Case Reports in Psychiatry The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Amlodipine and the Successful Management of Post-Electroconvulsive Therapy Agitation Wed, 03 Feb 2016 12:56:16 +0000 Electroconvulsive therapy (ECT) is a highly effective nonpharmacologic treatment for the management of depression and some other psychiatric disorders. Post-ECT agitation occurs in up to 12% of ECT treatments and is characterized by motor restlessness, irritability, disorientation, and panic-like behaviors. The severity of post-ECT agitation ranges from mild and self-limited to serious and severe forms requiring prompt medical intervention to protect the patient and the medical staff. In severe agitation medical management may be necessary which consists of using sedative agents, either benzodiazepines or propofol. The side-effects of these sedative agents, especially in the elderly population, necessitate finding ways that could help the prevention of the occurrence of agitation after ECT treatments. We report a 68-year-old female with major depression who was referred for ECT. She experienced severe post-ECT agitation requiring medical intervention after all ECT treatments. Administering of oral amlodipine (5 mg) one hour before ECT treatment successfully prevented the occurrence of post-ECT agitation in this patient. We briefly discuss the possible underlying mechanisms and pathophysiology of amlodipine in the prevention of post-ECT agitation. Ali Shahriari, Maryam Khooshideh, and Mahdi Sheikh Copyright © 2016 Ali Shahriari et al. All rights reserved. Foreign Accent Syndrome, a Rare Presentation of Schizophrenia in a 34-Year-Old African American Female: A Case Report and Literature Review Tue, 26 Jan 2016 08:02:17 +0000 Foreign Accent Syndrome (FAS) is a rare phenomenon where speech is characterized by a new accent to the patient’s native language. More than 100 cases with the syndrome have been published, the majority of which were associated with observed insults of the speech center. Some other cases have been described without identifiable organic brain injury, especially in patients with psychiatric illness. This paper presents a patient with schizophrenia and FAS, without any evidence of organic brain injury. FAS recurred during psychotic exacerbation and did not reverse before transfer to a long-term psychiatric facility. The case is discussed in the context of a brief review of the syndrome. Kenneth Asogwa, Carolina Nisenoff, and Jerome Okudo Copyright © 2016 Kenneth Asogwa et al. All rights reserved. Concomitant Use of Topiramate Inducing Neutropenia in a Schizophrenic Male Stabilized on Clozapine Sun, 24 Jan 2016 07:07:19 +0000 This is a case of a 23-year-old African American male with a history of paranoid schizophrenia that developed neutropenia on a clozapine-topiramate therapy. Clozapine had well addressed the patient’s psychotic symptoms, while topiramate was used as a weight-lowering agent. The patient had fairly stable leukocyte counts for eight months on clozapine 300 mg and topiramate 100 mg daily. Doubling the dosage of topiramate led to severe neutropenia after two months. Reviewing the patient’s laboratory reports showed a gradual decline of neutrophils occurring at a lower dosage, followed by a rapid decline after an increased dosage. In this case, we report that not only did topiramate act as the neutropenic agent, but also it might have done so in a dose-dependent manner. Pravesh Sharma, Jeffrey Davis, Vivekananda Rachamallu, and Manish Aligeti Copyright © 2016 Pravesh Sharma et al. All rights reserved. Paliperidone Palmitate Associated with Necrotizing Deep Tissue Infection and Sepsis Requiring Surgical Intervention Wed, 30 Dec 2015 09:17:41 +0000 Long-acting injectable antipsychotics provide the delivery of medication over an extended period of time requiring administration typically only every 2 to 4 weeks. The side effect profile of a long-acting injectable antipsychotic is predictable and similar to the oral formulation. However, injection site reactions may occur with this novel delivery system. The risk of an injection site reaction may be greater with the repeated administration of a lipophilic decanoate formulation and include pain, development of indurations, and fibrosis. Severe complications from injection site reactions have rarely been described in the literature with newer agents. We report the first case of a patient prescribed paliperidone palmitate every 3 weeks that developed severe sepsis requiring vasopressors and intubation due to delayed relayed recognition of a necrotizing infection at an injection site. Clinicians should be alerted to screen for injection site reactions when there is an unknown source infection in a patient receiving a long-acting injectable antipsychotic. Jonathan G. Leung, Kirstin J. Kooda, Erin N. Frazee, Sarah Nelson, and Katherine M. Moore Copyright © 2015 Jonathan G. Leung et al. All rights reserved. Severe Relapsing Clozapine-Withdrawal Catatonia Mon, 14 Dec 2015 13:51:29 +0000 Catatonia as a clozapine-withdrawal syndrome has only been documented in the medical literature as case reports. We are reporting a case in which a 32-year-old man develops a catatonic state upon withdrawal of clozapine. The state was quite severe and needed ICU admission. The course was chronic and intermittent which we think was caused by the poor adherence to antipsychotics. The importance of identifying such cases early is underlined. Tarek Shahrour, Muez Siddiq, Saad Ghalib, and Taoufik Alsaadi Copyright © 2015 Tarek Shahrour et al. All rights reserved. Is Valproate Depressogenic in Patients Remitting from Acute Mania? Case Series Tue, 17 Nov 2015 06:41:56 +0000 Valproate is an effective antimanic agent and is recommended as a first-line medication in the treatment of acute mania. Current evidence based guidelines recommend that valproate should be given as a loading dose as it produces a rapid antimanic and antipsychotic response with minimal side-effects. However, no clear guidelines are available on the appropriate dosing or serum levels of valproate in the continuation or maintenance phase of bipolar disorder. We present 4 clinical cases to hypothesize that the higher doses of valproate, such as those used in the treatment of acute mania, may cause a depressive switch. So consideration should be given to reducing the dose of valproate if a patient develops depressive symptoms following recovery from the manic episode, as a therapeutic strategy. The cases also indicate that relatively lower doses and serum levels of valproate are effective in the maintenance phase compared to those needed in the acute manic phase of bipolar disorder. This is the first set of case series that questions the depressogenic potential of valproate in patients remitting from an acute manic episode. It highlights that different doses and serum levels of valproate may be therapeutic in different phases of bipolar disorder. Kamini Vasudev and Priya Sharma Copyright © 2015 Kamini Vasudev and Priya Sharma. All rights reserved. Urinary Incontinence during Sleep Associated with Extended Release Form of Bupropion HCI Tue, 03 Nov 2015 13:30:06 +0000 Bupropion hydrochloride (HCI) is an antidepressant that acts as a norepinephrine and dopamine reuptake inhibitor and has three different dosage forms including immediate release (IR), sustained release (SR), and extended release (ER). Despite its relatively safe side effect profile bupropion may cause several side effects. Here, we aimed to report a case with major depression using extended release form of bupropion hydrochloride who was presented with urinary incontinence during sleep, an uncommon side effect of bupropion. Filiz Izci, Merve Iris Koc, Rabia Bilici, Murat Yalcin, and Engin Emrem Bestepe Copyright © 2015 Filiz Izci et al. All rights reserved. Manic Symptoms during a Switch from Paliperidone ER to Paliperidone Palmitate in a Patient with Schizophrenia Sun, 11 Oct 2015 11:18:10 +0000 Some antipsychotic drugs have treatment efficacy for mania and bipolar disorder. However, these drugs may rarely cause manic symptoms in some schizophrenic patients. We hereby report a 22-year-old female patient with schizophrenia who experienced a manic episode during a switch from paliperidone ER to paliperidone palmitate. This case is an important reminder that an abrupt switch from oral paliperidone to paliperidone palmitate may predispose certain patients to hypomanic or manic symptoms. Kadir Demirci, Süleyman Keleş, Arif Demirdaş, and Cafer Çağrı Korucu Copyright © 2015 Kadir Demirci et al. All rights reserved. Increased Anxiety, Akathisia, and Suicidal Thoughts in Patients with Mood Disorder on Aripiprazole and Lamotrigine Mon, 05 Oct 2015 09:49:14 +0000 Introduction. Akathisia affects around 18% of patients with bipolar disorder treated with aripiprazole and may worsen when aripiprazole is combined with lamotrigine and antidepressants. Case. This paper reports on two clinical cases involving patients with a diagnosis of mood disorder who developed severe akathisia, anxiety, and suicidal ideation while using a combination of aripiprazole, antidepressants, and lamotrigine. Discussion. We recommend that patients with a mood disorder taking multiple drugs should begin aripiprazole therapy with low doses and be monitored for the development of akathisia, increased anxiety, or suicidal thoughts. The appearance of these limiting side effects requires discontinuation of the drug. Milena Pereira Pondé and Antonio Carlos Cruz Freire Copyright © 2015 Milena Pereira Pondé and Antonio Carlos Cruz Freire. All rights reserved. Catatonia in Older Adult Individuals with Intellectual Disabilities Thu, 01 Oct 2015 11:59:32 +0000 Catatonia has been described in children with intellectual disabilities (IDs). These are the first three published cases of catatonia in adults older than 50 years of age with IDs. They were followed using the KANNER scale and, in one case, creatinine phosphokinase (CPK) monitoring. Case 1 is a 67-year-old Caucasian who probably had been having intermittent episodes of undiagnosed catatonia withdrawal for many years. His episodes of agitation and withdrawal behavior responded to lorazepam up to 8 mg/day. Case 2 is a 63-year-old Caucasian male who had probably had undiagnosed catatonic episodes since age 25. An agitation episode that rated 88 on Part 2 of the KANNER scale ended within minutes after he received 1 mg of intramuscular lorazepam. He had no symptom relapses for 4 years after getting stable oral lorazepam doses (3–8.5 mg/day). Case 3 is a 55-year-old African-American male with severe ID and bradycardia (with a pacemaker). He had been “institutionalized” since age 22 and his undiagnosed catatonic episodes appeared to have been intermittently present for at least the last ten years. As he became tolerant and experienced symptom relapse, oral lorazepam was slowly increased (1.5–18 mg/day). Electroconvulsive therapy was ruled out due to his pacemaker. Megan White, Edward Maxwell, Warren E. Milteer, and Jose de Leon Copyright © 2015 Megan White et al. All rights reserved. Anti-AMPA-Receptor Encephalitis Presenting as a Rapid-Cycling Bipolar Disorder in a Young Woman with Turner Syndrome Thu, 01 Oct 2015 11:34:52 +0000 Background. Autoimmune encephalitis is a disorder characterised by the subacute onset of seizures, short-term memory loss, and psychiatric and behavioural symptoms. Initially, it was recognised as a paraneoplastic disorder, but recently a subgroup of patients without systemic cancer was identified. Case Description. We describe a 20-year-old woman with Turner syndrome presenting with a treatment-resistant rapid cycling bipolar disorder with cognitive impairment. She was diagnosed with anti-AMPA-receptor encephalitis. She showed marked improvement after starting memantine and valproic acid. Conclusion. This case description emphasises the importance of timely recognition of autoimmune limbic encephalitis in patients with psychiatric manifestations and a possible predisposition to autoimmune conditions, in order to rule out malignancy and to quickly initiate treatment. Giuseppe Quaranta, Angelo Giovanni Icro Maremmani, and Giulio Perugi Copyright © 2015 Giuseppe Quaranta et al. All rights reserved. Beneficial Effects of Palmitoylethanolamide on Expressive Language, Cognition, and Behaviors in Autism: A Report of Two Cases Tue, 29 Sep 2015 13:28:02 +0000 Introduction. Autism spectrum disorders are defined by behavioral and language atypias. Growing body of evidence indicates inflammatory mediators may contribute to the condition. Palmitoylethanolamide (PEA) is naturally occurring and has been available as a nonprescription medical food supplement in Europe since 2008. PEA has been tested in thousands of human subjects without any noted significant side effects. Here we report the first cases of the administration of PEA to two children with autism. Case Presentations. The first 13-year-old male child (Subject 1) presented with a total IgE of 572 IU/mL (nl < 200) and with low mature CD57+ natural killer cell counts (32 cells/µL; nl = 60–300 cells/µL) and with significant eczema and allergic stigmata. Expressive language, as measured by mean length of utterance, and overall autism severity as measured by the Childhood Autism Rating Scale, Second Edition, improved significantly. Atopic symptoms diminished. No side effects were reported. The second male child, age 15 (Subject 2), also displayed noticeable and rapid improvements in cognitive, behaviors, and sociability. Conclusion. Currently, there is no definitive treatment for autism condition. Palmitoylethanolamide could be an effective treatment for autism syndrome. We propose appropriate double-blind clinical trials to further explore palmitoylethanolamide efficacy and safety. Nicola Antonucci, Alessandra Cirillo, and Dario Siniscalco Copyright © 2015 Nicola Antonucci et al. All rights reserved. Comorbidity of Obsessive-Compulsive Disorder and Schizophrenia in an Adolescent Mon, 21 Sep 2015 11:49:41 +0000 We report a case of a girl with a history of obsessive-compulsive disorder (OCD) subsequently exhibiting psychosis. She never attained remission since the outset. Initially she seemed to be resistant to most antipsychotics, namely, risperidone, haloperidol, paliperidone, quetiapine, and clozapine. However, she later responded remarkably better to risperidone after it was reintroduced for the second time. Recognizing and understanding the various pathogenesis of OCD or obsessive-compulsive symptoms (OCS) in schizophrenia are vital in laying out plan to manage the patient effectively. Ahmad Nabil Md. Rosli and Wan Salwina Wan Ismail Copyright © 2015 Ahmad Nabil Md. Rosli and Wan Salwina Wan Ismail. All rights reserved. Diffuse Hair Loss Induced by Sertraline Use Thu, 17 Sep 2015 11:39:21 +0000 Hair loss is a rare side effect of psychotropic drugs. The most related drug class with this side effect is the mood stabilizers. Studies reporting the sertraline-induced alopecia are limited in number. Sertraline is a potent antidepressant which inhibits the serotonin reuptake from the presynaptic terminals selectively. The reason for hair loss could not be elucidated completely. Psychotropic drugs are usually considered to lead to hair loss through influencing the telogen phase of hair follicle. This paper reports a 21-year-old male with diffuse hair loss induced by sertraline use and improved by quitting the drug. To the best of our knowledge, there are no other case reports on sertraline-induced alopecia within 2 weeks. Yüksel Kıvrak, İbrahim Yağcı, Mehmet Fatih Üstündağ, and Halil Özcan Copyright © 2015 Yüksel Kıvrak et al. All rights reserved. The Spectrum of Psychiatric Pathology in a Patient with Genetically Verified Huntington’s Disease Wed, 16 Sep 2015 06:21:19 +0000 Psychiatric and behavioral disturbances are common in Huntington’s disease (HD) and contribute significantly to its morbidity and mortality. We herein present the case of a 43-year-old woman with genetically verified HD, whose deteriorating psychiatric condition necessitated multiple inpatient psychiatric hospitalizations and featured a clinical spectrum of neuropsychiatric disturbances classically associated with HD. This paper reviews the literature concerning Huntington’s psychopathology and provides an illustrative case example of its clinical nature. Samir Alkabie, Daljinder Singh, Amy Hernandez, and Rhaisa Dumenigo Copyright © 2015 Samir Alkabie et al. 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.