A Case Study Exploration of Prosopometamorphopsia (PMO): The Complexities of Facial Distortions

Case Study 2: Sarah Jones and the Battle Against Distorted Faces:

Initial Presentation: Sarah Jones, a 42-year-old accountant, entered the neurology clinic with a tremor in her voice and worry etched on her face. For the past six months, she’d been plagued by a terrifying phenomenon – faces, both familiar and those of strangers, would morph and distort before her eyes. Describing it as a funhouse mirror come to life, Sarah explained how eyes would bulge grotesquely, noses contort into cartoonish hooks, and mouths stretch into unsettling grins. The constant visual distortions made daily life a challenge, leaving her barely able to recognize the people around her.

Medical History and Neurological Examination: Despite a clean bill of health with no history of migraines, epilepsy, or head injuries, a thorough neurological exam by the specialist revealed no abnormalities. However, Sarah’s vivid description of the distorted faces resonated with a rare condition – prosopometamorphopsia (PMO). Given the rarity of PMO, further investigation was necessary.

Diagnostic Imaging and Tests:

MRI Scan: An MRI scan aimed to rule out any structural abnormalities in the brain that might explain the bizarre visual disturbances. Thankfully, the scan came back clean, showing no signs of tumors, strokes, or any other lesions that could be causing the distortions.

Visual Evoked Potentials (VEPs): To delve deeper, visual evoked potentials (VEPs) were employed. This test measures the electrical activity of the brain in response to visual stimuli. While the VEP results weren’t conclusive, they didn’t contradict the possibility of PMO. Armed with the information from Sarah’s experience, the absence of alternative explanations, and the normal brain scans, the neurologist confidently diagnosed Sarah with PMO.

Treatment Plan:

Pharmacological Intervention: Crafting a treatment plan for Sarah required a multi-pronged approach. Although Sarah hadn’t reported a history of migraines, some PMO cases have been linked to migraines without aura. As a preventative measure, a low-dose daily medication typically used to prevent migraines was prescribed. The hope was that regulating brain activity in this way might offer some relief from the visual distortions.

Vision Therapy: Sarah was referred to a vision therapist with expertise in retraining the brain’s visual processing pathways. Through specifically designed exercises, the therapy aimed to improve Sarah’s visual perception and reduce the distressing distortions.

Psychological Support: Recognizing the emotional toll PMO can take, the neurologist also recommended psychological support. Therapy sessions focused on equipping Sarah with tools to manage the anxiety and social isolation that often accompany PMO.

Treatment Outcomes:

Initial Phase: The journey to manage PMO wasn’t a straight line for Sarah. The initial month brought minimal improvement. The facial distortions persisted, although the migraine medication did offer a glimmer of hope by reducing the frequency of the episodes.

Continued Progress: With consistent effort in visual therapy, positive results began to emerge by the third month. Sarah reported a slight decrease in the severity of the warping and a newfound ability to mentally reconstruct faces to their normal appearance, offering a sense of control over the distortions.

Long-Term Improvement: By the six-month mark, the impact of PMO on Sarah’s life had lessened considerably. The therapy sessions had equipped her with strategies to manage the anxiety, and the distortions themselves had become less pronounced and less frequent. While some distortions remained, they were no longer overwhelming, and Sarah could usually recognize familiar faces.

Medication and Treatment for Sarah Jones:

Case Study 2: Sarah Jones: Sarah Jones, a 42-year-old accountant, began her treatment with Propranolol (Inderal), a beta-blocker commonly used to prevent migraines. She started on 20 mg twice daily, with the dose adjusted up to 80 mg twice daily based on her response and tolerance. Alongside medication, Sarah was referred to a vision therapist who provided her with exercises designed to retrain her brain’s visual processing pathways, aiming to reduce the severity and frequency of her visual distortions.

Recognizing the emotional toll of her condition, Sarah’s treatment also included psychological support. She was referred to a psychologist for Cognitive Behavioral Therapy (CBT) to help manage the anxiety and stress associated with her PMO. Lifestyle modifications were another critical aspect of her treatment. Sarah implemented stress-reducing techniques like yoga, deep breathing exercises, and regular physical activity. She also worked on identifying and avoiding potential dietary triggers and maintaining a regular sleep schedule.

Sarah’s initial progress was slow, with minimal improvement in the first month. However, consistent effort in vision therapy and regular psychological support sessions began to show positive results by the third month. Sarah attended bi-weekly vision therapy sessions for the first three months, adjusting her exercise regimen as needed. Monthly sessions with a psychologist helped monitor and support her mental health. Based on her response, the dosage of Propranolol was adjusted. If Propranolol proved ineffective or poorly tolerated, alternatives like Amitriptyline or Topiramate were considered.

Long-term, Sarah continued taking Propranolol if it effectively managed her symptoms. She reduced her vision therapy sessions to monthly or as needed and maintained ongoing CBT sessions to help manage any residual anxiety. Regular bi-annual follow-ups with her neurologist ensured that her condition was continually reassessed, and her treatment remained effective.

Overall Implications and Future Directions:

The Michael Thompson and Sarah Jones cases underscore the complexity and variability of PMO and its management. While Michael’s PMO was closely linked to his migraines with aura, Sarah’s condition presented without a clear migraine history, requiring a broader diagnostic and therapeutic approach. These cases highlight several key implications for clinical practice and research:

Individualized Treatment Approaches: Tailoring treatment plans to the individual’s specific symptoms and medical history is crucial. For Michael, migraine prevention was the key, while for Sarah, a combination of migraine prevention, vision therapy, and psychological support proved effective.

Comprehensive Diagnostic Evaluation: A thorough diagnostic workup, including imaging and specialized tests like VEPs, is essential to rule out other causes and confirm the diagnosis of PMO.

Importance of Lifestyle Modifications: Addressing lifestyle factors that can exacerbate symptoms, such as stress and sleep patterns, is critical in managing PMO effectively.

Need for Further Research: Continued research is needed to better understand the pathophysiology of PMO, its connection to migraines, and the most effective treatment strategies.