Visual Hallucinations in Parkinson's Disease: a Hierarchy of Impairments Involving Perception, Source Monitoring and Reasoning

Up to 45% of patients with Parkinson's disease (PD) will develop visual hallucinations (VH) at some point in their illness. Although medication, depression, illness duration and ophthalmic abnormalities are identified as risk factors for VH-PD, specific perceptual and cognitive impairments may also play a role. The aim of this study was therefore to explore a hierarchy of low level perceptual processes, imagery and high level executive functions linked to reasoning in groups of VH and non VH PD. This study investigated 18 patients with non dementing idiopathic PD. Nine patients had a history of VH. The VH and non VH PD groups were matched for demographic (age, gender), neuropsychological (premorbid and current levels of functioning) and clinical characteristics (disease duration, motor symptom severity, daily levodopa medication) apart from presence of VH in the index group. The VH-PD and non VH PD groups completed tests of bottom-up object processing and recognition, visual imagery, and top-down executive functions such as response inhibition, response suppression, source monitoring and spatial and probabilistic reasoning. Compared to the non VH-PD group, VH-PD patients showed impairments in object perception and recognition impairments in cases when key identifying details were obscured. They also made more source misattribution errors, where self-generated images were misattributed to an external source. Finally, abnormalities in reasoning were evident. On the other hand, there were no differences between the VH-PD and non VH-PD groups on measures of visual perception using canonical views of objects, spatial perception, visual imagery, and other measures of executive function (initiation and suppression of responses, decision-making and self-monitoring). The findings are discussed in relation to models of delusion and hallucination formation.