Neuroleptics-induced persisting perception disorder

Olanzapine

"I was glad to find that I am not alone. I've been seeing visual snow or static since a hospitalization [Hospital A: February 2-4, 2005; Hospital B: February 5-12, 2005] for a suicide attempt via klonopin [clonazepam] overdose [February 2, 2005].

While in the hospital I was given zyprexa [olanzapine] – once [February 10, 2005]. I will never take it again. They gave it to me for sleep[less]ness and agitation because of a disturbing (probably psychotic) sense of a malign presence.

Instead of calming me down, I felt wired beyond anything I've experienced. I also had an insuppressible closed-eye cartoonish visualization of a scene where I was flying over a winding jungle river below the tree line. It was so vivid I was feeling motion sickness from the constant manoeuvring."

(kam [subject #84], Discussion - new member, April 14, 2006; additions in square brackets by Klaus Podoll)

"I did experience euphoric hypomania for 1 day in the hospital."

(kam [subject #84], Email to Klaus Podoll, April 30, 2006)

"I was kept in hospital for a week. Before I was released, I started seeing the static [February 12, 2005]. I reported it, but they dismissed my reports. It's been over a year now.

While in the hospital, I started (and have subsequently dropped) gabapentin and low-dose lithium, and elevated to high-dose wellbutrin [bupropion].

I'm back to a prior regimen of 300mg wellbutrin, 54 mg concerta (ritalin) [methylphenidate]. I've started low dose seroquel [quetiapine].

Along the way I've been off everything for months, so I've eliminated almost every theory except a persistent shift."

(kam[subject #84], Discussion - new member, April 14, 2006; additions in square brackets by Klaus Podoll)

"I took it [amitryptyline] for several years [from August 1995 to 2000] for depression. Even though it is given to help prevent migraine, I had frequent migraines while taking it [B.2]. I've only rarely experienced migraines before or since [B.3].

Thought this might be relevant considering the migraine-vs relationship."

(kam [subject #84], Discussion – did not help, April 17, 2006; additions in square brackets by Klaus Podoll)

"My headaches started (1-4 monthly) within 1 year of beginning amitryptyline and stopped within 1 month of terminating amitryptyline. I do not recall an aura & at that time wondered what was meant by the term. I did experience high sensitivity to light and sound during headaches."

(kam [subject #84], Email to Klaus Podoll, April 30, 2006)

"I started to get visual snow while in the hospital for overdosing on Klonopin (my sole attempt at suicide). However, I was also exposed for the first time to several other psych drugs. I had a strong, paradoxical reaction to Zyprexa: mania and vivid closed-eye cartoonish visuals. So vivid, I got motion sickness."

(kam [subject #84], Discussion – did not help, April 17, 2006; additions in square brackets by Klaus Podoll)

"I don't think I'm any more sensitive to light than I was before, but the extended afterimages are more pronounced in bright light."

(kam [subject #84], Discussion – did not help, April 18, 2006)

"My persisting perception disturbance consists of continuous shimmering in my visual field and annoyingly pronounced afterimages; most bothersome when looking at a low-contrast field (e.g., monochromatic) under bright lighting, or when looking at any scene under very low lighting."

(kam [subject #84], Email to Sofia Greene, April 28, 2006)

"The afterimages started along with the visual snow. I noticed the onset of the visual effects while I was still in the hospital, 8 days after the Klonopin overdose. I initially described it as being like the scintillating visual halo I sometimes saw when beginning to faint. The halo, or tunnel-like character, rapidly went away, leaving full-field visual shimmering. I also sometimes see wave fronts of relative brightness or dimness move through my visual field. The effect seems to be entoptic. I'm nearly certain it is the same imagery I normally see closed-eye, but open-eye visual input no longer overwhelms this noise.'"

(kam [subject #84], Email to Klaus Podoll, April 30, 2006)

"Ophthalmologic examination found nothing unusual. My physician and psychiatrist are unaware of any drug I take that could have this effect."

(kam [subject #84], Email to Sofia Greene, April 28, 2006)

"I did 6 experiments in February, 1992, with Morning Glory seeds (certain varieties such as Heavenly Blues, Pearly Gates, and Flying Saucers, naturally contain amides similar to LSD). I was fascinated by the visual distortions and what they implied about the normal functioning of vision."

(kam [subject #84], Email to Klaus Podoll, April 30, 2006)

The 47-year old subject reported a history of recurrent attacks of migraine without aura (with onset in her 40s at the latest) and longstanding psychiatric diagnoses including Generalized Anxiety Disorder and Recurrent Major Depression, the latter being treated with amitryptyline for five years from her mid 30s. According to the sufferer, "There has always been a bipolar-ish character to my mood cycles", raising the differential diagnosis with Bipolar Disorder, "but it's been hard to characterize my mood state when it is not baseline or depressed." At the age of 46, she was hospitalized following a suicide attempt with clonazepame overdose. Six days after the overdose, ordinary consciousness returned, and a couple of days later the psychopathological picture included sleeplessness, agitation and a disturbing sense of a malignant presence, suggesting paradoxical reactions occurring in conjunction with her benzodiazepine intoxication or a manic state with psychotic features (she recalls having experienced "euphoric hypomania for 1 day in the hospital") as the major differential diagnoses to be considered on the basis of the information available. After administration of a single dose of olanzapine, she experienced an "insuppressible closed-eye cartoonish visualization of a scene where I was flying over a winding jungle river below the tree line", accompanied by nausea akin to "motion sickness". Olanzapine was immediately discontinued, but although the vivid closed-eye visual hallucinations vanished thereafter, she noted the onset of visual snow or static and increased afterimages within a week after admission, which have persisted ever since.

Although kam's history of self-reported migraines raises the differential diagnoses of possible persistent aura without infarction (MAS score = 2) and HPPD (consumption of morning glory seeds in February 1992), the close temporal relationship between the onset of her persisting perceptual disorder and her admission to hospital suggests her mental disorder and/or her prescribed medications as the most likely cause(s) of her enduring visual disturbances. Since the effects of five different psychopharmacological drugs (in addition to possible after-effects of her experiments with hallucinogens 13 years earlier) could have been at work in the week of her treatment in hospital (clonazepam, olanzapine, gabapentin, lithium, bupropion), it is impossible to single out one drug as the culprit. This being said, it is remarkable to note that the administration of a single dose of olanzapine was followed first by "vivid closed-eye cartoonish visuals" and then by the persistent visual snow and static and the increased afterimages. This brings to mind the case report from Mancinelli et al. (2004) who described hypnopompic visual hallucinations during olanzapine treatment in a male schizophrenic patient (see here for a full reprint of the paper). However, these visual hallucinations of large spiders walking across the ceiling were fully reversible after discontinuation of olanzapine. To the best of our knowledge, there are no previous reports of persisting perception disorder following administration of olanzapine, so that the evidence for such a particular substance-specific claim in kam's case can be considered tenuous at the best.

References

Abraham HD, Mamen A. LSD-like panic from risperidone in post-LSD visual disorder. J Clin Psychopharmacol 1996; 16: 238-241. [PDF]
Lauterbach EC, Abdelhamid A, Annandale JB. Posthallucinogen-like visual illusions (palinopsia) with risperidone in a patient without previous hallucinogen exposure: possible relation to serotonin 5HT2a receptor blockade. Pharmacopsychiatry 2000; 33: 38-41.
Mancinelli I, Pompili M, Ruberto A, Tatarelli R. Hypnopompic hallucinations during olanzapine treatment. Can J Psychiatry 2004; 49: 496-497. (See here for a full reprint.)
Morehead DB. Exacerbation of hallucinogen-persisting perception disorder with risperidone. J Clin Psychopharmacol 1997; 17: 327-328.

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