Treatment of Charles Bonnet Syndrome Hallucinations
Education and reassurance are the first-line treatment for Charles Bonnet syndrome, with pharmacological intervention reserved only for patients experiencing severe distress despite non-pharmacological measures. 1
Initial Management: Education as Therapy
The cornerstone of CBS management is patient and caregiver education about the benign nature of these hallucinations. 1 This discussion alone provides significant relief for 15-60% of visually impaired patients with CBS. 1 The key message is that these hallucinations are not psychiatric in nature and do not indicate mental illness or dementia. 2
Non-Pharmacological Interventions to Recommend
- Teach self-management techniques including eye movements, changing lighting conditions, and distraction techniques—these are safe and may provide benefit despite limited evidence. 1
- Refer to vision rehabilitation services to optimize remaining vision through lighting modifications, magnification, and contrast enhancement, which improves vision-related quality of life. 1
- Connect patients with peer support groups where they can discuss their experiences, preventing social isolation and depression. 1
When Pharmacological Treatment Should Be Considered
Medications are NOT first-line and should only be used for patients with severe distress despite education and non-pharmacological measures. 1 The evidence for any pharmacological agent in typical CBS is limited. 1
Critical Caveat Before Prescribing
Do not prescribe antipsychotics reflexively for CBS hallucinations—typical CBS patients maintain insight and the hallucinations are benign. 1 First, rule out medication-induced causes such as anticholinergics, steroids, or dopaminergic agents that may contribute to hallucinations. 1
Pharmacological Options When Necessary
The evidence base is weak, consisting primarily of case reports and small case series with no definitive cure established. 2
Reported Agents with Variable Success:
Atypical antipsychotics (risperidone, olanzapine, quetiapine) have been used for control of problematic hallucinations, though evidence specifically for CBS is limited. 3 One case report showed risperidone was ineffective in CBS. 4
Anticonvulsants may be more promising than antipsychotics:
Donepezil can be a favorable option specifically in CBS patients who have developed comorbid Alzheimer's-type dementia, with one case report showing improvement in both hallucinations and cognitive function. 6
Typical neuroleptics and benzodiazepines have generally been found unpromising. 5
Red Flags Requiring Alternative Diagnosis
If the following features are present, this is NOT typical CBS and requires comprehensive neurological evaluation with brain MRI: 1
- Lack of insight despite CBS education (patient believes hallucinations are real) 1, 7
- Hallucinations that interact with the patient 1, 8
- Accompanying neurological signs or symptoms 1, 8
These atypical features suggest dementia with Lewy bodies, Parkinson's disease, or primary psychiatric disorders. 1
Essential Monitoring
Screen for depression and anxiety at all follow-up visits, as vision loss significantly increases risk of mental health deterioration. 1 Recommend professional psychiatric assessment for patients reporting severe mood changes, interference with daily life, or suicidal ideation. 1
Practical Algorithm
- Confirm diagnosis: Verify four characteristic features (recurrent vivid visual hallucinations, preserved insight, absence of other neurological explanations, vision loss). 1
- Provide education and reassurance about benign nature—this is therapeutic. 1
- Teach self-management techniques and refer to vision rehabilitation. 1
- Reserve medications only for severe distress unresponsive to above measures. 1
- If medication needed: Consider anticonvulsants (carbamazepine, valproate) over antipsychotics given limited evidence and better reported outcomes. 4, 5
- Monitor for depression and ensure psychological support is in place. 1