Case Reports in Psychiatry The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Severe Burns and Amputation of Both Arms in the First Psychotic Episode of a Schizophrenic Patient Mon, 31 Aug 2015 12:58:45 +0000 An alleged reduction of sensitivity to pain in people with schizophrenia has been reported, but the nature of this complex phenomenon has not been elucidated yet. Reports of insensitivity to burns from people with schizophrenia are extremely rare. We report the case of a 24-year-old man who set both of his arms on fire during the first break of paranoid schizophrenia. As a result of severe tissue damage, both of his limbs had to be amputated. Today, at the age of 59, the patient is physically and mentally rehabilitated and is adherent to treatment. Additionally, given the uncertainty about the true nature of the alleged hypoalgesia in schizophrenia, we postulate the need for a comprehensive phenomenological approach in the study of embodiment in people with this condition. Lizardo Cruzado, Ronald Villafane-Alva, Katia Caballero-Atencio, Carla Cortez-Vergara, and Patricia Núñez-Moscoso Copyright © 2015 Lizardo Cruzado et al. All rights reserved. Sibling Death after Being Thrown from Window by Brother with Autism: Defenestration, an Emerging High-Risk Behavior Mon, 03 Aug 2015 13:10:38 +0000 Children diagnosed with autistic spectrum disorders (ASD) may have serious behavioral problems such as aggression, self-injury, and violence. However, the literature on ASD either overrules any correlation between aggression and ASD or maintains the fact that the efforts to link them have so far been inconclusive. Although severe forms of violence are extremely rare in children with autism, there are a few cases reported in the literature with significant harm to siblings. We hereby report an 8-year-old boy with ASD who caused the death of his sibling by throwing her out of the window. Shared similarities of all defenestration cases indicate a pattern of high-risk behavior threatening the survival of minors. We recommend precautions against this high-risk behavior in children with ASD. Osman Sabuncuoglu, Mustafa Yasin Irmak, Nagehan Ucok Demir, Duygu Murat, Can Tumba, and Yuksel Yilmaz Copyright © 2015 Osman Sabuncuoglu et al. All rights reserved. Clozapine-Induced Myocarditis: A Case Report of an Adolescent Boy with Intellectual Disability Wed, 22 Jul 2015 06:40:14 +0000 Background. Although known for its efficacy in treatment-resistant schizophrenia, the usage of clozapine has been limited due to concerns over potential adverse effects. Myocarditis, one potential fatal complication, can develop at any point during treatment but has been most commonly observed 2-3 weeks after clozapine initiation. Objective. A case of acute clozapine-induced myocarditis is described, highlighting the history, onset, and treatment course of presentation. There is a need to raise awareness of this potential complication, especially in the pediatric population. Results. 17-year-old Puerto Rican boy, with history of schizophrenia, disorganized type (treatment resistant), and intellectual disability, developed myocarditis on the thirteenth day following clozapine commencement. Initial presenting symptoms included tachycardia, lethargy, and vague gastrointestinal distress. Patient fully recovered after supportive medical care and clozapine discontinuation. Conclusions. Myocarditis is a known potential complication of clozapine initiation; however, due to its limited usage in the pediatric population, reported cases are limited. There is a need to establish evidence-based monitoring guidelines for clozapine usage, particularly in the pediatric population where the presentation may be atypical and clinical suspicion may be overlooked. Lila Aboueid and Nitin Toteja Copyright © 2015 Lila Aboueid and Nitin Toteja. All rights reserved. Slow Progression of Cognitive Dysfunction of Alzheimer’s Disease in Sexagenarian Women with Schizophrenia Sun, 12 Jul 2015 10:57:45 +0000 Although both schizophrenia (SCZ) and Alzheimer’s disease (AD) are among the most common psychiatric diseases, the interaction of these two is not well-understood. We investigated three women with SCZ who developed AD in their 60s. The patients presented with cognitive dysfunction such as loss of recent memory, which was confirmed by both clinical observations and neuropsychological tests. Their magnetic resonance and functional imaging findings were consistent with AD. Their brain atrophy advanced significantly during a 6-year observation period. However, their global cognitive function did not deteriorate significantly during this period. Although the cognitive reserve model might account for this discrepancy, our results suggest some interactions between the neuropathology of SCZ and AD and warrant further research. Kazuo Sakai, Haruhiko Oda, Akira Terashima, Kazunari Ishii, and Kiyoshi Maeda Copyright © 2015 Kazuo Sakai et al. All rights reserved. Genetic or Psychogenic? A Case Study of “Folie à Quatre” Including Twins Thu, 25 Jun 2015 14:34:45 +0000 Shared psychotic disorder, characterized by shared delusion among two or more subjects (termed “Folie à deux,” “trois,” etc.), is often associated with strong religious beliefs or social isolation, factors creating strong psychological sympathy. Recently, we treated a rare familial case of “Folie à quatre” in central Tokyo without such influences. The proband was a schizophrenia patient and younger brother within monozygotic twins. Positive symptoms were “transmitted” to remaining family members, his elder brother, mother, and father father, in a relatively short period of three months. Although the pathophysiology of these positive symptoms (delusions and hallucinations) remains unclear, the transmission pattern suggests the primacy of social and environmental factors (and/or their interaction), while genetics appeared less influential in this “Folie à famille.” Although undiagnosed psychoses in the whole family cannot be excluded, they did not share the other negative schizophrenia symptoms of the proband. A strong familial connection appeared to be the most important factor for the common delusion and hallucination. Tohru Ohnuma and Heii Arai Copyright © 2015 Tohru Ohnuma and Heii Arai. All rights reserved. Anti-NMDA Receptor Encephalitis in a Patient with Previous Psychosis and Neurological Abnormalities: A Diagnostic Challenge Sun, 14 Jun 2015 13:41:00 +0000 Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is an autoimmune disorder characterized by IgG autoantibodies directed against the NR1 subunit of the NMDA glutamate receptor. Psychiatric symptoms are common and include psychosis, mania, depressed mood, aggression, and speech abnormalities. Neurological symptoms such as seizures, decreased responsiveness, dyskinesias, and other movement abnormalities and/or autonomic instability are frequently seen as well. We present the case of a woman who was followed up at our facility for over 14 years for the treatment of multiple neuropsychiatric symptoms. Initially, she presented with paresthesias, memory loss, and manic symptoms. Nine years later, she presented to our facility again, this time with left sided numbness, left eyelid droop, and word finding difficulties. Finally, five years later, she presented with manic symptoms, hallucinations, and memory impairment. During her hospitalization, she subsequently developed catatonic symptoms and seizures. During her stay, it was discovered that she was positive for anti-NMDA receptor antibodies and her symptoms responded well to appropriate therapy. This case demonstrates that it may be useful for clinicians to consider screening for anti-NMDA receptor antibodies in long-term patients with neuropsychiatric symptoms that have not adequately responded to therapy. R. David Heekin, Maria C. Catalano, Alfred T. Frontera, and Glenn Catalano Copyright © 2015 R. David Heekin et al. All rights reserved. Cotard Syndrome without Depressive Symptoms in a Schizophrenic Patient Mon, 25 May 2015 13:33:45 +0000 Introduction. Cotard syndrome is a rare condition characterized by nihilistic delusions concerning body or life that can be found in several neuropsychiatry conditions. It is typically associated with depressive symptoms. Method. We present a case of Cotard syndrome without depressive symptoms in the context of known paranoid schizophrenia. A literature review of Cotard syndrome in schizophrenia was performed. Results. Although there are few descriptions of this syndrome in schizophrenia, patients usually present depressive mood and psychomotor retardation, features not seen in our patient. Loss of the sense of the inner self, present in schizophrenia, could explain patient’s symptomatology but neurobiological bases of this syndrome remain unclear. Conclusion. Despite not being considered in actual classifications, Cotard syndrome is still relevant and psychiatric evaluation is critical to diagnosing and treating this condition in psychiatric patients. Pedro Morgado, Ricardo Ribeiro, and João J. Cerqueira Copyright © 2015 Pedro Morgado et al. All rights reserved. Levothyroxine Augmentation in Clozapine Resistant Schizophrenia: A Case Report and Review Mon, 11 May 2015 11:41:07 +0000 There are many reports that show different thyroid abnormalities in schizophrenia without clear establishment of their role in etiology and treatment outcome of schizophrenia. Among these reports, there are only a few that consider a role for thyroid hormones as augmenting agents in the treatment with antipsychotic drugs. This case report outlines symptom subsidence of a patient with clozapine refractory paranoid schizophrenia and normal thyroid function who added levothyroxine to clozapine and found that symptoms of psychosis returned once levothyroxine was discontinued. Although this observation needs to be confirmed in controlled clinical trials, we aimed to discuss possible hypothesized mechanisms underlying this observation. Ruohollah Seddigh, Somayeh Azarnik, and Amir-Abbas Keshavarz-Akhlaghi Copyright © 2015 Ruohollah Seddigh et al. All rights reserved. Treatment of a Prader-Willi Patient with Recurrent Catatonia Thu, 07 May 2015 06:24:49 +0000 Prader-Willi is a genetic disorder characterized by neonatal hypotonia, hyperphagia, short stature, hypogonadism, and mental delay. This disorder can result from multiple mechanisms, most commonly a deletion of paternal chromosome 15, leaving a single maternally derived chromosome 15. Individuals who have a maternal uniparental disomy of chromosome 15 have a higher risk for developing psychosis compared to other forms of Prader-Willi. The following report details the treatment course of a 24-year-old female with Prader-Willi and recurrent catatonia. The patient initially had a positive lorazepam challenge test but subsequently failed treatment with benzodiazepines. She then received eight electroconvulsive therapy (ECT) treatments after which she showed improvement from initial catatonic state. However, the resolution in her symptoms did not follow a linear course but would show periods of improvement followed by a return of catatonic features. This case provides an example of the complexity of treatment of a patient with a genetic disorder and recurrent catatonia. Hana M. Poser and Alexandru E. Trutia Copyright © 2015 Hana M. Poser and Alexandru E. Trutia. All rights reserved. Autism Spectrum Disorder and Amplified Pain Wed, 06 May 2015 11:28:26 +0000 Among the core features of ASD, altered sensitivities in all modalities have been accorded increasing importance. Heightened sensitivity to pain and unusual expressions of and reaction to pain have not hitherto been widely recognised as a presenting feature of ASD in general paediatrics. Failure to recognise ASD as a common cause of pain can lead to late diagnosis, inappropriate treatment, distress, and further disability. Two cases are presented which illustrate the late presentation of Autism Spectrum Disorder (Asperger’s Syndrome subtype) with chronic unusual pain. Conclusion. Pain in autism can be atypical in its experience and expression and for this reason may go unrecognised by physicians treating chronic pain disorders. Ciaran Clarke Copyright © 2015 Ciaran Clarke. All rights reserved. Three Patients Needing High Doses of Valproic Acid to Get Therapeutic Concentrations Mon, 27 Apr 2015 13:23:03 +0000 Valproic acid (VPA) can autoinduce its own metabolism. Cases requiring VPA doses >4000 mg/day to obtain therapeutic plasma concentrations, such as these 3 cases, have never been published. Case 1 received VPA for seizures and schizophrenia and had >50 VPA concentrations in 4 years. A high dose of 5,250 mg/day of VPA concentrate was prescribed for years but this dose led to an intoxication when switched to the enterocoated divalproex sodium formulation, requiring a normal dose of 2000 mg/day. VPA metabolic capacity was significantly higher (; df = 6.3, ) during the VPA concentrate therapy, possibly due to autoinduction in that formulation. Case 2 had VPA for schizoaffective psychosis with 10 VPA concentrations during an 8-week admission. To maintain a VPA level 50 μg/mL, VPA doses increased from 1500 to 4000 mg/day. Case 3 had tuberous sclerosis and epilepsy and was followed up for >4 years with 137 VPA concentrations. To maintain VPA concentrations 50 μg/mL, VPA doses increased from 3,375 to 10,500 mg/day. In Cases 2 and 3, the duration of admission and the VPA dose were strongly correlated (r around 0.90; ) with almost no change after controlling for VPA concentrations, indicating progressive autoinduction that increased with time. James Jackson, Betsy McCollum, Judy Ognibene, Francisco J. Diaz, and Jose de Leon Copyright © 2015 James Jackson et al. All rights reserved. Severe Psychotic Disorder as the Main Manifestation of Adrenal Insufficiency Sun, 12 Apr 2015 12:20:31 +0000 We describe a case of severe psychotic disorder as the only manifestation of primary adrenal insufficiency. A 63-year-old man presented with psychotic symptoms without any prior psychiatric history. During the clinical and laboratorial investigation, exams revealed a normovolemic hyponatremia. The patient showed no other clinical signs or symptoms compatible with adrenal insufficiency but displayed very high ACTH and low serum cortisol concentrations. Brain magnetic resonance imaging showed no significant changes, including the pituitary gland. The patient was initially treated with intravenous corticosteroids, resulting in rapid remission of the psychotic symptoms. The association between adrenal insufficiency and neuropsychiatric symptoms is rare but these symptoms can often be the first clinical presentation of the disease. Julia de Lima Farah, Carolina Villar Lauand, Lucas Chequi, Enrico Fortunato, Felipe Pasqualino, Luis Henrique Bignotto, Rafael Loch Batista, and Ivan Aprahamian Copyright © 2015 Julia de Lima Farah et al. All rights reserved. Top-Down Computerized Cognitive Remediation in Schizophrenia: A Case Study of an Individual with Impairment in Verbal Fluency Thu, 09 Apr 2015 12:52:35 +0000 The objective of this case study was to assess the specific effect of cognitive remediation for schizophrenia on the pattern of cognitive impairments. Case A is a 33-year-old man with a schizophrenia diagnosis and impairments in visual memory, inhibition, problem solving, and verbal fluency. He was provided with a therapist delivered cognitive remediation program involving practice and strategy which was designed to train attention, memory, executive functioning, visual-perceptual processing, and metacognitive skills. Neuropsychological and clinical assessments were administered at baseline and after three months of treatment. At posttest assessment, Case A had improved significantly on targeted (visual memory and problem solving) and nontargeted (verbal fluency) cognitive processes. The results of the current case study suggest that (1) it is possible to improve specific cognitive processes with targeted exercises, as seen by the improvement in visual memory due to training exercises targeting this cognitive domain; (2) cognitive remediation can produce improvements in cognitive processes not targeted during remediation since verbal fluency was improved while there was no training exercise on this specific cognitive process; and (3) including learning strategies in cognitive remediation increases the value of the approach and enhances participant improvement, possibly because strategies using verbalization can lead to improvement in verbal fluency even if it was not practiced. Marjolaine Masson, Til Wykes, Michel Maziade, Clare Reeder, Marie-Anne Gariépy, Marc-André Roy, Hans Ivers, and Caroline Cellard Copyright © 2015 Marjolaine Masson et al. All rights reserved. New-Onset Panic, Depression with Suicidal Thoughts, and Somatic Symptoms in a Patient with a History of Lyme Disease Wed, 01 Apr 2015 11:51:56 +0000 Lyme Disease, or Lyme Borreliosis, caused by Borrelia burgdorferi and spread by ticks, is mainly known to cause arthritis and neurological disorders but can also cause psychiatric symptoms such as depression and anxiety. We present a case of a 37-year-old man with no known psychiatric history who developed panic attacks, severe depressive symptoms and suicidal ideation, and neuromuscular complaints including back spasms, joint pain, myalgias, and neuropathic pain. These symptoms began 2 years after being successfully treated for a positive Lyme test after receiving a tick bite. During inpatient psychiatric hospitalization his psychiatric and physical symptoms did not improve with antidepressant and anxiolytic treatments. The patient’s panic attacks resolved after he was discharged and then, months later, treated with long-term antibiotics for suspected “chronic Lyme Disease” (CLD) despite having negative Lyme titers. He however continued to have subsyndromal depressive symptoms and chronic physical symptoms such as fatigue, myalgias, and neuropathy. We discuss the controversy surrounding the diagnosis of CLD and concerns and considerations in the treatment of suspected CLD patients with comorbid psychiatric diagnoses. Amir Garakani and Andrew G. Mitton Copyright © 2015 Amir Garakani and Andrew G. Mitton. All rights reserved. Synthetic Cannabis-Induced Mania Mon, 09 Mar 2015 11:42:43 +0000 Synthetic cannabinoids (SC), cannabinoid 1 and cannabinoid 2 receptors agonists, are the psychoactive substances. SC was originally produced to treat medical conditions. Compared to other narcotics, SC is easier to obtain, cheap, and highly potent and has a long half-life. In addition, routine analysis does not detect SC, which has led to widespread use. A case is presented that manic episode was developed with the use of SC. Hospitalization and admission to psychiatric units depending on SC use have been observed mostly with psychosis. Although SC-induced affective symptoms were mentioned in the literature, mania has not been reported before. We aimed to discuss the psychiatric conditions induced by widespread use of SC via our case. Mehmet Fatih Ustundag, Esra Ozhan Ibis, Atakan Yucel, and Halil Ozcan Copyright © 2015 Mehmet Fatih Ustundag et al. All rights reserved. Amisulpride Augmentation for Clozapine-Refractory Positive Symptoms: Additional Benefit in Reducing Hypersialorrhea Mon, 09 Mar 2015 07:45:18 +0000 One-third to half of patients taking clozapine suffer from refractory symptoms despite adequate treatment. Among other adverse effects, clozapine-induced hypersalivation (CIH) occurs in approximately half of all patients. This is a case of a 30-year-old male with refractory schizophrenia; in this patient, the remission of residual positive symptoms, as well as the reduction of CIH, was achieved by treatment with clozapine augmented with amisulpride. Fabiani Bogorni, Frederico Fernandes Moreira, Eduardo Mylius Pimentel, Géder Evandro Motta Grohs, and Alexandre Paim Diaz Copyright © 2015 Fabiani Bogorni et al. 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.