Case Reports in Psychiatry The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . 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. Trifluoperazine-Induced Angioedema Sun, 17 Aug 2014 12:50:44 +0000 Angioedema is a serious adverse drug reaction that can rarely be associated with trifluoperazine treatment. We present the case of a 44-year-old male with an established diagnosis of schizoaffective disorder, for which trifluoperazine therapy was considered. He presented to the emergency department with bilateral lower limb oedematous painful erythematous swelling that eased off completely when trifluoperazine was stopped. The possibility of allergic reaction, such as angioedema, should always be kept in mind by psychiatrists and mental health professionals when prescribing trifluoperazine antipsychotic. Mugtaba Osman, Daniel Edwards, and Mona Kilduff Copyright © 2014 Mugtaba Osman et al. All rights reserved. Adolescent Catatonia Successfully Treated with Lorazepam and Aripiprazole Tue, 12 Aug 2014 08:56:57 +0000 Catatonia is especially concerning in children and adolescents. It leads to significant impairment, including emotional distress, difficulty communicating, and other debilitating symptoms. In this case report, we discuss a patient with no previous history of neuroleptic medication or psychotic symptoms, presenting with first-episode catatonia in the presence of disorganized, psychotic thoughts. We then review the catatonia syndrome, citing examples in the literature supporting its underdiagnosis in children and adolescents, and discuss successful treatment modalities. It is important to diagnose and treat catatonia as efficiently as possible, to limit functional and emotional distress to the patient. Aaron J. Roberto, Subhash Pinnaka, Abhishek Mohan, Hiejin Yoon, and Kyle A. B. Lapidus Copyright © 2014 Aaron J. Roberto et al. All rights reserved. First Reported Case of Lorazepam-Assisted Interview in a Young Indian Female Presenting with Dissociative Identity Disorder and Improvement in Symptoms after the Interview Tue, 05 Aug 2014 05:38:15 +0000 Dissociative identity disorder (DID) is one of the most fascinating disorders in psychiatry. The arduous search to reveal the obscurity of this disorder has led to colossal research in this area over the years. Although drug-assisted interviews are not widely used, they may be beneficial for some patients that do not respond to conventional treatments such as supportive psychotherapy or psychopharmacotherapy. Drug-assisted interviews facilitate recall of memories in promoting integration of dissociative information. We report a case of a 16-year-old female with dissociative identity disorder (DID) that was treated with lorazepam-assisted interview and there was rapid improvement in symptoms after the interview. Raheel Mushtaq, Sheikh Shoib, Tasleem Arif, Tabindah Shah, and Sahil Mushtaq Copyright © 2014 Raheel Mushtaq et al. 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.