Indian Journal of Private Psychiatry
Volume 15 | Issue 1 | Year 2021

Auditory Hallucinations in Charles Bonnet Syndrome: A Case Report

Prashant Chaudhari1, Sagar Karia2, Nilesh Shah3, Avinash Desousa4

1–4Department of Psychiatry, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India

Corresponding Author: Avinash Desousa, Department of Psychiatry, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India, Phone: +91 9820696828, e-mail:

How to cite this article: Chaudhari P, Karia S, Shah N, et al. Auditory Hallucinations in Charles Bonnet Syndrome: A Case Report. Ind J Priv Psychiatry 2021;15(1):47–48.

Source of support: Nil

Conflict of interest: None


Charles Bonnet syndrome (CBS) is a common occurrence of visual hallucinations in the elderly with visual impairment. It is generally benign and is managed supportively and non-pharmacologically with interventions to restore vision. In its atypical form, it also has hallucinations in other modalities. We report here a case of atypical CBS in a 56-year-old man with bilateral vision loss due to an old injury in one eye and the mature cataract in another eye. The patient responded well to olanzapine.

Keywords: Atypical, Charles Bonnet syndrome, Hallucinations, Olanzapine


Charles Bonnet syndrome (CBS) is a condition where visual impairment leads to the occurrence of hallucinations in visual modality in the presence of intact cognitive functioning.1 It is common in the elderly, and its diagnosis is important due to the relatively benign nature of the course and differential diagnosis of visual hallucinations in this age-group, such as delirium and Lewy body dementia.2 Atypical presentations with hallucinations in other modalities in addition to visual hallucinations in some cases make diagnosis all the more important.3 Although CBS is widely regarded as transient and benign presentation, there are studies indicating bad prognosis in about 32% of cases. Long-lasting hallucinations lead to significant impairment in daily life.4 We report a case of atypical CBS in a 56–year-old man with bilateral vision loss responding to olanzapine.


A 56-year-old man was brought to us with chief complaints of seeing many people around him, standing, and looking at him, occasionally moving about, talking to him, and calling him by his name, which would occur to him throughout the day. The symptoms started 4 months back and increased gradually over time. He claimed to have been aware of the false nature of these images and voices since he could not see due to an old injury in the left eye and a cataract in the right eye. He claimed to have not being able to see for 4–5 months and affirms to have been seeing things invisible to others around the same time. At first, it started around the time he was falling asleep to later have these hallucinations even while awake and soon to be present throughout the day. They were fear-inducing and made it difficult for him to fall asleep. He has also followed up the figures and voices in an attempt to ward them off. As his behavior worsened, family members decided to seek medical attention, and he was admitted to our ward for the same. All routine investigations sent were within normal limits. He was started on oral olanzapine 5 mg twice a day. His sleep improved, and he claimed to be no longer fearful of the hallucinations in a week post-treatment. The visual hallucinations continued despite improvement in his behavior. On history, he affirmed to having seen images at first and then hearing voices and getting fearful of them chronologically. He had no delusions, no disorientation in time, place and person, no big talk or big ideas, no ritualistic behavior, no disorganized behavior, no forgetfulness, or no history of any substance use disorder. He had no history suggestive of any psychiatric problems in the past. Magnetic resonance imaging of the brain was done, which was within normal limits. On examination, his vision was finger counting 1 in the right eye with mature cataract. There was also no family history suggestive of any psychiatric illness, and there were no psychosocial factors that could have affected the patient. We decided to consider the diagnosis of atypical CBS, and he was advised cataract surgery. He was maintained on olanzapine 5 mg twice a day and an ophthalmology reference was made. His cataract surgery was done while being admitted in our ward. After surgery, his vision recovered in 7–8 days. He was continued on the same medication for a month thereafter. The patient reported no visual hallucinations during the day, but occasional uneasiness and imagery in the dark or while falling asleep for about 15 days. He was counseled and started on general supportive psychotherapy. He reported complete improvement in about 2 months. He was continued on the same dose of olanzapine owing to auditory hallucinations for about 6 months after which he stopped following up. On last follow-up, he had complete improvement with no psychiatric symptoms.


Although reassurance of benign nature of CBS with measures to restore vision remains the mainstay of this disease, the use of antipsychotics is warranted on case-to-case basis.57 There is an ongoing debate to understand this syndrome concerning many specialties and to understand psychological comorbidities with CBS so as to make a distinction between typical and atypical CBS.8 Frequent misdiagnosis of this syndrome warrants a closer look and an multidisciplinary approach.9,10

Another diagnosis which was considered was fantastic hallucinosis in our patient.11 But it was ruled out in favor of CBS due to response to treatment, which was alleviation of symptoms post-cataract surgery. Hori et al. had described two cases of CBS having auditory hallucinations and also recommended changing criteria proposed by Gold and Rabins and Teunisse et al. of including other sensory modality hallucinations in CBS.12

In this report, we presented a patient with atypical CBS responding to olanzapine and supportive psychotherapy. It is important for clinicians to be aware of this common presentation with visual hallucinations to avoid misdiagnosis of psychosis and provide the necessary care. It underlines careful assessment of psychiatric symptomatology to understand that the patient has CBS and not schizophrenia or psychosis.


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