|Year : 2016 | Volume
| Issue : 2 | Page : 168-171
Sensory deprivation leading to late onset psychosis
Swapnajeet Sahoo, Pradyumna, Sandeep Grover
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Web Publication||13-Dec-2016|
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
Sensory deprivation is understood as diminution or absence of perceptual experiences to the usual external stimuli. Sensory deprivation in elderly is reported to be associated with depression, anxiety, psychosis, dementia, etc. In this report, we present the case of an 84-year- elderly man who developed auditory hallucination and after 1 year of onset of hearing difficulties. He was managed with quetiapine, with which he showed significant improvement.
Keywords: Auditory hallucinations, hearing impairment, sensory deprivation
|How to cite this article:|
Sahoo S, Pradyumna, Grover S. Sensory deprivation leading to late onset psychosis. J Geriatr Ment Health 2016;3:168-71
| Introduction|| |
Sensory deprivation is usually defined as a diminution or absence of usual external stimuli or perceptual experiences, resulting in psychological distress, and aberrant functioning if prolonged. It can be congenital or acquired and can involve one or more sensory modalities (vision, hearing, tactile, and taste). 
Sensory deprivation syndrome is not a new entity. It has been known since long back. Charles Bonnet (1760) described a syndrome in mentally healthy people who develop vivid, complex recurrent visual hallucinations following significant vision loss and the same has been replicated in a number of studies/case reports. ,, Later on, Kraepelin described the presence of paranoia and persecutory delusions in patients with impaired hearing. 
Sensory deprivation has been reported among elderly subjects and is associated with poor quality of life in all domains of activities of daily living and communication. It has also been linked to the development of psychiatric disorders such as depression, anxiety, psychosis, dementia, and mental confusion. , In elderly particularly, sensory deprivation has been linked with decline in cognitive functions which further add to their difficulty. Of all the listed psychiatric disorders in individuals with sensory deprivation, late onset psychosis is an uncommon entity. Since 1950s, several studies have tried to find out an association between late onset psychosis and sensory deprivation/deficits, especially deafness. , It is suggested that sensory deprivation can lead to the development of auditory hallucinations among elderly. , Association between sensory deprivation and psychotic experiences/illness in the elderly population is not a consistent finding as it has been reported in young/adolescents. ,
In this case report, we present the description of an elderly individual with minimal cognitive deficits who developed psychosis following sensory deprivation (hearing impairment).
| Case Report|| |
Mr. S, an 84-year-old retired clerical man, residing in a joint family set up in an urban area was brought by his family members to our psychiatry outpatient services due to excess and unmanageable problematic behavior. He had a history of coronary artery disease with atrial flutter detected 6 years back and was on medications for the same.
Detail exploration of psychiatric history revealed a history suggestive of recurrent depressive disorder, the first episode occurring at the age of 65 years, with 5 episodes in the intervening period. For these episodes, he would be treated with selective serotonin reuptake inhibitors with good response. The last episode of depression was 6 years back. He attained remission and soon discontinued medications prescribed to him.
About 3 years prior to presentation, he was noticed to have difficulty in hearing and family members had to speak to him at a louder volume or had to speak very close to his ear. He consulted an otorhinolaryngologist for these complaints and after audiometry evaluation was found to have profound hearing loss and was advised hearing aids. He would use the hearing aids regularly but still was not able to overcome his hearing problem. Over the period, his hearing impairment kept on progressing. After about a year of starting of hearing impairment, he began to hear derogatory auditory hallucinations of discussing type in clear consciousness. He would get irritated over the same and start searching for the source of voices and abuse and respond back to the voices. Initially, the voices were present for a shorter duration, but gradually the frequency of voices increased; began to hear voices almost throughout the day, threatening to kill him. Due to the same, he would restless, have anger outbursts and reduced going out. Later he also developed delusion of persecution and delusion of reference. Onset and progress of psychosis were associated with worsening of hearing impairment. However, during this period, there was also deterioration of cognitive functions. Throughout the period, there was no evidence of any abnormal movements, history of fall, urinary or fecal incontinence, clouding of consciousness, relapse of depressive symptoms and episodes of delirium.
In view of the psychotic symptoms occurring independently of depressive symptoms, diagnoses of late onset schizophrenia with recurrent depressive disorder currently in remission, mild cognitive impairment, presbycusis, and coronary artery disease with arterial flutter were considered.
At the initial evaluation, his physical examination was unremarkable, except for the evidence of bilateral sensory neural hearing impairment. His mental status examination revealed the presence of delusion of persecution, delusion of reference and auditory hallucinations. His affect was euthymic. His Mini-Mental State Examination score was 22. His routine investigations did not reveal any abnormality. Investigations in the form of electroencephalogram, ultrasound abdomen and pelvis, serum Vitamin-B12 levels, serum folic acid levels, Vitamin-D levels, and thyroid function test did not reveal any abnormality. Contrast-enhanced magnetic resonance imaging revealed gliotic infarcts in left cerebellar hemisphere. The psychometric evaluation revealed evidence of significant cognitive deficits in domains of intelligence, memory, and perceptuomotor functions.
Initially, he was started on tablet risperidone which was slowly increased to 3 mg/day. His psychotic symptoms improved with risperidone, but there was the emergence of depressive symptoms. In addition, he developed oral dyskinesia, shuffling gait, and mask-like facies. Hence, risperidone was replaced with quetiapine (started at 12.5 mg/day and slowly increased to 200 mg/day), and additionally he was prescribed mirtazapine 7.5 mg/day, donepezil 10 mg/day, and aspirin 75 mg/day along with multivitamin supplements. His hearing aids were upgraded after consultation with otorhinolaryngologist, which led to improvement in the hearing ability by 40%. With the above treatment over the period of 4 weeks, his psychotic and depressive symptoms improved along with resolution of extrapyramidal symptoms. The patient continues to follow-up on the same medication without any recurrence of psychotic and depressive symptoms. His MMSE scores fluctuate around 19-22.
| Discussion|| |
Prevalence of sensory deprivation syndrome (hearing impairment and visual impairment) increases with age. Prevalence of hearing impairment is estimated at 30-40% in population aged 65-74 years and at 50-80% in population aged >75 years. 
Hearing impairment associated psychotic disorder has been found to be is quite prevalent in older persons. ,, A 10 year follow-up study of 47 individuals diagnosed with late paraphrenia (first episode psychosis after the age of 60 years) revealed that about 70% (33 individuals) had co-morbid sensory deprivation (deafness and/or visual impairment).  Furthermore, the literature on evaluation of risk factors for late paraphrenia points toward sensory deprivation to be one of the robust risk factor for development of late paraphrenia. Specifically patients having hearing impairment had 4-fold increased risk for developing psychosis in late life apart from other risk factors (female gender, staying alone, social isolation, and presence of neurological soft signs). ,
Available evidence suggest an association of increase in severity levels of hearing impairment and an increased prevalence of paraphrenia or other late onset psychotic disorders and schizophrenia in later life. ,,, However, there are few studies which refute such an association. 
Several different explanations have been suggested to explain the association between sensory impairment (leading to sensory deprivation) and late onset paranoid psychosis. First, hearing impairment poses difficulty in verbal communication, which in turn results in reduced social interaction, a feeling of social isolation and loneliness, especially in elderly people with acquired hearing impairment. ,, Communication difficulties may provoke misinterpretation of social cues and in turn may induce feelings of paranoia. Second, presbycusis has been reported as a risk factor and fragility marker for cognitive decline and long term cognitive impairment in elderly individuals.  Age related hearing impairment has been found to accelerate cognitive decline and Alzheimer's dementia.  The decreased cognitive capacity may mediate the association between hearing impairment and psychosis in elderly people, particularly delirium.  Third, it is known that sensory input is highly essential for adequate source monitoring.  Hearing challenged individuals receive less external information input and hence may be susceptible to an externalizing attribution bias which predisposes them to experience hallucinations.  Last but not the least both the sensory impairment and psychosis may result from intracranial lesions or some other pathologic processes,  or they may coexist by coincidence. 
Index case had vulnerabilities in the form of hearing impairment, higher age and cognitive impairment, all of which possibly contributed to development of psychosis. Accordingly, it can be said that clinicians managing elderly patients should always assess the patients for hearing and visual impairments. Further, when present these must be addressed adequately in time to reduce the chance of developing psychosis.
Several studies have reported paranoid elderly individuals with dementia and sensory deprivation have a poorer outcome  or are difficult to treat. Hence, this case report is unique as the index case has a very good outcome with treatment.
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Conflicts of interest
There are no conflicts of interest.
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