Case Reports in Psychiatry The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Robust and Sustained Effect of Ketamine Infusions Coadministered with Conventional Antidepressants in a Patient with Refractory Major Depression Wed, 04 Mar 2015 09:50:07 +0000 Antidepressant treatments show low capacity to achieve full clinical remissions. Electroconvulsive therapy is an alternative treatment which has been shown to be more effective but it is not well tolerated and there are concerns regarding its safety. We present the case of a patient with resistant depression and modest and transient response to ECT and who showed a robust and maintained response after six i.v. ketamine (0.5 mg/kg) infusions without withdrawing her antidepressant regimen. Ketamine was very well tolerated. This case illustrates the potential role of ketamine as a booster to standard antidepressants. José Manuel Montes, Elena Luján, Fernado Pascual, Jose María Beleña, Jose Luis Perez-Santar, Luis Javier Irastorza, and Jerónimo Saiz-Ruiz Copyright © 2015 José Manuel Montes et al. All rights reserved. Self-Inflicted Needle Injuries to the Eye: A Curing Pain Tue, 24 Feb 2015 10:38:23 +0000 There are few reports of severe self-injury to eyes in patients with schizophrenia. We report on a 41-year-old woman, primarily visiting for symptoms of endophthalmitis resulting from self-inflicted needles. Further evaluations established the diagnosis of schizophrenia because of arguing and commenting on auditory hallucinations and negative symptoms including social isolation, decreased self-care, blunt affect, and a monotone voice. The patient had been suffering from auditory hallucinations for several years and found relief in bodily pain caused by needles. The patient received 6 mg of risperidone. Hallucinations were resolved and self-injury behaviour was not repeated. Shahrokh Amiri, Asghar Arfaei, and Sara Farhang Copyright © 2015 Shahrokh Amiri et al. All rights reserved. The Management of Catatonia in Bipolar Disorder with Stimulants Thu, 19 Feb 2015 11:53:10 +0000 Catatonia, while not a rare occurrence in bipolar disorder, has not been widely discussed in the literature. We present a case of a married Caucasian male with a history of bipolar disorder, exhibiting catatonia and experiencing difficulty in day-to-day functioning. He demonstrated impairment in cognition and an inability to organize simple activities of daily life. After exhausting a number of options for medical management, including benzodiazepines, atypical antipsychotics, and amantadine, he only displayed significant clinical improvement with the addition of a stimulant, methylphenidate. In time, the patient saw a complete return to normal functioning. The use of stimulants for catatonia in bipolar disorder may be an interesting and effective option for treatment. While this is not the first time this treatment has been suggested, there is very little data in support of it; our case confirms the discoveries of previous case reports. Waheed K. Bajwa, Ali Rastegarpour, Omar A. Bajwa, and Jessica Babbitt Copyright © 2015 Waheed K. Bajwa et al. All rights reserved. Psychogenic Polydipsia: The Result, or Cause of, Deteriorating Psychotic Symptoms? A Case Report of the Consequences of Water Intoxication Wed, 21 Jan 2015 13:40:30 +0000 Water intoxication is a rare condition characterised by overconsumption of water. It can occur in athletes engaging in endurance sports, users of MDMA (ecstasy), and patients receiving total parenteral nutrition. This case outlines water intoxication in a patient with psychogenic polydipsia. When the kidney’s capacity to compensate for exaggerated water intake is exceeded, hypotonic hyperhydration results. Consequences can involve headaches, behavioural changes, muscular weakness, twitching, vomiting, confusion, irritability, drowsiness, and seizures. Cerebral oedema can lead to brain damage and eventual death. In this case, psychogenic polydipsia led to significant hyponatraemia, cerebral oedema, and tonic-clonic seizures. Differential diagnoses for hyponatraemia are outlined. The aetiology of psychogenic polydipsia is uncertain, but postulated hypotheses are explored. Psychogenic polydipsia occurs in up 20% of psychiatric patients and this case serves to remind us to be cognizant of water overconsumption. Melissa Gill and MacDara McCauley Copyright © 2015 Melissa Gill and MacDara McCauley. All rights reserved. LPG Dependence after a Suicide Attempt Tue, 13 Jan 2015 11:21:32 +0000 Inhalant abuse is a problem that is getting more common all around the world. The increase in prevalence of inhalant abuse escalates morbidity and mortality rates. About 22% of people using inhalant have died at their first attempt. Particularly propane, butane, or propane-butane mixture has highest mortality rates. Sudden sniffing death syndrome, cardiomyopathy, central nervous system toxicity, hematological abnormalities, kidney toxicity, and hepatocellular toxicities are the major complications of inhalant abuse. Herein we present a patient with inhalant use disorder. At the age of 19, after a stressful life event he had unsuccessfully tried to suicide by inhaling LPG (liquefied petroleum gas, a mixture of butane and propane gases). After he realized that he had hallucinations and felt better during the inhalation, he started to abuse it. He was addicted to LPG for 10 years at the time of admission. Besides being dangerous for the society security, this intense level of LPG inhalation (12 liters a day) not giving any physical harm makes this case interesting. Ebru Aldemir, Betül Akyel, A. Ender Altıntoprak, Rezzan Aydın, and Hakan Coşkunol Copyright © 2015 Ebru Aldemir et al. All rights reserved. Severe Growing-Up Phobia, a Condition Explained in a 14-Year-Old Boy Sun, 21 Dec 2014 00:10:13 +0000 We present the clinical case of a 14-year-old boy with gerascophobia or an excessive fear of aging, who felt his body development as a threat, to the point where he took extreme measures to stop or otherwise hide growth. He had a history of separation anxiety, sexual abuse, and suffering bullying. He presented with anxious and depressive symptoms and food restriction, criticized his body image, had negative feelings towards the maturation process, suffered at the thought of being rejected, and was preoccupied with certain physical characteristics. We conducted an analysis of biological, psychological, and environmental factors and their possible interactions and established treatment with psychotherapy and fluoxetine. Because of the favorable results, this approach could be considered a good option in such cases. Laurencia Perales-Blum, Myrthala Juárez-Treviño, and Daniela Escobedo-Belloc Copyright © 2014 Laurencia Perales-Blum et al. All rights reserved. First Episode of Psychosis in a Middle-Aged Patient with a 14-Year History of Conversion Disorder Thu, 18 Dec 2014 06:41:26 +0000 We present a case of a middle-aged male patient with a long history of conversion disorder and histrionic personality, who presented with newly onset psychotic symptoms while being engaged to treatment with a community mental health team in a primary care setting. The symptoms could not be attributed to an organic cause. After a short course of olanzapine treatment which caused adverse effects, the symptomatology responded well to low dose amisulpride. Conversion symptoms were stable throughout the psychotic episode. This case illustrates the complex interplay between disorders classified in different categories (somatoform versus psychotic disorders). Vaios Peritogiannis, Thiresia Manthopoulou, and Venetsanos Mavreas Copyright © 2014 Vaios Peritogiannis et al. All rights reserved. Perampanel and Challenging Behaviour in Intellectual Disability and Epilepsy: A Management Dilemma Wed, 17 Dec 2014 00:10:25 +0000 We describe a case of a patient with a diagnosis of moderate learning disability with challenging behaviour and treatment refractory epilepsy. Antiepileptics can increase challenging behaviour; however, antipsychotics can provoke seizures. This results in a difficult balance for patient care. Due to worsening seizures, the patient was prescribed perampanel. This increased her aggression and agitation resulting in admission. We trialled four antipsychotic drugs to reduce her challenging behaviour, two of which worsened her seizures. It was necessary to continue antiepileptic medication to maintain adequate seizure control. However, the resulting uncontrolled challenging behaviour persisted, meaning she was unable to return to her family home on discharge. This case emphasises the difficult scenario clinician’s encounter when balancing the use of antipsychotics and antiepileptics. The case demonstrates the significant functional loss due to challenging behaviour, balanced against controlling life threatening seizures. Emily Dolton and Ansar Choudry Copyright © 2014 Emily Dolton and Ansar Choudry. All rights reserved. Persistent Genital Arousal Disorder: Confluent Patient History of Agitated Depression, Paroxetine Cessation, and a Tarlov Cyst Thu, 27 Nov 2014 00:10:10 +0000 We report a case of a woman suffering from persistent genital arousal disorder (PGAD) after paroxetine cessation. She was admitted to a psychiatric department and diagnosed with agitated depression. Physical investigation showed no gynaecological or neurological explanation; however, a pelvic MRI scan revealed a Tarlov cyst. Size and placement of the cyst could not explain the patient’s symptoms; thus neurosurgical approach would not be helpful. Her depression was treated with antidepressant with little effect. Electroconvulsive therapy improved the patient’s symptoms though they did not fully resolve. More awareness of PGAD and thorough interdisciplinary conferences are necessary to insure an unequivocal treatment strategy. Simone Eibye and Hans Mørch Jensen Copyright © 2014 Simone Eibye and Hans Mørch Jensen. All rights reserved. Feigning Acute Intermittent Porphyria Tue, 25 Nov 2014 13:02:19 +0000 Acute intermittent porphyria (AIP) is an autosomal dominant genetic defect in heme synthesis. Patients with this illness can have episodic life-threatening attacks characterized by abdominal pain, neurological deficits, and psychiatric symptoms. Feigning this illness has not been reported in the English language literature to date. Here, we report on a patient who presented to the hospital with an acute attack of porphyria requesting opiates. Diligent assessment of extensive prior treatment records revealed thirteen negative tests for AIP. Rania Elkhatib, Modupe Idowu, Gregory S. Brown, Yasmeen M. Jaber, Matthew B. Reid, and Cheryl Person Copyright © 2014 Rania Elkhatib et al. All rights reserved. Psychogenic Nonepileptic Spells in Chronic Epilepsy Patients with Moderate Cognitive Impairment: The Need for Video EEG Monitoring for Adequate Diagnosis Wed, 19 Nov 2014 09:22:14 +0000 The objective of our study was to emphasize the importance of intensive video EEG monitoring in patients with a well-established diagnosis of epilepsy with moderate cognitive impairment. The idea was to diagnose new onset frequent atypical events prompting the need for frequent emergency room and clinic visits and hospital admissions. Retrospective chart reviews were conducted on patients with chronic epilepsy with moderate cognitive impairment who had an increased incidence of new onset episodes different from the baseline seizures. Data were acquired from electronic medical records. The hospital’s Institutional Review Board gave approval for this retrospective analysis of patient records. We retrospectively analyzed data from three patients with an established diagnosis of epilepsy. Extensive chart reviews were performed with emphasis on type and duration of epilepsy and description of baseline seizures and description of new events. There were two men and one woman with moderate cognitive impairment. One subject had generalized epilepsy and other two had temporal lobe epilepsy. The patients were on an average of two to three antiepileptic medicines. The duration of follow-up in our neurology clinic ranged from 9 months to 5 years. The occurrence of increased frequency of these atypical events as described by the caregivers, despite therapeutic anticonvulsant levels, prompted the need for 5-day intensive video EEG monitoring. New atypical spells were documented in all three patients and the brain waves were normal during those episodes. The diagnosis of pseudoseizures was made based on the data acquired during the epilepsy monitoring unit stay. Our data analysis showed that intensive video EEG monitoring is an important tool to evaluate change in frequency and description of seizures even in cognitively impaired patients with an established diagnosis of epilepsy for adequate seizure management. Diana Mungall Robinson and Batool F. Kirmani Copyright © 2014 Diana Mungall Robinson and Batool F. Kirmani. All rights reserved. Supersensitivity Psychosis and Its Response to Asenapine in a Patient with Delusional Disorder Thu, 13 Nov 2014 09:54:00 +0000 Supersensitivity psychosis is a recognized complication of long-term antipsychotic treatment, in which patients develop new or reemergent psychotic symptoms, generally accompanied by dyskinetic movements, due to prolonged dopamine receptor blockade and resultant supersensitivity. Though it is most closely associated with schizophrenia and the use of typical antipsychotic agents, it has also been documented in patients with other diagnoses, and in those receiving atypical antipsychotics. There is no established treatment for this condition. In this paper, we describe a patient with persistent delusional disorder, jealous type, who developed a supersensitivity psychosis characterized by persecutory delusions, auditory hallucinations, and thought insertion in association with mild tardive dyskinesia. These symptoms resolved completely following six weeks of treatment with the second-generation antipsychotic asenapine, 20 mg/day. The mechanisms and implications of the patient’s symptomatology and response are discussed. Ravi Philip Rajkumar Copyright © 2014 Ravi Philip Rajkumar. All rights reserved. Diagnosis and Treatment of Psychiatric Comorbidity in a Patient with Charles Bonnet Syndrome Thu, 06 Nov 2014 11:54:20 +0000 Background. A significant proportion of patients with neurological disorders may have comorbid psychiatric symptomology, which may be managed by primary outpatient neurologists. Referral to their psychiatric colleagues is mediated by available consultation-liaison units and according to clinical opinion. Aims of Case Report. We present the case of a patient whose initial referral to epilepsy clinic led to a workup which ultimately diagnosed her with nonepileptic seizures (NES). In the course of her follow-up, she developed intractable headaches, and worsening mood symptoms and eventually exhibited Psychotic Features for which psychiatry became coinvolved in her care. Major Depression with Psychotic Features and Charles Bonnet syndrome were considered as a likely comorbid diagnoses. Her pharmacologic management on venlafaxine and quetiapine eventually caused substantial amelioration of her psychiatric symptomology as longitudinally followed by PHQ-9 and GAD-7 scores. Conclusion. Optimal evaluation and management of mental illness in patients with complex neurologic symptomology may require independent evaluation and treatment by psychiatrists when clinically appropriate. Jasper J. Chen Copyright © 2014 Jasper J. Chen. All rights reserved. Pyrethroid as a Substance of Abuse Thu, 06 Nov 2014 09:58:00 +0000 This is a case of a 22-year-old Hispanic male with a history of bipolar disorder and methamphetamine dependence who was admitted after presenting with suicidal ideations by slashing his throat with a machete. The patient had been smoking and inhaling “processed” pyrethroid for about eight weeks as an inexpensive methamphetamine substitute. He reported experiencing a “rush” similar to methamphetamine after using pyrethroid from liquid insecticide that had been heated (electrocuted) or sprayed on hot metal sheets until it crystallized. The patient presented with no significant physical markings or findings but claimed to have his suicidal ideations precipitated by concerns of ill effects of pyrethroid on his health. He also had positive urine drug screen for methamphetamine, which he admitted to using on the day of admission. We conclude that it is important for physicians to maintain a high level of suspicion for alternate and uncommon substances of abuse as well as risks for suicidal tendencies in these patients. Pravesh Sharma, Stephen Manning, Regina Baronia, and Saira Mushtaq Copyright © 2014 Pravesh Sharma et al. All rights reserved. QT Interval Prolongation Associated with Intramuscular Ziprasidone in Chinese Patients: A Case Report and a Comprehensive Literature Review with Meta-Analysis Tue, 04 Nov 2014 00:00:00 +0000 Intramuscular (IM) ziprasidone has been associated with QTc interval prolongations in patients with preexisting risk factors. A 23-year-old male Chinese schizophrenia patient experienced an increase of QTc interval of 83 milliseconds (ms) after receiving 20 mg IM ziprasidone (baseline and increased QT/QTc were, respectively, 384/418 and 450/501). This was rated as a probable adverse drug reaction (ADR) by the Liverpool ADR causality assessment tool. A systematic review including all types of trials reporting the effect of IM ziprasidone on the QTc interval prolongation identified 19 trials with a total of 1428 patients. Mean QTc change from baseline to end of each study was −3.7 to 12.8 ms after IM ziprasidone. Four randomized trials (3 of 4 published in Chinese) were used to calculate a meta-analysis of QTc interval prolongation which showed no significant differences between IM ziprasidone and IM haloperidol groups (risk ratio 0.49 to 4.31, 95% confidence interval 0.09 to 19.68, P = 0.06 to 0.41). However, our review included two cases of patients who experienced symptoms probably related to QTc prolongation after IM ziprasidone. Thus, careful screening and close monitoring, including baseline ECG, should be considered in patients receiving IM ziprasidone for the first time. Xian-Bin Li, Yi-Lang Tang, Wei Zheng, Chuan-Yue Wang, and Jose de Leon Copyright © 2014 Xian-Bin Li et al. All rights reserved. Treating Methamphetamine-Induced Resistant Psychosis with Clozapine Tue, 28 Oct 2014 06:56:35 +0000 Background. Methamphetamine-induced psychosis (MIP) in Iran has turned into a serious issue in terms of health and treatment, lacking any obvious treatment methods for its resistant cases. Aims of Case Report. In the present study, a number of two cases of treatment of MIP with clozapine, which were resistant to the treatment with other antipsychotics, have been reported. Both cases completely responded to the treatment in only 2 weeks and no signs of psychosis relapse were seen in an 8-9 follow-up. Conclusion. Because of its particular pharmacologic features, clozapine may be effective in treating MIP. Ruohollah Seddigh, Amir-Abbas keshavarz-Akhlaghi, and Behnam Shariati Copyright © 2014 Ruohollah Seddigh et al. All rights reserved. Dissociative Disorders: Between Neurosis and Psychosis Wed, 22 Oct 2014 11:28:09 +0000 Dissociative disorders are a set of disorders defined by a disturbance affecting functions that are normally integrated with a prevalence of 2.4 percent in industrialised countries. These disorders are often poorly diagnosed or misdiagnosed because of sharing common clinical features with psychotic disorders, but requiring a very different trajectory of care. Repeated clinical situations in a crisis centre in Geneva provided us with a critical overview of current evidence of knowledge in clinical and etiopathological field about dissociative disorders. Because of their multiple expressions and the overlap with psychotic disorders, we focused on the clinical aspects using three different situations to better understand their specificity and to extend our thinking to the relevance of terms “neurosis” and “psychosis.” Finally, we hope that this work might help physicians and psychiatrists to become more aware of this complex set of disorders while making a diagnosis. C. Devillé, C. Moeglin, and O. Sentissi Copyright © 2014 C. Devillé et al. All rights reserved. A Case of Priapism with Risperidone Tue, 14 Oct 2014 12:35:35 +0000 Priapism is a urologic emergency defined as a prolonged, possibly painful, penile erection. There are several known causes of priapism including psychotropic medications. One of the mechanisms by which antipsychotics are believed to induce priapism is through alpha-1 antagonism. This is case of a 50-year-old male with a history of schizophrenia with previous priapism related to trazodone, who presents with new onset priapism associated with risperidone. In this case, the treatment of priapism includes discontinuation of the offending agent and drainage of the corpus cavernosum twice along with intracavernosal phenylephrine injections. It is important to educate patients on priapism as a possible side effect of medications. It is also important to consider previous episodes of medication-induced priapism when prescribing psychotropic medications as this may increase the patient’s future risk of priapism. Almari Ginory and Mathew Nguyen Copyright © 2014 Almari Ginory and Mathew Nguyen. All rights reserved. Anti-NMDA Receptor Encephalitis Presenting as an Acute Psychotic Episode in a Young Woman: An Underdiagnosed yet Treatable Disorder Tue, 07 Oct 2014 13:57:45 +0000 Anti-NMDA receptor (NMDAR) encephalitis is a recently identified autoimmune disorder with prominent psychiatric symptoms. Patients usually present with acute behavioral change, psychosis, catatonic symptoms, memory deficits, seizures, dyskinesias, and autonomic instability. In female patients an ovarian teratoma is often identified. We describe a 32-year-old woman who presented with acute psychosis. Shortly after admission, she developed generalized seizures and deteriorated into a catatonic state. Although ancillary tests including MRI, electroencephalogram, and cerebrospinal fluid (CSF) analysis were unremarkable, the presentation of acute psychosis in combination with recurrent seizures and a relentless course suggested autoimmune encephalitis. The patient underwent pelvic ultrasound which disclosed a dermoid cyst and which led to an urgent cystectomy. Plasmapheresis was then initiated, yielding partial response over the next two weeks. Following the detection of high titers of anti-NMDAR antibodies in the CSF, the patient ultimately received second line immunosuppressive treatment with rituximab. Over several months of cognitive rehabilitation a profound improvement was eventually noted, although minor anterograde memory deficits remained. In this report we call for attention to the inclusion of anti-NMDAR encephalitis in the differential diagnosis of acute psychosis. Prompt diagnosis is critical as early immunotherapy and tumor removal could dramatically affect outcomes. Shikma Keller, Pablo Roitman, Tamir Ben-Hur, Omer Bonne, and Amit Lotan Copyright © 2014 Shikma Keller et al. All rights reserved. Lifetime Autism Spectrum Features in a Patient with a Psychotic Mixed Episode Who Attempted Suicide Wed, 01 Oct 2014 00:00:00 +0000 We present a case report of a young man who attempted suicide during a mixed episode with psychotic symptoms. The patient’s history revealed the lifetime presence of signs and features belonging to the autism spectrum realm that had been completely overlooked. We believe that this case is representative of an important and barely researched topic: what happens to children with nondiagnosed and nontreated subthreshold forms of autism when they grow old. The issue of early recognition of autism spectrum signs and symptoms is discussed, raising questions on the diagnostic boundaries between autism and childhood onset psychotic spectrums among patients who subsequently develop a full-blown psychotic disorder. Marly Simoncini, Mario Miniati, Federica Vanelli, Antonio Callari, Giulia Vannucchi, Mauro Mauri, and Liliana Dell’Osso Copyright © 2014 Marly Simoncini et al. All rights reserved. Acute Psychotic Symptoms due to Benzydamine Hydrochloride Abuse with Alcohol Mon, 29 Sep 2014 09:42:05 +0000 Benzydamine hydrochloride is a locally acting nonsteroidal anti-inflammatory drug. Benzydamine hydrochloride overdose can cause stimulation of central nervous system, hallucinations, and psychosis. We presented a young man with psychotic symptoms due to benzydamine hydrochloride abuse. He received a total dose of 1000 mg benzydamine hydrochloride with alcohol for its hallucinative effects. Misuse of benzydamine hydrochloride must be considered in differential diagnosis of first-episode psychosis and physicians should consider possibility of abuse in prescribing. Yahya Ayhan Acar, Mustafa Kalkan, Rıdvan Çetin, Erdem Çevik, and Orhan Çınar Copyright © 2014 Yahya Ayhan Acar et al. All rights reserved. Perfectionistic Self-Presentation and Suicide in a Young Woman with Major Depression and Psychotic Features Wed, 24 Sep 2014 08:03:15 +0000 A woman in her midtwenties with a history of major depressive disorder and a recent major depressive episode with mood-congruent psychotic features died by suicide. Two weeks before her death, she demonstrated exceptional elevations on the nondisplay of imperfection factor of Hewitt and Flett’s Perfectionistic Self-Presentation Scale. Perfectionism and especially perfectionistic self-presentation have been strongly associated with suicide across several populations, accounting for unique variance in suicidality beyond depression and hopelessness. Yet interpersonal facets of perfectionism are not recognized as clinical risk factors for suicide. There is also a paucity of research on perfectionism in relation to psychotic symptoms. This case account illustrates the role of perfectionistic self-presentation in suicides that occur seemingly without warning and, to our knowledge, this is the first examination of perfectionistic self-presentation and suicide in a case where psychotic features occurred. This study, though single case-based, draws attention to perfectionism and perfectionistic self-presentation and their potential roles in suicide, especially when accompanied by other risk factors. Future research in this area may elucidate the role of perfectionism in suicide, singularly and in the context of a comprehensive clinical risk assessment, demonstrating whether perfectionism confers information about suicide risk beyond known clinical risk factors. Sabrina Hassan, Gordon L. Flett, Rohan Ganguli, and Paul L. Hewitt Copyright © 2014 Sabrina Hassan et al. All rights reserved. Accelerated Hypertension after Venlafaxine Usage Wed, 24 Sep 2014 06:24:41 +0000 Venlafaxine is the first antidepressant that acts via inhibiting serotonin and noradrenaline reuptake. Hypertension is observed in doses exceeding 300 mg/day and is the most feared complication. We report a patient with accelerated hypertension after venlafaxine use observed at a dose of 150 mg/day. A 23-year-old patient with symptoms of insomnia, depression, anhedonia, fatigue admitted our clinic. Venlafaxine at a dose of 75 mg/day was initiated after he was diagnosed with major depressive disorder. After 5 months, venlafaxine dose was uptitrated to 150 mg/day due to inadequate response to drug. After using venlafaxine for ten months at the dose of 150 mg/day, he admitted our clinic with headache and epistaxis. He was hospitalized after his blood pressure was measured as 210/170 mmHg. No secondary causes for hypertension were found, and venlafaxine treatment was considered possible etiologic factor. After stopping venlafaxine treatment, his blood pressure was reverted back to normal limits. While mild elevation of blood pressure could be observed after venlafaxine treatment, this case shows that accelerated hypertension with a diastolic blood pressure rise above 120 mmHg could be observed at relatively low doses of venlafaxine. Close monitoring of blood pressure is necessary after initiation of treatment, as accelerated hypertension could cause endorgan damage with potentially catastrophic results. Yüksel Kıvrak, Tolga Sinan Güvenç, Nurcihan Akbulut, İbrahim Yağcı, Gülşen Çığşar, Süleyman Gündüz, and Bahattin Balcı Copyright © 2014 Yüksel Kıvrak et al. All rights reserved. The Comorbidity of Reduplicative Paramnesia, Intermetamorphosis, Reverse-Intermetamorphosis, Misidentification of Reflection, and Capgras Syndrome in an Adolescent Patient Tue, 23 Sep 2014 05:07:41 +0000 Delusional misidentification syndromes may be superimposed on neurological or psychiatric disorders and include delusional beliefs that the people, objects, or places around the patient change or are made to change with one another. In this paper, an adolescent patient displaying Capgras syndrome, metamorphosis, reverse-intermetamorphosis, misidentification of reflection, and reduplicative paramnesia was presented. The findings that our patient struggled with visuospatial tests applied in the acute phase as well as the observation that she refused to meet her family face-to-face while accepting to speak on the phone may support the role of right hemisphere and visuospatial functions in the development of those syndromes. Further studies or case series evaluated more extensively are needed to reveal the relationship between right hemisphere functions and delusional misidentification syndromes. Ozden Arısoy, A. Evren Tufan, Rabia Bilici, Sarper Taskiran, Zehra Topal, Nuran Demir, and M. Akif Cansız Copyright © 2014 Ozden Arısoy et al. All rights reserved. Modified Electroconvulsive Therapy in a Patient with Gastric Adenocarcinoma and Metastases to Bone and Liver Tue, 16 Sep 2014 11:25:35 +0000 Background. In addition to general anesthesia, muscle relaxants are given prior to electroconvulsive therapy (ECT) in order to prevent musculoskeletal injury. Higher doses of muscle relaxants have been suggested for patients at high risk for bone fractures; however, there are adverse side effects associated with these higher doses. Aims. We present a successful case of ECT to treat chronic major depressive disorder in a 62-year-old woman at high risk of bone fracture due to gastric adenocarcinoma with metastases to bone and liver. Case. Increasing doses of the muscle relaxant succinylcholine (0.45–0.74 mg/kg) were sufficient to prevent musculoskeletal complications throughout the course of 9 bifrontal ECT treatments. Following treatment, the patient reported and demonstrated markedly improved mood and functionality, enabling her transfer to a palliative care facility. Conclusion. Standard doses of succinylcholine were sufficient to mitigate the risk of pathological fractures in this patient with metastatic bone lesions. As there are established risks to using high doses of succinylcholine, with no evidence that higher doses reduce the incidence of fractures in high-risk populations, we suggest taking a conservative approach, using clinical observation and periodic plain radiography to dictate succinylcholine dose titration in such high-risk patients. Gennie Wang, Brian Milne, Rachel Rooney, and Tarit Saha Copyright © 2014 Gennie Wang et al. All rights reserved. Near-Infrared Spectroscopy during the Verbal Fluency Task before and after Treatment with Image Exposure and SSRI Therapy in Patients with Obsessive-Compulsive Disorder Tue, 16 Sep 2014 09:00:38 +0000 Drug therapy with selective serotonin reuptake inhibitors (SSRIs) has been used as a treatment for obsessive-compulsive disorder (OCD). In the present case report, exposure therapy was used in addition to escitalopram (20 mg) to treat a 28-year-old female patient with OCD for 6 months. Her obsessive-compulsive symptoms comprised thoughts of words such as rape, crematorium, neck hanging, unhappy, death, die, and kill and images such as a shelf of gods, a shrine, a Buddhist altar, the sun, the sky, and the faces of her parents, siblings, and relatives. As exposure therapy, she was asked to view the images associated with these symptoms three times a day along with drug therapy. With the combination of drug and exposure therapies, her obsessive-compulsive symptoms improved within 6 months, with no interference in her daily life. Multichannel near-infrared spectroscopy (NIRS) showed improvement of brain function in the temporal and frontal lobes after treatment. These results suggest that NIRS can be used as an indicator of brain function improvement in patients with OCD. Mari Nakanishi, Harumi Oshita, Yoshihiro Tanaka, Ayako Inoue, Chiwa Kawashima, Kana Okamoto, Shunsuke Kobayashi, Yoshinobu Ishitobi, Taiga Ninomiya, and Jotaro Akiyoshi Copyright © 2014 Mari Nakanishi et al. All rights reserved. Cognitive Restructuring and Graded Behavioural Exposure for Delusional Appraisals of Auditory Hallucinations and Comorbid Anxiety in Paranoid Schizophrenia Thu, 11 Sep 2014 07:38:11 +0000 The prevalence of diagnostic comorbidity between psychosis and anxiety disorders has been found to be considerable. Cognitive models of psychosis suggest that anxiety does not arise directly from positive symptoms of schizophrenia but rather from an individual interpretation of such experiences. In the United Kingdom, cognitive-behavioural therapy for psychosis (CBTp) has been recommended within clinical guidelines as a psychological treatment of choice for those diagnosed with schizophrenia. However, despite empirical evidence supporting CBTp, the treatment provision remains infrequent and not routinely available. This case describes a successful implementation of CBTp. Sixteen sessions were delivered to a 40-year-old male with diagnoses of paranoid schizophrenia and comorbid anxiety, focusing primarily on cognitive restructuring of paranoid appraisals of auditory hallucinations and behavioural experiments employed progressively via graded exposure to anxiety-inducing stimuli. Standardised measurements, behavioural frequency sampling, and subjective data indicated a considerable reduction in both paranoia and anxiety. Also, the client’s psychosocial functioning improved substantially. This report indicates that the treatment may help those with experiences of psychosis and comorbid anxiety reach a significant improvement in their quality of life and offers an encouraging and innovative perspective on direct engagement with the content of paranoia and voices at the onset of therapy. Pawel D. Mankiewicz and Colin Turner Copyright © 2014 Pawel D. Mankiewicz and Colin Turner. All rights reserved. Quality Improvement Opportunities in Caring for Patients with Nonepileptic Seizures Tue, 09 Sep 2014 12:05:28 +0000 Background. Patients with nonepileptic seizures (NES) are challenging to treat for myriad reasons. Often patients may be misdiagnosed with having epilepsy and then may suffer unintended consequences of treatment side effects with antiepileptic medication. In addition, patients may be maligned by health care providers due to a lack of ownership by both psychiatrists and neurologists and a dearth of dedicated professionals who are able to effectively treat and reduce severity and frequency of symptoms. Aims of Case Report. Many psychiatrists and neurologists are unaware of the extent of the barriers to care faced by patients with NES (PWNES) and the degree of perception of maltreatment or lack of therapeutic alliance at various stages of their care, including medical workup, video-EEG monitoring, and follow-up plans. We present the case of a patient with NES who experienced numerous barriers as well as incoordination to her care despite being offered a breadth of resources and discuss the quality improvement opportunities that may exist to improve care of patients with NES. Conclusion. No known literature has documented the extensive barriers to care of PWNES in parallel to quality improvement opportunities for improving their care. We endeavor to contribute to the overall formulation and development of a clinical care pathway for PWNES. Jasper J. Chen, Devendra S. Thakur, Krzysztof A. Bujarski, Barbara C. Jobst, Erik J. Kobylarz, and Vijay M. Thadani Copyright © 2014 Jasper J. Chen et al. All rights reserved. Suicidal Behavior in a Patient with Burning Mouth Syndrome Tue, 26 Aug 2014 08:29:49 +0000 Introduction. Chronic pain of the oral cavity is a long-term condition and like all other types of chronic pain is associated with numerous comorbidities such as depression or anxiety. Case Presentation. This is a case of a 93-year-old patient suffering from chronic oral cavity pain who repeatedly stabbed his palate due to ongoing local pain, over the last few months, which he could not further tolerate. The patient was suffering from depression and also a diagnosis of “burning mouth syndrome” (BMS) was made. Discussion. Burning mouth syndrome (BMS) is characterized by a burning sensation in the tongue or other oral sites. BMS has high psychiatric comorbidity but can occur in the absence of psychiatric diagnosis. Patients with multiple forms of pain must be considered as potential candidates for underdiagnosed depression (major) and suicidal thoughts. Konstantinos Kontoangelos, Evmorfia Koukia, Vasilis Papanikolaou, Aris Chrysovergis, Antonis Maillis, and George N. Papadimitriou Copyright © 2014 Konstantinos Kontoangelos et al. All rights reserved. Bidirectional Tachycardia after an Acute Intravenous Administration of Digitalis for a Suicidal Gesture Sun, 24 Aug 2014 06:17:49 +0000 Acute digoxin intoxication is a life-threating condition associated with severe cardiotoxicity. Female gender, age, low lean body mass, hypertension, and renal insufficiency may worsen the prognosis. Arrhythmias caused by digitalis glycosides are characterized by an increased automaticity coupled with concomitant conduction delay. Bidirectional tachycardia is pathognomonic of digoxin intoxication, but it is rarely observed. An 83-year-old woman was admitted to the Emergency Department after self-administration of 5 mg of digoxin i.v. for suicidal purpose. Her digoxin serum concentration was 17.4 ng/mL. The patient developed a bidirectional tachycardia and the Poison Control Center of the hospital provided digoxin immune fab. Bidirectional tachycardia quickly reversed and the patient remained stable throughout the hospital stay. This case shows that a multiple disciplinary approach, involving cardiologists and toxicologists, is essential for the management of digoxin intoxication. The optimal treatment of this rare event depends on the clinical conditions and on the serum drug concentration of the patient. Digoxin immune fab represents a safe, effective, and specific method for rapidly reversing digitalis cardiotoxicity and should be started as soon as the diagnosis is defined. Diletta Sabatini, Giovanni Truscelli, Antonio Ciccaglioni, Carlo Gaudio, and Maria Caterina Grassi Copyright © 2014 Diletta Sabatini et al. All rights reserved.