Delusional Parasitosis in a Patient With a History of COVID-19 and Substance Use Disorder.

Delusional parasitosis is a psychotic disorder that manifests as a belief that the skin is infested with parasites. This case report documents the association between COVID-19 infection and new-onset delusional parasitosis superimposed on preexisting psychosis, which has not been previously documented in the current literature. A 28-year-old male presented with new-onset delusional parasitosis superimposed on existing psychosis following COVID-19 infection. Computed tomography scan of the head was unremarkable. He was treated with olanzapine, which appeared to lessen the intensity of the delusions. This case report should encourage increased monitoring of COVID-positive patients with psychosis.

Epidemiology and phenomenology of the Charles Bonnet syndrome in low-vision patients.

BACKGROUND: The occurrence of visual hallucinations in visually impaired people without mental impairment is known as Charles Bonnet Syndrome (CBS). To date, the prevalence of CBS has been reported with high variance. The present study aims at evaluating the prevalence of CBS among low-vision patients. METHODS: From March 2018 to February 2022, 194 patients with a visual acuity ≥ 0.5 logMAR approached the low vision section of the Eye Clinic Sulzbach. Of these, 50 patients were found eligible, agreed to participate in the study and were screened for CBS. The course of the disease, its phenomenology and characteristics, the circumstance of onset, the ability to manipulate and resolve the hallucinations, and the psychosocial aspects of CBS were investigated. RESULTS: 26% of patients with low vision suffered from CBS. Women did not suffer from CBS significantly more often than men. Often, insight into the unreality of the images is not achieved immediately. Patterns or so-called "simple" hallucinations occurred just as frequently as other types of images such as people, body parts or faces. The most frequent images were animals. Visual hallucinations, lasting only for seconds in most cases, occurred more frequently during the day and in bright surroundings. All patients experienced the hallucinations exclusively with their eyes open. The hallucinations generally did not move with the eyes. Many sufferers did neither communicate about their hallucinations nor consult any physician. CONCLUSIONS: CBS among low-vision patients is common. Its prevalence constitutes clinical relevance. Future management of CBS may benefit from encouraging patients to share their experiences and consult a physician.

Top-down modulation of dichotic listening affects interhemispheric connectivity: an electroencephalography study.

Introduction: Dichotic listening (DL) has been extensively used as a task to investigate auditory processing and hemispheric lateralisation in humans. According to the "callosal relay model," the typical finding of a right ear advantage (REA) occurs because the information coming from the right ear has direct access to the left dominant hemisphere while the information coming from the left ear has to cross via the corpus callosum. The underlying neuroanatomical correlates and neurophysiological mechanisms have been described using diffusion tensor imaging (DTI) and lagged phase synchronization (LPS) of the interhemispheric auditory pathway. During the non-forced condition of DL, functional connectivity (LPS) of interhemispheric gamma-band coupling has been described as a relevant mechanism related to auditory perception in DL. In this study, we aimed to extend the previous results by exploring the effects of top-down modulation of DL (forced-attention condition) on interhemispheric gamma-band LPS. Methods: Right-handed healthy participants (n = 31; 17 females) performed three blocks of DL with different attention instructions (no-attention, left-ear attention, right-ear attention) during simultaneous EEG recording with 64 channels. Source analysis was done with exact low-resolution brain electromagnetic tomography (eLORETA) and functional connectivity between bilateral auditory areas was assessed as LPS in the gamma-band frequency range. Results: Twenty-four participants (77%) exhibited a right-ear advantage in the no-attention block. The left- and right-attention conditions significantly decreased and increased right-ear reports, respectively. Similar to the previous studies, functional connectivity analysis (gamma-band LPS) showed significantly increased connectivity between left and right Brodmann areas (BAs) 41 and 42 during left ear reports in contrast with right ear reports. Our new findings notably indicated that the right-attention condition exhibited significantly higher connectivity between BAs 42 compared with the no-attention condition. This enhancement of connectivity was more pronounced during the perception of right ear reports. Discussion: Our results are in line with previous reports describing gamma-band synchronization as a relevant neurophysiological mechanism involved in the interhemispheric connectivity according to the callosal relay model. Moreover, we newly added some evidence of attentional effects on this interhemispheric connectivity, consistent with the attention-executive model. Our results suggest that reciprocal inhibition could be involved in hemispheric lateralization processes.

Neuroanatomical correlates and predictors of psychotic symptoms in Alzheimer's disease: a systematic review and meta-analysis.

BACKGROUND: Psychotic symptoms (hallucinations and delusions) are a type of neuropsychiatric symptom found during Alzheimer's Disease (AD). OBJECTIVE: This systematic review aims to comprehensively capture, analyse, and evaluate the body of evidence that has investigated associations between brain regions/networks and psychotic symptoms in AD. METHODS: The protocol, created according to the PRISMA guidelines, was pre-registered on OSF (https://osf.io/tg8xp/). Searches were performed using PubMed, Web of Science and PsycInfo. A partial coordinate-based meta-analysis (CBMA) was performed based on data availability. RESULTS: Eighty-two papers were selected: delusions were found to be associated mainly with right fronto-temporal brain regions and the insula; hallucinations mainly with fronto-occipital areas; both were frequently associated with the anterior cingulate cortex. The CBMA, performed on the findings of fourteen papers on delusions, identified a cluster in the frontal lobe, one in the putamen, and a smaller one in the insula. CONCLUSIONS: The available evidence highlights that key brain regions, predominantly in the right frontal lobe, the anterior cingulate cortex, and temporo-occipital areas, appear to underpin the different manifestations of psychotic symptoms in AD and MCI. The fronto-temporal areas identified in relation to delusions may underpin a failure to assimilate correct information and consider alternative possibilities (which might generate and maintain the delusional belief), and dysfunction within the salience network (anterior cingulate cortex and insula) may suggest a contribution for how internal and external stimuli are identified; the fronto-occipital areas linked to hallucinations may indicate diminished sensory processing and non-optimal predictive processing, that together contribute to misinterpretation of stimuli and misperceptions; the fronto-temporal and occipital areas, as well as the anterior cingulate cortex were linked to the psychotic cluster.

Associations between early experiences of thought interference and auditory-verbal hallucinations with first-rank symptoms and suicidality in adulthood.

BACKGROUND: Suicide is one of the major causes of premature death in patients diagnosed with a schizophrenia-spectrum psychotic disorder. However, associations between psychotic-like experiences in youth and suicidality in later life remain under-researched. AIMS: We aimed to investigate any associations between early experiences of thought interference and auditory-verbal hallucinations (AVHs) with first-rank symptoms of schizophrenia and suicidal thoughts and behaviours in adulthood. METHOD: This study used data from the Avon Longitudinal Study of Parents and Children (ALSPAC). We calculated combined thought interference score at ages 11 years 8 months, 13 years 1 month, 14 years 1 month and 16 years 6 months. We also assessed AVHs at the same age points. For outcome variables, we used specific variables measuring delusions of control, AVHs and suicidality at 24 years of age. We carried out logistic regressions and mediation analyses to assess the relationships among these variables. RESULTS: Thought interference and AVHs at all ages throughout childhood and adolescence were associated with suicidal thoughts and behaviours, and also with clinically more significant symptoms of delusions of control and AVHs at age 24. Substance use-induced psychotic-like experiences mediated a large proportion of the relationship between early psychotic-like experiences and suicidality in later life. CONCLUSIONS: Thought interference and AVHs in childhood and adolescence are associated with first-rank symptoms and suicidality in adulthood. Mental health interventions in children and adolescents need to take into account the impact of specific psychotic-like experiences and allow for the early detection of thought interference and AVH-related symptoms.

A computational account of the development and evolution of psychotic symptoms.

The mechanisms of psychotic symptoms like hallucinations and delusions are often investigated in fully-formed illness, well after symptoms emerge. These investigations have yielded key insights, but are not well-positioned to reveal the dynamic forces underlying symptom formation itself. Understanding symptom development over time would allow us to identify steps in the pathophysiological process leading to psychosis, shifting the focus of psychiatric intervention from symptom alleviation to prevention. We propose a model for understanding the emergence of psychotic symptoms within the context of an adaptive, developing neural system. We will make the case for a pathophysiological process that begins with cortical hyperexcitability and bottom-up noise transmission, which engenders inappropriate belief formation via aberrant prediction error signaling. We will argue that this bottom-up noise drives learning about the (im)precision of new incoming sensory information because of diminished signal-to-noise ratio, causing a compensatory relative over-reliance on prior beliefs. This over-reliance on priors predisposes to hallucinations and covaries with hallucination severity. An over-reliance on priors may also lead to increased conviction in the beliefs generated by bottom-up noise and drive movement toward conversion to psychosis. We will identify predictions of our model at each stage, examine evidence to support or refute those predictions, and propose experiments that could falsify or help select between alternative elements of the overall model. Nesting computational abnormalities within longitudinal development allows us to account for hidden dynamics among the mechanisms driving symptom formation and to view established symptomatology as a point of equilibrium among competing biological forces.

Visual Hallucinations With Arsenic Trioxide Therapy in Acute Promyelocytic Leukemia.

A 68-year-old male with a history of diabetes and hypertension was diagnosed with acute promyelocytic leukemia (APML). He underwent induction therapy with all-trans retinoic acid (ATRA) and arsenic trioxide. He had a complete hematologic response and was initiated on consolidation therapy with arsenic trioxide (0.15 mg/kg/day intravenous (IV)) and ATRA (45 mg/per meter square of body surface area/day IV). He developed blurred vision and floaters after a few days. Soon after, he felt that his diabetic neuropathy had suddenly worsened. The floaters and flashing lights worsened and morphed into visual hallucinations. He reported seeing figures watching him from the corner of the room. He was admitted and head imaging was unremarkable. Routine labs did not show anything unusual. Arsenic trioxide therapy was held. The hallucinations gradually started decreasing and eventually subsided after around eight weeks. ATRA was continued but arsenic was permanently discontinued. Arsenic is known to cause poisoning if exposed in significant amounts. The arsenic dose used for APML is substantially low (0.15 mg/kg/day IV). We delineate this unanticipated case of arsenic toxicity leading to severe neurological symptoms like visual hallucinations which has not been previously reported in the literature. It is imperative to closely monitor patients who are on arsenic therapy and inform them about possible rare toxicities.

The relationship between specific auditory hallucinations and acute PTSD vs. complex PTSD following direct and indirect exposure to the October 7 events in Israel.

This preliminary study examines the link between war-related auditory (pseudo)hallucinations and symptoms of acute ICD-11 posttraumatic stress disorder (PTSD) and Complex PTSD (CPTSD) amidst ongoing conflict, with a specific focus on CPTSD. The research, which analyzed data from 2028 Israeli residents following the traumatic events of October 7, 2023, investigated the perception of non-existent sirens and their association with acute PTSD and CPTSD symptoms. The findings reveal that (pseudo)hallucinations were more prevalent among individuals with acute CPTSD symptoms compared to those with PTSD symptoms alone. Additionally, auditory (pseudo)hallucinations were significantly associated with a higher likelihood of CPTSD versus PTSD. These results were consistent for those directly and indirectly exposed individuals to the October 7 attack. Despite its cross-sectional nature, the study provides valuable insights into trauma-related auditory (pseudo)hallucinations in wartime contexts.

Charcot and hallucinations: A study in insight and blindness.

Jean-Martin Charcot (1825-1893) showed little interest in mental disorders, the domain of nineteenth-century alienists. But hallucinations are not confined to the field of psychiatry, and Charcot, who had once tested the hallucinogenic effects of hashish in his youth, went on to describe hallucinations in the course of various neurological conditions as just another semiological element. Most of his or his disciples' writings on hallucinations can be found in his work on hysteria. Hallucinations and delusions were part of "grand hysteria" and occurred at the end of the attack (third or fourth phase). Hypnosis or chemical agents could also induce hallucinations. Charcot and his disciples did not go so far as to emphasize the importance of hallucinations when they evoked past trauma, especially sexual trauma. Charcot's materialistic orientation led him and his disciples-especially D. M. Bourneville (1840-1909), G. Gilles de la Tourette (1857-1904), and the neurologist and artist P. Richer (1849-1833)-to seek hysteria in artistic representations of "possessed women" and in the visions of nuns and mystics. Finally, Charcot recognized the importance of hallucinations in neurological semiology, by means of precise and relevant observations scattered throughout his work. Preoccupied with linking hysteria to neurology, Charcot only scratched the surface of the possible significance of hallucinations in this context, paving the way for the work of his students Pierre Janet (1859-1947) and Sigmund Freud (1856-1939).

Echoes of the Mind: Auditory Charles Bonnet Syndrome.

Musical hallucinations (MH) represent a rare and complex auditory phenomenon where individuals perceive music without external stimuli. This case study explores auditory Charles Bonnet syndrome (ACBS) in a 51-year-old male with a history of bilateral sensorineural hearing loss. The patient reported hearing recognizable prayer chants, initially perceived as external sounds from a nearby temple. Over time, these hallucinations persisted and interfered with his daily activities, prompting medical consultation. Despite the absence of psychiatric illness, the patient was diagnosed with ACBS and treated with risperidone, an atypical antipsychotic. The intervention led to a significant reduction in the frequency and intensity of the hallucinations, alongside improved sleep and concentration. The patient also experienced a recurrence of symptoms upon discontinuation of the medication, highlighting the importance of adherence to treatment. This case underscores the need for awareness and understanding of non-psychotic auditory hallucinations in individuals with hearing impairments. The pathophysiology of MH is not fully understood but is believed to involve abnormal activity in the auditory associative cortices due to sensory deprivation. Treatment approaches often include both pharmacological and non-pharmacological strategies, such as optimizing hearing with aids and providing psychoeducation. This study contributes to the limited literature on ACBS and emphasizes the efficacy of antipsychotics in managing MH. Further research is essential to explore the underlying mechanisms and to develop comprehensive management plans for patients experiencing these distressing auditory phenomena. The findings advocate for a multidisciplinary approach to treatment, integrating audiological and psychiatric care to improve patient outcomes.

The efficacy and safety of continuous theta burst stimulation for auditory hallucinations: a systematic review and meta-analysis of randomized controlled trials.

Objective: Auditory hallucinations are the most frequently occurring psychotic symptom in schizophrenia. Continuous theta burst stimulation (cTBS) has been used as an adjuvant treatment for auditory hallucinations. This meta-analysis focused on randomized controlled clinical trials (RCTs) to assess the efficacy of adjuvant cTBS on auditory hallucinations in schizophrenia. Methods: We performed a comprehensive search of four international databases from their inception to January 14, 2024, to identify relevant RCTs that assessed the effects of adjuvant cTBS on auditory hallucinations. The key words included "auditory hallucinations", "continuous theta burst stimulation" and "transcranial magnetic stimulation". Inclusion criteria included patients with auditory hallucinations in schizophrenia or schizoaffective disorder. The Revised Cochrane risk-of-bias tool for randomized trials (RoB1) were used to evaluate the risk of bias and the Review Manager Software Version 5.4 was employed to pool the data. Results: A total of 4 RCTs involving 151 patients with auditory hallucinations were included in the analysis. The Cochrane risk of bias of these studies presented "low risk" in all items. Preliminary analysis showed no significant advantage of adjuvant cTBS over sham stimulation in reducing hallucinations [4 RCTs, n = 151; SMD: -0.45 (95%CI: -1.01, 0.12), P = 0.13; I2 = 61%]. Subgroup analysis revealed that patients treated with adjuvant cTBS for more than 10 stimulation sessions and total number of pulses more than 6000 [3 RCTs, n = 87; SMD: -4.43 (95%CI: -8.22, -0.63), P = 0.02; I2 = 47%] had a statistically significant improvement in hallucination symptoms. Moreover, the rates of adverse events and discontinuation did not show any significant difference between the cTBS and sham group. Conclusions: Although preliminary analysis did not revealed a significant advantage of adjuvant cTBS over sham stimulation, subgroup analysis showed that specific parameters of cTBS appear to be effective in the treatment of auditory hallucinations in schizophrenia. Further large-scale studies are needed to determine the standard protocol of cTBS for treating auditory hallucinations. Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42024534045.

Effectiveness of Imagery Rescripting for Trauma-Affected Voice Hearers: An Open Trial.

OBJECTIVE: People who hear voices (auditory verbal hallucinations) often have post-traumatic stress disorder (PTSD) symptoms. Cognitive behavioural therapies (CBT) have yielded inconsistent findings when treating voices and PTSD symptoms in voice hearers. Preliminary evidence suggests imagery rescripting (ImRs) is associated with large reductions in voice hearing and PTSD symptoms. This study replicated past studies using a larger sample to examine the effectiveness of ImRs in reducing such symptoms. METHOD: Participants (N = 49; 65.3% female; Mage = 35.86) were clients at an Australian transdiagnostic clinic for voice hearers. A one-arm open trial design was used with three pre-treatment baselines and a mid-treatment, post-treatment and 3-month follow up assessments of PTSD symptoms (Posttraumatic Diagnostic Scale for DSM-5), voices (Hamilton Program for Schizophrenia Voices Questionnaire) and emotional symptoms (Depression Anxiety and Stress Scales-21). Five single-item measures were administered weekly to explore the trajectories of change in trauma intrusions, voice-related distress, voice frequency and positive and negative voice valance. RESULTS: ImRs was associated with very large reductions in PTSD symptoms and voices (both emotional and physical characteristics of voices) and emotional symptoms at post-treatment and follow-up (η2 p = 0.24-0.44). There were medium-large to large reductions in weekly symptoms of intrusions, voice-related distress, voice frequency and negative voices (η2 p = 0.12-0.16) and a non-significant increase in positive voices (η2 p = 0.05). CONCLUSIONS: This study provides further evidence that ImRs is an effective treatment for voices and PTSD symptoms in voice hearers with a range of diagnoses. Randomised controlled trials are needed to compare the efficacy of ImRs to CBT protocols.

New Psychoactive Substances Toxicity: A Systematic Review of Acute and Chronic Psychiatric Effects.

New psychoactive substances (NPSs) are a heterogenous group of psychotropic molecules and diverted pharmaceutical drugs sold worldwide as legal substitutes for controlled drugs. The psychiatric consequences of NPS use are relatively unknown, although evidence of related psychotic symptoms has been described in the literature. We sought to summarize the available evidence on NPS-related psychiatric disorders, to facilitate the interpretation of the molecular mechanism underlying their specific pathologies. A literature search of Scopus, PubMed and Google Scholar was conducted including studies published between 2013 and 2024, in which a correlation between NPS consumption and psychiatric symptoms was reported. Furthermore, the short- and long-term psychopathological effects were included. The literature search resulted in 109 NPS-related intoxication cases in which acute or chronic psychiatric symptoms were reported, mostly related to synthetic cannabinoids, followed by synthetic cathinones, hallucinogens, natural NPSs and stimulants. The most common acute symptoms were hallucinations, aggressiveness, and psychotic and bizarre behavior, related to the molecular disbalance of neurotransmitters in the central nervous systems, with different mechanisms. The lack of clear diagnostic criteria and toxicological analyses has resulted in crucial complications in psychiatric diagnoses related to NPS intoxication. Hence, the implementation of toxicological screening procedures in emergency rooms, including the main NPS classes, should support the diagnosis of acute intoxication and its proper therapeutic treatment. Finally, proper follow-up should be implemented to assess the chronic sequelae.

Dynamic predictive templates in perception.

Hallucinations are vivid and transient experiences of objects, such as images or sounds, that occur in the absence of a corresponding stimulus.1,2,3,4,5,6,7,8,9 To understand the neurocomputational mechanisms of hallucinations, cognitive neuroscience has focused on experiments that induce false alarms (FAs) in healthy participants,1,2,3,4,5,9 psychosis-prone individuals,1,3,4 and patients diagnosed with schizophrenia.5 FAs occur when participants make decisions about difficult-to-detect stimuli and indicate the presence of a signal that was, in fact, not presented. Since FAs are, at heart, reports, they must meet two criteria to serve as an experimental proxy for hallucinations: first, FAs should reflect perceptual states that are characterized by specific contents10,11,12 (criterion 1). Second, FAs should occur on a timescale compatible with the temporal dynamics of hallucinations13,14 (criterion 2). In this work, we combined a classification image approach15 with hidden Markov models16 to show that FAs can match the perceptual and temporal characteristics of hallucinations. We asked healthy human participants to discriminate visual stimuli from noise and found that FAs were more likely to occur during an internal mode of sensory processing, a minute-long state of the brain during which perception is strongly biased toward previous experiences17 (serial dependency). Our results suggest that hallucinations are driven by dynamic predictive templates that transform noise into transient, coherent, and meaningful perceptual experiences.

Investigating AVHs narratives through text analysis: the proposal of Dialogic Science for tackling stigmatization.

BACKGROUND: Auditory verbal hallucinations (AVHs) are a significant symptom of various psychological conditions, often stigmatized and misunderstood. Moving beyond traditional psychological, psychotherapeutic and psychiatric approaches, recent research shifts focus on understanding AVHs through community perspectives and the resulting stigmatization. This research approach is crucial for better support and understanding of AVHs, however it still suffers from the lack of a rigorous and shared methodology for studying and reducing stigma. METHODS: Our study, part of the Italian "PsicoVoice" project, aims to investigate community discourses on AVHs, in order to observe whether and to what extent they are drivers of stigmatisation processes. Engaging 268 participants with direct (hearers) and indirect (such as relatives and professionals) experiences of AVHs, the research analyzes a corpus of 54,320 instances using MADIT: a text analysis methodology which is both qualitative and quantitative. MADIT allows for an innovative examination of the rhetorical-argumentative structures within narratives, producing an index for measuring the narratives' practical impact on people' interactions around AVHs. RESULTS: The analysis revealed that the overall community discourses are predominantly shaped by absolute and personal belief-driven modalities. This way of conveying sense, even with non-necessarily-judgmental words, contributes to a stigmatizing environment for individuals with AVHs, cementing a static representation dominated by personal opinions and reducing the potential for more nuanced, diverse interactions about AVHs. CONCLUSION: The study's findings underscore the importance of addressing the narrative structures within community discourses. By intervening in these narratives, there is potential to shift towards a less stigmatizing social construction of AVHs. Thus, the article concludes using the results to provide some insights on how to generate these interventions. This approach could significantly impact how communities understand and interact with individuals experiencing AVHs, promoting more inclusive and supportive environments and interventions.

"My sister wants to kill me": A case report and systematic review of literature of co-occurring multiple sclerosis and psychosis.

Background: Multiple sclerosis (MS) is a neurological disorder with demyelination of neuronal matter, especially of white matter, with multiple episodes occurring temporally. It has been associated with multiple neurological and psychiatric sequelae. Depression and other affective symptoms are commonly associated with MS. Previous research has also suggested that psychotic symptoms may co-occur with MS as well. Material and Methods: A case report was prepared on the patient admitted to the inpatient unit. Subsequently, a systematic literature review of literature was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) model on three databases. Search terms included (MS OR multiple sclerosis) AND (Psychosis OR schizophrenia OR schizoaffective disorder OR psychotic OR hallucination OR delusion). Results: The literature review led to an initial discovery of 2711 hits on PubMed, 1276 hits on PsycINFO, and 5429 hits on Embase. Some patients were diagnosed with MS at an earlier age with a later onset of psychosis, while some were initially diagnosed with psychosis (or schizophrenia) first and subsequently with MS. Psychotic symptoms observed included persecutory delusions, lack of insight, delusions of reference, auditory hallucinations, grandiose delusions, and passivity. The commonly prescribed antipsychotics included risperidone, olanzapine, quetiapine, and aripiprazole. The presence of co-occurring psychosis in MS patients underscores the need for a comprehensive evaluation of symptoms. Conclusion: This case highlights the importance of conducting a magnetic resonance imaging (MRI) brain not only for initial onset psychosis but also for any sudden changes in patients who have had a relatively stable course. Moreover, psychosis can affect treatment adherence in MS, making it all the more critical to identify and manage it promptly.

Non-Pharmacological Interventions in the Management of Dementia-Related Psychosis: A Systematic Review and Meta-Analysis.

OBJECTIVE: As populations age globally, there is an increasing prevalence of dementia, with an estimated 153 million living with dementia by 2050. Up to 70% of people with dementia experience dementia-related psychosis (D-RP). Antipsychotic medications are associated with many adverse effects in older people. This review aims to evaluate the evidence of non-pharmacological interventions in managing D-RP. METHOD: The search of Medline, EMBASE, Web of Science, CINAHL, PsycINFO, and Cochrane included randomised controlled trials that evaluated non-pharmacological interventions. Data extraction and assessment of quality were assessed independently by two researchers. Heterogenous interventions were pooled using meta-analysis. RESULTS: A total of 18 articles (n = 2040 participants) were included and categorised into: sensory-, activity-, cognitive- and multi-component-orientated. Meta-analyses showed no significant impact in reducing hallucinations or delusions but person-centred care, cognitive rehabilitation, music therapy, and robot pets showed promise in single studies. CONCLUSIONS AND IMPLICATIONS: Future interventions should be developed and evaluated with a specific focus on D-RP as this was not the aim for many of the included articles.

A Case Report and Review of the Literature of ICU Delirium.

This case report focuses on what patients and family members may experience when a neurological trauma transpires and resultant intensive care (ICU) delirium occurs. It is the personal account of the patient (A.B.) and spouse's (R.G.B.) perspectives when the patient (A.B) suffered a vertebral artery aneurysm and hemorrhage and experienced intensive care unit (ICU) delirium after being in the ICU for 22 days. This case report provides the patient's and spouse's perspectives regarding delirium, i.e., A.B.'s inability to discern reality, loss of memory, paranoia and hallucinations, agency and recovery, post-ICU syndrome, and post-traumatic stress disorder (PTSD). Clinical diagnosis by the neurosurgeon indicated delirium, with treatment consisting of sleep sedation and uninterrupted sleep. A.B. was able to regain consciousness yet experienced post-traumatic stress disorder up to one year afterward. Consistent family participation in the patient's delirium care is crucial. Family member care and family-centered strategies are provided with implications for future research and health care.

Metamorphopsia with SMART Syndrome: A Case Report.

Introduction: SMART syndrome is a rare complication of brain radiotherapy. This is the first described presentation of SMART syndrome with metamorphopsia, which responded to aspirin, verapamil, and high-dose L-arginine therapy. Case Presentation: A 43-year-old man presented with 3 weeks of migraine headaches with metamorphopsia and complex visual hallucinations affecting the left lower quadrant of both visual fields. This occurred on a background of high-dose radiotherapy for right cerebellar astrocytoma 32 years ago. MRI brain demonstrated unilateral gyriform enhancement and FLAIR hyperintense cortical swelling in the right occipital lobe consistent with SMART syndrome. Conclusion: Unusual presentations of SMART syndrome exist and require consideration in all patients with focal neurological deficit post-brain radiotherapy. Validated diagnostic and treatment modalities for SMART syndrome are urgently required.