loss have mandated investigation for an underlying organic cause. As for conclusion, what we would like to emphasize in this presentation include: hallucinations that may lead to confusion in diagnosis may be caused by an organic cause, subtle neurologic findings in neurologic examination may give valuable clues for an organic cause and possibility of late stroke must be considered in the presence of psychiatric symptoms.