Case Reports in Psychiatry The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. Hyperammonemic Encephalopathy due to Valproic Acid and Topiramate Interaction Thu, 17 Jul 2014 12:01:49 +0000 Valproic acid-induced hyperammonemic encephalopathy is a rare yet serious adverse drug reaction. Medication interactions such a valproic acid and topiramate can precipitate an event. We present the case of a 52-year-old female that presented with acute mental status change and hypersomnolence due to hyperammonemia caused by a valproic acid derivative. The patient improved after withdrawal of the offending medications and treatment with lactulose. Clinicians should remain hypervigilant in monitoring for valproic acid-induced hyperammonemic encephalopathy and risk factors such as polypharmacy. Jennifer D. Twilla and Andrew S. Pierce Copyright © 2014 Jennifer D. Twilla and Andrew S. Pierce. All rights reserved. Treatment of Anxiety and Depression in a Patient with Brugada Syndrome Thu, 10 Jul 2014 07:44:10 +0000 Background. Brugada syndrome is rare and has been a clinically diagnosable entity since 1992. Its clinical manifestations are highly variable, and while some patients remain asymptomatic, others endure sudden cardiac death. Initial presenting symptoms may include palpitations, seizures, syncope, and nocturnal agonal respiration. The diagnosis of Brugada syndrome relies on both clinical findings and characteristic ECG patterns that occur spontaneously or are induced by usage of sodium-channel blocking agents. Aims of Case Report. Many psychiatrists may be unaware of the possibility of medical cocontributing etiologies to physical symptoms of anxiety and depression. We present a case of a patient who was treated psychiatrically for anxiety and panic attacks and who was subsequently diagnosed with Brugada syndrome and treated medically with an implantable cardioverter defibrillator (ICD), the only treatment option demonstrated to be effective. Her psychiatric symptoms predated her diagnosis of Brugada syndrome by at least fifteen years. Conclusion. The patient's eventual diagnosis of Brugada syndrome altered the course of her psychopharmacologic medication management and illustrates the utility of a psychosomatic approach to psychiatric symptom management. Jasper J. Chen and Rajbir S. Sangha Copyright © 2014 Jasper J. Chen and Rajbir S. Sangha. All rights reserved. Immunosuppressant-Associated Neurotoxicity Responding to Olanzapine Wed, 09 Jul 2014 12:05:12 +0000 Immunosuppressants, particularly tacrolimus, can induce neurotoxicity in solid organ transplantation cases. A lower clinical threshold to switch from tacrolimus to another immunosuppressant agent has been a common approach to reverse this neurotoxicity. However, immunosuppressant switch may place the graft at risk, and, in some cases, continuation of the same treatment protocol may be necessary. We report a case of immunosuppressant-associated neurotoxicity with prominent neuropsychiatric manifestation and describe psychiatric intervention with olanzapine that led to clinical improvement while continuing tacrolimus maintenance. James A. Bourgeois and Ana Hategan Copyright © 2014 James A. Bourgeois and Ana Hategan. All rights reserved. A Case Study of Anorexia Nervosa Driven by Religious Sacrifice Sun, 06 Jul 2014 00:00:00 +0000 Anorexia nervosa (AN) is considered a relatively “modern” disorder; however, a number of scholarly works have cited examples of voluntary self-starvation dating back to several centuries. In particular, there are many examples of female starvation for religious reasons during the medieval period, with many being elevated to sainthood. We present a case of an elderly woman with AN who began restricting her diet when she was 13-years old while studying to be a nun at a Catholic convent. She reports that, during the development of her disease, she had no mirrors and, rather than restricting her diet to be thin or attractive, she restricted her diet to be closer to God in hopes of becoming a Saint. This unique case presents an opportunity to deepen our understanding of AN and the cultural context that affects its development. Amelia A. Davis and Mathew Nguyen Copyright © 2014 Amelia A. Davis and Mathew Nguyen. All rights reserved. Bipolar Disorder after Stroke in an Elderly Patient Wed, 04 Jun 2014 10:20:08 +0000 The onset of bipolar disorder (BD) secondary to a stroke event is a rare clinical entity. Although it may be related to specific regions of the brain, several other factors have been linked to its expression such as subcortical atrophy or chronic vascular burden. While precise locations and cerebral circuits involved in the bipolarity expression after stroke still need to be determined, their investigation represents an opportunity to study brain function and BD etiopathogenesis. We present a BD secondary to multiple subcortical biparietal lacunar infarctions, a lacunar infarction in left putamen and an ischemic lesion at the cerebral trunk evolving the right median portion, in a 65-year-old male patient who experienced manic, hypomanic, and depressive episodes, after 6, 10, and 16 months, respectively, of the cerebrovascular events. Raquel Calvão de Melo, Rui Lopes, and José Carlos Alves Copyright © 2014 Raquel Calvão de Melo et al. All rights reserved. Transient Serotonin Toxicity Evoked by Combination of Electroconvulsive Therapy and Fluoxetine Sun, 01 Jun 2014 11:02:51 +0000 The serotonin syndrome has been described only in rare instances for electroconvulsive therapy combined with an antidepressant medication. We describe a case of serotonin toxicity induced by electroconvulsive therapy in combination with fluoxetine. René Klysner, Birgitte Bjerg Bendsen, and Maja Soon Hansen Copyright © 2014 René Klysner et al. All rights reserved. Effects of Adenotonsillectomy on Neurocognitive Function in Pediatric Obstructive Sleep Apnea Syndrome Mon, 26 May 2014 06:40:35 +0000 Obstructive sleep apnea syndrome (OSAS) in children does not only present with symptoms of sleep disturbances but also with associated symptoms such as growth failure, enuresis, academic learning difficulties, and behavioral problems, including attention deficit/hyperactivity disorder- (ADHD-) like symptoms. We evaluated neurocognitive functions before and after adenotonsillectomy in a patient with OSAS. An 11-year-old boy suspected of having ADHD with nocturnal enuresis was referred for evaluation. He was found to have adenotonsillar hypertrophy. Presence of snoring was evident only after detailed medical interview. Polysomnography confirmed the diagnosis of OSAS, which was subsequently treated by adenotonsillectomy. The apnea/hypopnea index decreased from 21.9 at baseline to 1.8 after surgery, and the frequency of enuresis fell from almost nightly to 2-3 times per month. Neurocognitive and behavioral assessment after the treatment of OSAS showed significant improvement in cognitive functions, especially attention capacity and considerable amelioration of behavioral problems including ADHD-like symptoms. As the most common cause of pediatric OSAS is adenotonsillar hypertrophy, medical interview and oropharyngeal examination should always be performed in children suspected of having ADHD. The necessity of sleep evaluation for children with ADHD-like symptoms was also emphasized. Fumie Horiuchi, Yasunori Oka, Kenjiro Komori, Yasumasa Tokui, Teruhisa Matsumoto, Kentaro Kawabe, and Shu-ichi Ueno Copyright © 2014 Fumie Horiuchi et al. All rights reserved. Unusual Presentation of Uncommon Disease: Anorexia Nervosa Presenting as Wernicke-Korsakoff Syndrome—A Case Report from Southeast Asia Thu, 22 May 2014 11:49:26 +0000 Anorexia nervosa presenting as Wernicke-Korsakoff syndrome is rare. The causes of Wernicke-Korsakoff syndrome are multiple like alcohol abuse, thyrotoxicosis, haemodialysis, severe malnutrition because of gastric carcinoma and pyloric obstruction, hyperemesis gravidarum, and prolonged parenteral feeding. We report a case of anorexia nervosa, who presented with Wernicke's encephalopathy and progressed to Korsakoff's syndrome. Knowledge, awareness, and early intervention of anorexia nervosa by mental health professionals can prevent development of Wernicke-Korsakoff syndrome. Raheel Mushtaq, Sheikh Shoib, Tabindah Shah, Mudasir Bhat, Randhir Singh, and Sahil Mushtaq Copyright © 2014 Raheel Mushtaq et al. All rights reserved. Considering Patients’ Mental Capacity When Giving Them Bad News May Help Their Well-Being: A Case of Suicide Attempt after Being Informed of Lung Cancer Diagnosis Wed, 21 May 2014 11:29:41 +0000 Mental capacity is a central determinant of patients’ ability to make autonomous decisions about their care and deal with bad news. Physicians should be cognizant of this when giving patients bad news in efforts to help them to cope with the illness and to avoid a deterioration of their mental well-being. To show the importance of this concept, a case of suicide attempt with lung cancer is exemplified. A 76-year-old woman attempted suicide after receiving a diagnosis of lung cancer. Her recent life had been emotionally turbulent and she did not have sufficient mental capacity to accept and cope with this truth. She developed depression before attempting suicide. Toshiyuki Kobayashi, Satoshi Kato, and Mitsuo Takeuchi Copyright © 2014 Toshiyuki Kobayashi et al. All rights reserved. Adult-Onset Case of Undiagnosed Neurodegeneration with Brain Iron Accumulation with Psychotic Symptoms Tue, 20 May 2014 11:06:15 +0000 Neurodegeneration with brain iron accumulation (NBIA) is a collective term to indicate a group of neurodegenerative diseases presenting accumulation of iron in the basal ganglia. These disorders can result in progressive dystonia, spasticity, parkinsonism, neuropsychiatric abnormalities, and optic atrophy or retinal degeneration. Onset age ranges from infancy to late adulthood and the rate of progression is very variable. So far, the genetic bases of nine types of NBIA have been identified, pantothenate-kinase-associated neurodegeneration (PKAN) being the most frequent type. The brain MRI “eye-of-the-tiger” sign, T2-weighted hypointense signal in the globus pallidus with a central region of hyperintensity, has been considered virtually pathognomonic for PKAN but recently several reports have denied this. A significant percentage of individuals with clinical and radiographic evidence of NBIA do not have an alternate diagnosis or mutation of one of the nine known NBIA-associated genes (idiopathic NBIA). Here we present an adult-onset case of “undiagnosed” NBIA with the brain MRI “eye-of-the-tiger” sign, and with psychotic symptoms which were successfully treated with antipsychotic and mood stabilizer medications. Here, the term “undiagnosed” is used because the patient has not been screened for all known NBIA genes, but only for two of them. Luigi Attademo, Enrico Paolini, Francesco Bernardini, Roberto Quartesan, and Patrizia Moretti Copyright © 2014 Luigi Attademo et al. All rights reserved. The Melatonin Receptor Agonist Ramelteon Effectively Treats Insomnia and Behavioral Symptoms in Autistic Disorder Wed, 14 May 2014 12:06:45 +0000 Children with autism spectrum disorders (ASD), including autistic disorder, frequently suffer from comorbid sleep problems. An altered melatonin rhythm is considered to underlie the impairment in sleep onset and maintenance in ASD. We report three cases with autistic disorder in whom nocturnal symptoms improved with ramelteon, a selective melatonin receptor agonist. Insomnia and behavior, assessed using the Clinical Global Impression-Improvement Scale, improved in two cases with 2 mg ramelteon and in the third case with 8 mg ramelteon. Our findings demonstrate that ramelteon is effective not only for insomnia, but for behavioral problems as well, in patients with autistic disorder. Kentaro Kawabe, Fumie Horiuchi, Yasunori Oka, and Shu-ichi Ueno Copyright © 2014 Kentaro Kawabe et al. All rights reserved. A Case of Psychosis in Disulfiram Treatment for Alcoholism Thu, 10 Apr 2014 12:10:39 +0000 Background. Disulfiram, a drug used in the treatment of alcohol dependence, is an inhibitor of dopamine-β-hydroxylase causing an increase in the concentration of dopamine in the mesolimbic system. In addition to the physical symptoms associated with concomitant use of alcohol, disulfiram may lead to adverse events, when used alone, including psychosis. Aims. To report a case of a rare complication when using disulfiram for alcoholism treatment in a patient in alcoholic abstinence. Case Report. We describe the case of a 42-year-old male patient, who developed psychotic symptoms 3 weeks after initiating treatment with disulfiram for alcohol dependency. The patient had a history of chronic alcoholism for 12 years and was under disulfiram treatment (250 mg/day) for 1 month, with no other past history of psychiatric illness. The symptoms worsened after he initiated alcohol consumption, while taking disulfiram. The patient was hospitalized and disulfiram was suspended. After 4 days he was asymptomatic and at 6-week follow-up remained asymptomatic. Conclusion. Treatment with disulfiram can lead to the appearance of psychosis in patients with increased vulnerability. In clinical practice, psychosis in the context of alcoholism with disulfiram therapy is often neglected and should be taken into account. Raquel Calvão de Melo, Rui Lopes, and José Carlos Alves Copyright © 2014 Raquel Calvão de Melo et al. All rights reserved. Tackling Negative Symptoms of Schizophrenia with Memantine Thu, 10 Apr 2014 08:46:21 +0000 We present a case of a 52-year-old male patient suffering from chronic schizophrenia stabilized on risperidone long-acting injection (37,5 mg/2 weeks) and biperiden 4 mg/day. Residual symptoms are affective flattening, alogia, avolition, and asociality. Memantine 10 mg/day was added. After 1.5 months, the patient spontaneously referred to “feel better being in company of my relatives.” The following scales have been completed: the Scale for the Assessment of Negative Symptoms (96), the Scale for the Assessment of Positive Symptoms (3), the Mini Mental Scale Examination (26), and the Calgary Depression for Schizophrenia Scale (2). Memantine was increased to 20 mg/day and biperiden was decreased to 2 mg/day. Two months later, apathy and asociality considerably improved and affective flattening, alogia, and attention slightly got better (SANS 76, SAPS 1, MMSE 26, and CDSS 1). After two more months, the improvement continued in the same domains (SANS: 70, SAPS: 1 MMSE: 27, and CDSS: 1). Positive symptoms remained in full remission. It has been hypothesized that one of the causes of schizophrenia is glutamate excitotoxicity. Memantine, a glutamate receptor antagonist, could possibly ameliorate schizophrenia symptoms, the negative ones among them, used as add-on therapy to atypical antipsychotics. Memantine could be of potential help in schizophrenia patients with severe residual negative symptoms. Antonios Paraschakis Copyright © 2014 Antonios Paraschakis. All rights reserved. 31-Year-Old Female Shows Marked Improvement in Depression, Agitation, and Panic Attacks after Genetic Testing Was Used to Inform Treatment Tue, 18 Mar 2014 12:11:40 +0000 This case describes a 31-year-old female Caucasian patient with complaints of ongoing depression, agitation, and severe panic attacks. The patient was untreated until a recent unsuccessful trial of citalopram followed by venlafaxine which produced a partial response. Genetic testing was performed to assist in treatment decisions and revealed the patient to be heterozygous for polymorphisms in 5HT2C, ANK3, and MTHFR and homozygous for a polymorphism in SLC6A4 and the low activity (Met/Met) COMT allele. In response to genetic results and clinical presentation, venlafaxine was maintained and lamotrigine was added leading to remission of agitation and depression. Scott Lawrence Copyright © 2014 Scott Lawrence. All rights reserved. Effectiveness of Saikokaryukotsuboreito (Herbal Medicine) for Antipsychotic-Induced Sexual Dysfunction in Male Patients with Schizophrenia: A Description of Two Cases Mon, 27 Jan 2014 07:45:12 +0000 Antipsychotics sometimes cause sexual dysfunction in people with schizophrenia. The authors report the effectiveness of Saikokaryukotsuboreito (Japanese traditional herbal medicine, Chai-Hu-Jia-Long-Gu-Mu-Li-Tang in Chinese) for antipsychotic-induced sexual dysfunction in two male patients with schizophrenia. The first patient was a 28-year-old man with schizophrenia who suffered erectile dysfunction induced by olanzapine 10 mg/day; the erectile dysfunction significantly improved following the treatment of Saikokaryukotsuboreito 7.5 g/day. The other case was a 43-year-old man with schizophrenia who was receiving fluphenazine decanoate at 50 mg/month and had difficulties in ejaculation; add-on of Saikokaryukotsuboreito 7.5 g/day recovered his ejaculatory function. There has been no report on the effectiveness of Japanese herbal medicine formulations for antipsychotic-induced sexual dysfunction. Although the effectiveness of Saikokaryukotsuboreito needs to be tested in systematic clinical trials, this herbal medicine may be a treatment option to consider for this annoying side effect. Tsuboi Takashi, Hiroyuki Uchida, Takefumi Suzuki, and Masaru Mimura Copyright © 2014 Tsuboi Takashi et al. All rights reserved. Clozapine-Induced Myocarditis: Is Mandatory Monitoring Warranted for Its Early Recognition? Thu, 23 Jan 2014 12:15:14 +0000 Clozapine is an atypical antipsychotic used for treatment resistant schizophrenia. Its potential to induce agranulocytosis is well known but it can also cause myocarditis. Clozapine is the only antipsychotic known to induce this side effect, typically early in the treatment, and literature is scarce on this condition. We are presenting a case report of a 21-year-old schizophrenic male who developed myocarditis within 3 weeks of starting on clozapine for his treatment resistant psychosis. We then aim to review some of the available literature and raise awareness among physicians as this condition can potentially be fatal if not detected early. T. A. Munshi, D. Volochniouk, T. Hassan, and N. Mazhar Copyright © 2014 T. A. Munshi et al. All rights reserved. Manic Episode after Ventricular-Peritoneal Shunt Replacement in a Patient with Radiation-Induced Hydrocephalus: The Role of Lifetime Subthreshold Bipolar Features Sun, 12 Jan 2014 13:20:28 +0000 We present a case report of a woman hospitalized for a ventricular-peritoneal shunting replacement, who developed a manic episode with psychotic symptoms after hydrocephalus resolution. We have no knowledge of cases of manic episodes due to hydrocephalus resolution by ventricular-peritoneal shunt replacement, although previous case reports have suggested that hydrocephalus might induce rapid-onset affective episodes or mood cycles. The patient’s history revealed the lifetime presence of signs and features belonging to the subthreshold bipolar spectrum, in absence of previous full-blown episodes of a bipolar disorder. Our hypothesis is that such lifetime sub-threshold bipolar features represented precursors of the subsequent full-blown manic episode, triggered by an upregulated binding of striatum D2 receptors after the ventricular-peritoneal shunt replacement. Antonio Callari, Valentina Mantua, Mario Miniati, Antonella Benvenuti, Mauro Mauri, and Liliana Dell'Osso Copyright © 2014 Antonio Callari et al. All rights reserved. Catatonic Dilemma in a 33-Year-Old Woman: A Discussion Thu, 12 Dec 2013 15:46:02 +0000 Case. We report a case of catatonia with elevated CK, elevated temperature, and hypoferritinemia after abrupt discontinuation of clozapine in a patient with known proneness to catatonic symptoms. Reinstatement of clozapine therapy was contraindicated due to leukopenia. Neuroleptic malign syndrome could not be ruled out by the administration of quetiapine; this prevented the quick use of other potent D2 antagonists. Some improvement was achieved through supportive therapy, high dose of lorazepam, and a series of 10 ECT sessions. Returning to baseline condition was achieved by a very careful increase of olanzapine. Discussion. Catatonic symptoms in schizophrenia as well as in NMS might be caused by a lack of striatal dopamine (CS) or dopamine D2 antagonism (NMS). CS might be a “special” kind of schizophrenia featuring both hypo- and hyperactivity of dopaminergic transmission. ECT has been described as a “psychic rectifier” or a “reset for the system.” The desirable effect of ECT in cases of CS might be dopaminergic stimulation in the striatum and decrease of both the dopaminergic activity in the limbic system and the serotonergic activity on 5-HT2 receptors. The desirable effect of ECT in NMS would be explained by activation of dopaminergic transmission and/or liberation of dopaminergic receptors from the causative neuroleptics. Alexander Koch, Karin Reich, Jan Wielopolski, Marion Clepce, Marie Fischer, Johannes Kornhuber, and Norbert Thuerauf Copyright © 2013 Alexander Koch et al. All rights reserved. Treatment of Anxiety Disorders and Comorbid Alcohol Abuse with Buspirone in a Patient with Antidepressant-Induced Platelet Dysfunction: A Case Report Thu, 12 Dec 2013 13:38:45 +0000 The risk of abnormal bleeding with serotonin reuptake inhibitors has been known, but there is insufficient evidence base to guide pharmacological treatment of anxiety in patients with underlying haematological conditions. The following case report is about a 50-year-old female with generalized anxiety disorder, social phobia, obsessive compulsive disorder, and alcohol abuse where pharmacological treatment of anxiety symptoms has been difficult as it would lead to bruising due to the patient’s underlying qualitative platelet dysfunction. Treatment with venlafaxine, citalopram, escitalopram, and clomipramine resulted in improvement and anxiety symptoms, as well as reduction in alcohol use, but pharmacological treatment has to be discontinued because of bruising and hematomas. In view of an active substance use disorder, benzodiazepines were avoided as a treatment option. The patient’s anxiety symptoms and comorbid alcohol abuse responded well to pharmacological treatment with buspirone which gradually titrated up to a dose of 30 mg BID. Patient was followed for around a six-month period while she was on buspirone before being discharged to family doctor’s care. Buspirone is unlikely to have a significant effect on platelet serotonin transponder and could be an effective alternative for pharmacological treatment of anxiety in patients with a bleeding diathesis. Mir Mazhar, Tariq Hassan, and Tariq Munshi Copyright © 2013 Mir Mazhar et al. All rights reserved. Treatment Choices in Women with Bipolar Disorder Seeking Pregnancy: A Clinical Case Illustration Thu, 24 Oct 2013 13:12:17 +0000 After ten years of successful maintenance treatment with lithium and olanzapine, a 40-year-old woman with bipolar disorder expressed concerns about continuing the use of medicines, as she was planning a pregnancy. In the past, she had suffered from five severe manic episodes with hospital admissions. After consultations with the treating psychiatrist, gynaecologist, and family doctor, olanzapine was stopped and lithium was gradually withdrawn. After few months, the patient, still in treatment with lithium 300 mg/die, experienced a new manic episode with hospital admission. Treatment with lithium and olanzapine was restored, and she progressively recovered. This case suggests that the risk of manic recurrence after ten years of maintenance treatment may be as high as the well-known risk of recurrence after few years of maintenance treatment, a consideration that doctors may find useful in the light of a complete absence of evidence on treatment choices after five years of successful maintenance treatment. Corrado Barbui, Andrea Bertolazzi, Batul Hanife, and Andrea Cipriani Copyright © 2013 Corrado Barbui et al. All rights reserved. Mirtazapine Treatment of a Severe Depressive Episode and Resolution of Elevated Inflammatory Markers Wed, 09 Oct 2013 16:43:06 +0000 Depression has been shown to be associated with systemic inflammatory activity and the mode of action of several antidepressants appears to involve immunomodulation. Effects on immune system activity have also recently been observed in correlation with therapeutic response to mirtazapine in cardiac patients with depression, but no study has yet examined these effects in otherwise physically healthy depressed patients treated with mirtazapine. This report describes an association between a clinical antidepressant response and a decrease in markers of systemic inflammation observed during pharmacotherapy with mirtazapine in a severely depressed but physically well patient. This observation adds to the evidence that changes in inflammatory responses may be implicated in the mode of action of antidepressants. Further studies of antidepressant responses to mirtazapine and levels of inflammatory markers in depressed patients without medical comorbidity can help elucidate the role of the immune system in the pathophysiology of depression, and hence contribute to the development of novel antidepressant therapies. Shahzad M. Alikhan, Jessica A. Lee, and Luiz Dratcu Copyright © 2013 Shahzad M. Alikhan et al. All rights reserved. Transcranial Magnetic Stimulation for the Treatment of Pharmacoresistant Nondelusional Auditory Verbal Hallucinations in Dementia Wed, 02 Oct 2013 08:45:41 +0000 Auditory verbal hallucinations (AVHs) are known as a core symptom of schizophrenia, but also occur in a number of other conditions, not least in neurodegenerative disorders such as dementia. In the last decades, Transcranial Magnetic Stimulation (TMS) emerged as a valuable therapeutic approach towards several neurological and psychiatric diseases, including AVHs. Herein we report a case of a seventy-six-years-old woman with vascular-degenerative brain disease, complaining of threatening AVHs. The patient was treated with a high-frequency temporoparietal (T3P3) rTMS protocol for fifteen days. A considerable reduction of AVHs in frequency and content (no more threatening) was observed. Although further research is needed, this seems an encouraging result. Anna Marras and Stefano Pallanti Copyright © 2013 Anna Marras and Stefano Pallanti. All rights reserved. Augmentative Asenapine in a Recurrent Manic Catatonic Patient with Partial Response to Clozapine Thu, 19 Sep 2013 14:26:27 +0000 Catatonia is a severe but treatable neuropsychiatric syndrome known since the middle of the nineteenth century. It has been considered for a long time as a subtype of schizophrenia, even though this association occurs only in 10% of cases. In contrast, it is frequently observed in bipolar patients. First-line treatment consists of benzodiazepines, while in case of resistance electroconvulsive therapy (ECT) and clozapine have shown positive results. In addition, recent studies reported the efficacy of some atypical antipsychotics. The present case shows the clinical response to augmentative asenapine in a catatonic manic patient with a partial response to clozapine. Massimiliano Buoli, Cristina Dobrea, Alice Caldiroli, Laura Cremaschi, and A. Carlo Altamura Copyright © 2013 Massimiliano Buoli et al. All rights reserved. Catatonia, Neuroleptic Malignant Syndrome, and Cotard Syndrome in a 22-Year-Old Woman: A Case Report Wed, 04 Sep 2013 15:42:31 +0000 The following case study describes a 22-year-old woman with depression and symptoms of psychosis who developed neuroleptic malignant syndrome after using Risperidone, thus requiring life support equipment and Bromocriptine, later recovering after seven days. From a psychiatric and neurological point of view, however, the persistence of catatonic syndrome and Cotard syndrome delusions was observed, based on assertions such as “I do not have a heart,” “my heart is not beating,” “I can not breathe,” “I am breaking apart,” “I have no head” (ideas of negation) and statements about the patient being responsible for the “death of the whole world” (ideas of enormity). Brain NMR revealed leukoencephalopathy, interpreted as scar lesions caused by perinatal neurological damage, after discarding other pathologies. The patient responded well to electroconvulsive therapy after 11 sessions. Organic vulnerability to these syndromes, as well as their coexistence and clinical differentiation is discussed in the light of the data observed. C. Weiss, J. Santander, and R. Torres Copyright © 2013 C. Weiss et al. All rights reserved. Delayed Onset and Prolonged ECT-Related Delirium Tue, 03 Sep 2013 14:44:36 +0000 Electroconvulsive therapy (ECT) is effective in the treatment of depression. Delayed post-ECT delirium is rare but can occur in a small subset of patients with risk factors and in most cases resolves with the use of psychotropic medications. We report a unique presentation of a patient who developed a delayed post-ECT delirium with fecal incontinence that commenced 24 hours after the administration of ECT. The condition resolved spontaneously after 48 hours without the use of psychotropic medications. Sameer Hassamal, Ananda Pandurangi, Vasu Venkatachalam, and James Levenson Copyright © 2013 Sameer Hassamal et al. All rights reserved. Venlafaxine-Induced Orthostatic Hypotension in a Geriatric Patient Wed, 31 Jul 2013 13:07:13 +0000 Venlafaxine is not usually associated with risk of orthostatic hypotension. A 65-year-old US Caucasian female taking 225 mg/day of venlafaxine extended-release developed symptomatic orthostatic hypotension. The systolic and diastolic blood pressure dropped by 25 and 18 mm Hg, respectively, from supine position to standing position within 3 minutes. The patient was otherwise healthy and the orthostatic hypotension resolved with venlafaxine discontinuation. This was a probable venlafaxine adverse drug reaction according to the Naranjo scale. This case contributes to the scarce literature that indicates that clinicians need to be aware that occasionally venlafaxine can induce clinically significant orthostatic hypotension, particularly in geriatric patients. Our patient did not have orthostatic hypotension when she was taking venlafaxine at 60 years of age in higher venlafaxine doses (300 mg/day) but developed this adverse drug reaction when venlafaxine was restarted at the geriatric age. This case indicates that a history of prior tolerance to venlafaxine does not guarantee tolerance after 65 years of age. If a clinician decides to use venlafaxine in geriatric patients, the clinician should warn the patient about the risk of orthostatic hypotension and consider very slow titration and low doses. Vidyashree Chikkaramanjegowda and Jose de Leon Copyright © 2013 Vidyashree Chikkaramanjegowda and Jose de Leon. All rights reserved. Is the Concept of Delirious Mania Valid in the Elderly? A Case Report and a Review of the Literature Sun, 28 Jul 2013 09:33:35 +0000 Delirious mania has been well recognized in the published literature and in the clinic. Over the years there has been refinement of understanding of its clinical features, course, and treatment. The literature suggests that delirious mania should be considered in individuals who present with a constellation of sudden onset delirium, mania, and psychosis. However, delirious mania is not recognized under a formal classification system nor are there any formal guidelines for its treatment. We, as such, question if the concept of delirious mania in the elderly is valid. We present a case of an elderly man with marked features of delirium with minimal manic or psychotic features who had a previous diagnosis of bipolar I disorder. On thorough clinical assessments no identifiable cause of his delirium was found. We therefore considered his presentation to be more likely due to delirious mania. Electroconvulsive therapy was considered and offered to which he responded very well. We invite the reader to consider whether delirious mania is a valid concept in the elderly, where features of delirium may be more prominent than manic or psychotic features. Pramudith M. Maldeniya and Akshya Vasudev Copyright © 2013 Pramudith M. Maldeniya and Akshya Vasudev. All rights reserved. Importance of Video-EEG Monitoring in the Diagnosis of Refractory Panic Attacks Wed, 24 Jul 2013 13:51:27 +0000 Partial seizures can be misdiagnosed as panic attacks. There is considerable overlap of symptoms between temporal lobe seizures and panic attacks making the diagnosis extremely challenging. Temporal lobe seizures can present with intense fear and autonomic symptoms which are also seen in panic disorders. This results in delay in diagnosis and management. We report an interesting case of a young woman who was diagnosed with right temporal lobe seizures with symptoms suggestive of a panic attack. Batool F. Kirmani and Diana Mungall Copyright © 2013 Batool F. Kirmani and Diana Mungall. All rights reserved. A Case of Bipolar Affective Disorder and Aspiration Pneumonia Mon, 15 Jul 2013 15:09:46 +0000 Adults with mental illness are at a higher risk of aspiration pneumonia than the general population. We describe the case of a patient with bipolar affective disorder and two separate episodes of aspiration pneumonia associated with acute mania. We propose that he had multiple predisposing factors, including hyperverbosity, sedative medications, polydipsia (psychogenic and secondary to a comorbidity of diabetes insipidus), and neuroleptic side effects. Alessandro Gerada and Gaetano Dell'Erba Copyright © 2013 Alessandro Gerada and Gaetano Dell'Erba. All rights reserved. Lamotrigine Augmentation of Serotonin Reuptake Inhibitors in Severe and Long-Term Treatment-Resistant Obsessive-Compulsive Disorder Sun, 14 Jul 2013 09:35:16 +0000 The treatment recommendations in obsessive-compulsive disorder (OCD) after lack of response to selective serotonin reuptake inhibitors (SSRIs) include augmentation with other drugs, particularly clomipramine, a more potent serotonin reuptake inhibitor (SRI), or antipsychotics. We present two cases of response to lamotrigine augmentation in treatment-refractory OCD; each received multiple SRI trials over a >10-year period. The first patient had eleven years of treatment with multiple combinations including clomipramine and SSRIs. She had a >50% decrease of Y-BOCS (from 29 to 14) by augmenting paroxetine (60 mg/day) with lamotrigine (100 mg/day). The second patient had 22 years of treatment with multiple combinations, including combinations of SSRIs with clomipramine and risperidone. She had an almost 50% decrease of Y-BOCS (from 30 to 16) and disappearance of tics by augmenting clomipramine (225 mg/d) with lamotrigine (200 mg/day). These two patients were characterized by lack of response to multiple treatments, making a placebo response to lamotrigine augmentation unlikely. Prospective randomized trials in treatment-resistant OCD patients who do not respond to combinations of SSRIs with clomipramine and/or antipsychotics are needed, including augmentation with lamotrigine. Until these trials are available, our cases suggest that clinicians may consider lamotrigine augmentation in such treatment-resistant OCD patients. Manuel Arrojo-Romero, María Tajes Alonso, and Jose de Leon Copyright © 2013 Manuel Arrojo-Romero et al. All rights reserved.