Can muscular dystrophy cause hallucinations?

Can Muscular Dystrophy Cause Hallucinations?

Muscular dystrophy itself does not directly cause hallucinations, but specific subtypes—particularly myotonic dystrophy—can be associated with hypersomnia-related hallucinations, and certain muscular dystrophies may rarely present with psychiatric symptoms including hallucinations.

Direct Association: Myotonic Dystrophy and Hypersomnia

Myotonic dystrophy is specifically identified as a medical condition that can cause hypersomnia, which in turn may present with hallucinations. 1

• Patients with hypersomnia due to myotonic dystrophy may experience hypnagogic hallucinations (visual hallucinations occurring at sleep onset) as part of the excessive daytime sleepiness syndrome 1
• These hallucinations occur in the context of a 3-month history of excessive daytime sleepiness and are accompanied by other symptoms such as memory lapses, concentration problems, automatic behavior, and ptosis 1
• The hallucinations are secondary to the sleep disorder rather than a primary neuropsychiatric manifestation of the muscular dystrophy itself 1

Rare Psychiatric Presentations

In extremely rare cases, muscular dystrophy patients may develop schizophrenic symptoms including auditory hallucinations, though this appears to be coincidental rather than causally related. 2

• A case report documented a 23-year-old male with Becker muscular dystrophy who developed auditory hallucinations and delusions, though he maintained insight into his illness and showed natural emotional communication unlike typical schizophrenia 2
• This patient also had intellectual impairment (IQ 58) and the psychiatric symptoms responded to antipsychotics 2
• Such presentations are exceptionally rare and do not represent a typical feature of muscular dystrophy 2

Cardiac and Respiratory Complications: Indirect Pathways

The cardiac and respiratory complications of muscular dystrophy can create conditions that secondarily lead to hallucinations through delirium or hypoxia.

• Duchenne muscular dystrophy patients develop sleep-disordered breathing and alveolar hypoventilation, with symptoms including nocturnal awakenings, daytime sleepiness, and morning headache 1
• Sleep hypoventilation correlates with elevated awake PaCO2 (≥45 mm Hg), which can contribute to altered mental status 1
• Cardiac involvement is universal in DMD, with dilated cardiomyopathy potentially leading to congestive heart failure and associated delirium 1
• Respiratory failure and pulmonary hypertension can result in right ventricular failure, creating metabolic derangements that may precipitate confusion or hallucinations 1

Clinical Evaluation When Hallucinations Occur

When a patient with muscular dystrophy presents with hallucinations, prioritize evaluation for treatable secondary causes rather than assuming a direct relationship.

• First, screen for delirium by assessing consciousness level, attention, and fluctuating symptoms, as delirium represents a medical emergency 3, 4, 5
• Perform immediate medication review for anticholinergics, corticosteroids (commonly used in DMD), and dopaminergic agents 3, 4
• Assess for respiratory insufficiency with arterial blood gas, overnight pulse oximetry, and continuous CO2 monitoring to detect sleep hypoventilation 1
• Evaluate cardiac function with ECG and echocardiogram, as cardiac failure can precipitate delirium with hallucinations 1
• Check for infections (urinary tract infection, pneumonia) and metabolic derangements (electrolytes, renal function, glucose) as these are common precipitants in patients with neuromuscular disease 3, 4

Key Distinctions from Neurodegenerative Hallucinations

Muscular dystrophies are fundamentally different from synucleinopathies and should not be confused with conditions where hallucinations are a core feature.

• Unlike dementia with Lewy bodies where visual hallucinations occur in up to 80% of patients and are a core diagnostic criterion, hallucinations are not a characteristic feature of muscular dystrophies 4, 5, 6
• Synucleinopathies present with visual, short-lived hallucinations with preserved insight for extended periods, whereas any hallucinations in muscular dystrophy patients are typically secondary to metabolic, respiratory, or medication-related causes 6
• The "double hit" theory requiring dysfunction of both associative visual areas and limbic/ventral striatal changes does not apply to muscular dystrophies 6

Common Pitfalls to Avoid

Do not assume psychiatric illness without completing a thorough medical workup, as 63% of patients with new psychiatric complaints have an underlying medical cause. 5

• Avoid attributing hallucinations directly to the muscular dystrophy diagnosis without investigating sleep-disordered breathing, cardiac complications, and medication effects 1
• Do not overlook corticosteroid-induced psychiatric symptoms, as steroids are routinely used in DMD to slow disease progression and can cause hallucinations 1
• Remember that malnutrition and obesity are each present in approximately 44% of young adults with DMD, and metabolic derangements from nutritional issues can contribute to altered mental status 1