Psychosis in PD (PDP): By Dr. De Leon

Image result for images of psychotic people

Since there are so many people that have this problem including myself in the past due to medications, I thought I would address some of the salient points which could help take care of our loved ones better as well as help those of us who live with the disease to manage our symptoms better if present because this is the highest cause of care-giver burden and stress. The presence of PDP also leads to significant disability and poor quality of life. The risk increases with disease duration.

First of all, there are many causes of underlying neuropsychiatric disturbances which can present in the confines’ of Parkinson’s disease. These can be related to treatment(s) or disease itself.

  1. PD process- including visual processing e.g. contrast recognition, visual acuity, and color acuity reduction
  2. Abnormal activation of brainstem and cortical regions
  3. Sleep disturbances
  4. Brain abnormalities e.g. Lewy body
  5. Genetic factors – i.e./ APO E – particularly the E4 allele which increases risk of Alzheimer’s.
  6. Over activation of dopamine neurons by chronic use of dopamine replacement
  7. Decreased serotonin ( due to 6)
  8. Over activity of acetylcholine – same as above

Parkinson’s disease may be associated with a wide range of psychotic symptoms, including delusions, hallucinations in multiple sensory modalities –i.e. auditory, tactile, olfactory, visual, and gustatory). Psychotic symptoms may occur with retained insight, or may involve severe paranoid delusions and confusional states. In the early stage, PD-related hallucinations are primarily visual, with retained insight and a clear sensorium. (Meaning patients are fully aware and awake not confused!) With PD progression (late stages), patients may exhibit worsening hallucinations, with loss of insight. Visual hallucination are most common, (22% to 38% of patients with PD). Visual hallucinations are generally well formed, and may consist of people or animals (less commonly, inanimate objects), tend to persist over time, and typically involve recurring content. Up to 20% of patients experience auditory hallucinations, which usually accompany visual hallucinations and are less likely to occur in isolation. Olfactory and tactile hallucinations are less common, but can occur. These hallucinations tend to occur most often during periods of decreased stimulation (e.g., in the evening or when the lighting is low).

Delusions are also part of the neuropsychiatric disturbances in PD affecting approximately 5% of patients. The delusions tend to be of the paranoid either persecutory or jealous in nature. I myself suffered extreme jealousy directed towards my husband – un -common for me. The subject of mine and the majority of my patients has been an unshakable belief of spousal infidelity). I also have had on occasion independent of any other problems and not related to medication but mere factor of my PD some gustatory and olfactory hallucinations which last only but a few seconds.

Visual hallucinations tend to be non-invasive and non-frightening to the individual since they usually involve children or small animals. the family are the ones usually troubled by this. bit on occasion they can be violent and extremely frightening for patient and scary to watch for family members – these must be treated always.

Of Note, although auditory hallucinations can present themselves in PD, this is an extremely rare occurrence. Auditory hallucinations usually imply a underlying brain structural abnormality ( i.e., stroke), schizophrenia, or  substance abuse.

In PD patients, clinical rating scales like UPDRS, sleep scale, the Hamilton scale, and the PD psychosis questionnaire can help to identify psychotic symptoms and other common comorbid neuropsychiatric disorders, such as depression ( more common in early stage), anxiety( present in about 40% and associated with worsening motor function), impulse control disorders (ICDs) and disorders of sleep. Sleep disorders are an integral part of the disease and occur in as many as 90% of patients. Some of the problems commonly seen are insomnia (my major problem and many of ours – sleep wake cycle appears to be shifted), hypersomnia, sleep fragmentation, sleep terrors, nocturnal movements, restless legs syndrome, sleep apnea, and Rem Behavior disorder. However, to date there are no well validated scales and we depend on clinical diagnosis and exclusion of other things.

In the geriatric PD population common causes of psychosis:

  • Steroids are frequently a cause of psychosis
  • Dehydration
  • Infection (urine especially)
  • Lack of sleep
  • Medications – e.g. amantadine, artane, dopamine agonists


How do you treat PDP?

FIRST! Stop offending drugs or correct any of above deficits or infections


  1. Seroquel (quetiapine)- biggest side effect is orthostatic hypotension (low bp) and sedation which is not always a bad thing we often want this to normalize sleep wake cycle. Oher side effects include dry mouth, hyperlipidemia, constipation, dyspepsia, dizziness, weight gain, increased appetite, fatigue, hyperglycemia, dysarthria, and nasal congestion. – I not had problem with these in past much.
  2. Clozaril (clozapine) not used much because of weekly blood draws needed due to possible agranulocytosis.
  3. New medication FDA approved is PRIMAVENSERIN (non-dopaminergic- actually serotonergic antipsychotic) 0nce daily – 2 tablets 17 mg each – the biggest side effect is peripheral edema and confusion. (should be first line of treatment)

Cholinesterase inhibitor:

Exelon (rivastigmine) only FDA medicine approved for PD dementia

So it is possible to have sensory hallucinations early on in the disease as part of illness itself which does not necessarily require intervention if patients are aware and not bothered or interfering with activities of daily living or social aspect. Usually these are olfactory or tactile and occasionally visual. However, as disease progresses visual hallucinations and delusions become more prominent and as PD advances there is a higher likelihood of being related to underlying dementia. Treat symptoms, remove offending causes and treat underlying dementia. But for all PD patients although no current treatment to prevent progression of disease or prevent dementia several things like staying mentally and physically active can help greatly as well as proper nutrition and adequate sleep. Seek immediate attention, if you or loved one experience any of these problems.


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