report

1. 1
Mental Health Consultation
Patient Name: somaesthetic hallucinations Facility: OMRNC
Date: 9- 9-13
History and Background Information can be found elsewhere in this chart and will not be
repeated here.
Reasonfor Referral: 88-year-old, white, widowed, female… I was asked to evaluate her
because “she complains about a hair in her mouth and bugs coming out of her ears”. She was
admitted from XXXX on 12-20-10. There is very little history available on this lady…no records
from her psychiatrist concerning her bipolar disorder and no stroke history or neuroimaging.
Current Medications: Aricept, Coumadin, Insulin, Prilosec, Cardizem, Nitro prn, Compazine
prn, Lotensin, Norvasc, Spiriva, Claritin, Imdur, Lasix, Zyprexa 5mg qam & 10mg qhs,
Cymbalta 60mg bid, Klonopin 0.5mg qhs, Lamictal 200mg qd.
Medical History: GERD, Type II Diabetes Mellitus, Congestive Heart Failure, Hypertension,
Coronary Artery Disease, Bipolar Disorder, Osteoarthritis, Atrial-Fibrillation, Anxiety State,
history of Stroke/TIA, Diverticulosis, COPD. 8/30 and 7/13 labs showed high BUN & Creatinine
Mental Status Exam: I found her in bed sleeping but rousable to alert. She had a dazed facial
expression. She was hard of hearing and related in childlike manner. Her speech was coherent
and relevant but underproductive. Her affect was flat and she denied depression, anxiety and
biological signs of depression such as early morning awakening, loss of appitite with weight loss
and crying spells. She gave a fragmented history and admitted to memory problems. She was
oriented to year and with some prompting month but gave place as xxxxx something. She said
she continues to feel like there is a “hair growing in my throat…it makes me feel like I have to
gag”. Her insight and judgment were both limited.
Findings and Recommendations: There were no obvious clinical manifestations of Bipolar
Disorder. In every respect, this lady looked like a typical patient with a moderately advanced
vascular dementia (VaD) with the usual features:
memory impairment, poor judgment, lack of spontaneity, perseveration, psychomotor slowing,
lack of initiative and perseverance,diminished engagement with the social environment, fatigue,
general loss of vigor, dilapidation of cognitive functioning, irritability, disinhibition and apathy.
Neurological signs include: gait problems and falls, parkinsonism, weakness,ataxia, rigidity,
dysarthria and urinary incontinence.
The course is usually progressive and stepwise, sometimes referred to as a “stuttering course”.
VaD patients are especially vulnerable to delirium and depression. Episodes of nocturnal
confusion, “delirium-like” episodes and fluctuating mental status are common in VaD patients.

2. 2
The high BUNs & Creatinine suggest renal problems which could cause an overlay of chronic
mild delirium which could explain the hallucinations. However, her hallucinations are fairly rare
somaesthetic hallucinations “bugs crawling” is a kinesthetic hallucination (outside the body)
known as formication which I have only seen in people withdrawing from alcohol or drugs and
“hair growing in the throat” is a visceral hallucination (inside the body). Visceral hallucinations
are sometimes an antiparkinson’s medication side-effect or occur following seizures and may be
caused by thalamic or right parietal lesions. These kinds of hallucinations can be associated with
Bipolar Disorder but are more often organic in origin.
1. The literature shows that there has been some success in the use of Pimozide (2 mg qd;
increase 2 mg every other day; not to exceed 10 mg qd) in treating visceral
hallucinations; as a step short of that, would try switching her from Zyprexa to a less
radical high potency drug such as Risperdal 2mg bid which = lower equivalent dose than
the Zyprexa and observe.
2. Klonopin is an intermediate acting benzodiazepine and can have a cumulative effect
causing confusion and delirium even in the elderly who do not suffer from possible renal
insufficiency. Therefore would DC her Klonopin.
3. Would reduce her Cymbalta to 60mg qd. I do not see a rational for twice the maximum
daily recommended dose.
4. Please obtain records from her Buffalo Psychiatrist, his name is in her chart and if
possible her stroke history with neuroimaging.
5. Keep her exposure to high levels stimulation to an absolute minimum. Find a calm and
quiet spot for her to pass her time.
6. Reduce, as much as possible, drugs with anticholinergic effects which may be causing
dry mouth and triggering the feeling of hair in the throat. Also provide her with water
and cough drops.
___________________________
Drew Chenelly, Psy.D.
Clinical Neuropsychologist