Case Reports in Psychiatry The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Trichotillomania as a Manifestation of Dementia Thu, 20 Oct 2016 14:37:21 +0000 Pathological hair-pulling or trichotillomania, which is commonly associated with anxiety and depression, obsessive-compulsive disorder, and neurodevelopmental disorders, has been rarely associated with dementing illnesses. Investigators have not clarified the neural correlates and treatment of trichotillomania in dementia. We report a patient who developed an early-onset cognitive decline with genetic, cerebrospinal fluid biomarker and structural and functional neuroimaging studies consistent with Alzheimer’s disease. Eight years into her disease, she developed severe, repetitive hair-pulling behavior leading to marked hair loss, along with other repetitive and “frontal” behaviors. Selective serotonin reuptake inhibitors (SSRIs) were ineffective in controlling her hair-pulling behavior, which subsequently responded to quetiapine 150 mg/day. This patient and a review of the literature suggest that trichotillomania may be a compulsive-related symptom in dementias of different etiologies as they involve frontal areas and release primitive grooming behavior from frontostriatal dysfunction. Dopamine blockade, rather than SSRIs, may be effective in managing trichotillomania in dementia. Pongsatorn Paholpak and Mario F. Mendez Copyright © 2016 Pongsatorn Paholpak and Mario F. Mendez. All rights reserved. Rational Suicide, Euthanasia, and the Very Old: Two Case Reports Wed, 19 Oct 2016 11:38:03 +0000 Suicide amongst the very old is an important public health issue. Little is known about why older people may express a wish to die or request euthanasia and how such thoughts may intersect with suicide attempts. Palliative care models promote best care as holistic and relieving suffering without hastening death in severely ill patients; but what of those old people who are tired of living and may have chronic symptoms, disability, and reduced quality of life? Two cases of older people who attempted suicide but expressed a preference for euthanasia were it legal are presented in order to illustrate the complexity underlying such requests. The absence of a mood or anxiety disorder underpinning their wishes to die further emphasises the importance of understanding the individual’s narrative and the role of a formulation in guiding broad biopsychosocial approaches to management. Anne Pamela Frances Wand, Carmelle Peisah, Brian Draper, Carolyn Jones, and Henry Brodaty Copyright © 2016 Anne Pamela Frances Wand et al. All rights reserved. Diagnosis of Dilated Cardiomyopathy: Patient Reaction and Adaptation—Case Study and Review of the Literature Sun, 16 Oct 2016 15:52:58 +0000 Objective. Heart failure remains a major cause of morbidity and mortality. Given that heart failure generally has a chronic course, it is important to appreciate the impact it can have on the quality of life of patients and also their partners or family carers. Method. Questionnaires were given to a patient newly diagnosed with dilated cardiomyopathy, during his hospital admission, as well as after discharge. The responses are summarised and explored in the discussion section, where we used review of the literature to discuss the implications of a new diagnosis of heart failure. Results. The patient’s responses to the questionnaires suggest certain anxieties that are part of his adaptation to the diagnosis of heart failure. Conclusion. Depression is a common comorbid condition in patients with heart failure. Various tools can be used to screen for depression in patients with heart failure. Both pharmacological and nonpharmacological options are available. Rapid evaluation of ongoing problems and active participation by a psychiatrist can ensure that the patient receives the best possible clinical care. Solomis Solomou, Maria Stavrou, and Justin Marley Copyright © 2016 Solomis Solomou et al. All rights reserved. A Case of Aripiprazole-Induced Tardive Dyskinesia with Dramatic Evolution Wed, 12 Oct 2016 13:41:23 +0000 Aripiprazole is reported to be a good clinical safety profile antipsychotic. However, recent data suggest that the risk of tardive dyskinesia could be higher than initially thought. We report the case of aripiprazole-induced tardive dyskinesia with dramatic evolution in a patient with several risk factors, including older age and exposure to antipsychotic over a period longer than six months. This case and its dramatic evolution, associated with other cases recently published, suggest reconsidering the real risk of tardive dyskinesia associated with aripiprazole, particularly in the elderly. Edwige Heitzmann, Hervé Javelot, Luisa Weiner, and Bruno Michel Copyright © 2016 Edwige Heitzmann et al. All rights reserved. Synthetic Cannabis Overdose and Withdrawal in a Young Adult: A Case Report, Commentary on Regulation, and Review of the Literature Thu, 29 Sep 2016 09:59:48 +0000 Introduction. Marijuana has been used for its psychotropic effects including enhanced relaxation and perceptual alterations. However, the use of synthetic marijuana (SM) leads to more frequent and drastic side effects than the typical use of regular marijuana, owing to the fact that SM has a shorter duration and an earlier peak of action. Despite all the potential adverse health effects associated with SM use, current health policies on SM are very limited. It is believed that the popularity of SM has increased, due to its easy accessibility in the US and lack of detection in typical urine drug screens for THC. Case Report. One case presented is of a young adult patient, with histories of recurrent synthetic cannabis and recreational cannabis use, who had developed drastic physiological and psychiatric symptoms, including the development of acute-onset psychosis. Conclusion/Discussion. This case, as many others nationwide, exemplifies the impact of synthetic cannabinoid use and abuse in adolescents. Side effects and adverse health consequences of synthetic cannabinoid use warrant stricter regulations and policies in order to decrease psychiatric hospital admissions and associated healthcare costs. John Samaan, Gerardo F. Ferrer, Boye Akinyemi, Patricia Junquera, Juan Oms, and Rhaisa Dumenigo Copyright © 2016 John Samaan et al. All rights reserved. Sexual Masochism Disorder with Asphyxiophilia: A Deadly yet Underrecognized Disease Thu, 22 Sep 2016 14:14:46 +0000 DSM-5 distinguishes between paraphilias and paraphilic disorders. Paraphilias are defined as atypical, yet not necessarily disordered, sexual practices. Paraphilic disorders are instead diseases, which include distress, impairment in functioning, or entail risk of harm one’s self or others. Hence, DSM-5 new approach to paraphilias demedicalizes and destigmatizes unusual sexual behaviors, provided they are not distressing or detrimental to self or others. Asphyxiophilia, a dangerous and potentially deadly form of sexual masochism involving sexual arousal by oxygen deprivation, are clearly described as disorders. Although autoerotic asphyxia has been associated with estimated mortality rates ranging from 250 to 1000 deaths per year in the United States, in Italy, knowledge on this condition is very poor. Episodes of death caused by autoerotic asphyxia seem to be underestimated because it often can be confounded with suicide cases, particularly in the Italian context where family members of the victim often try to disguise autoerotic behaviors of the victims. The current paper provides a review on sexual masochism disorder with asphyxiophilia and discusses one specific case as an example to examine those conditions that may or may not influence the likelihood that death from autoerotic asphyxia be erroneously reported as suicide or accidental injury. Anna Coluccia, Mario Gabbrielli, Giacomo Gualtieri, Fabio Ferretti, Andrea Pozza, and Andrea Fagiolini Copyright © 2016 Anna Coluccia et al. All rights reserved. Retracted: Combined Case of Blood-Injury-Injection Phobia and Social Phobia: Behavior Therapy Management and Effectiveness through Tilt Test Sun, 18 Sep 2016 07:41:56 +0000 Case Reports in Psychiatry Copyright © 2016 Case Reports in Psychiatry. All rights reserved. Development of Tinnitus at a Low Dose of Sertraline: Clinical Course and Proposed Mechanisms Thu, 15 Sep 2016 16:02:20 +0000 Introduction. Serotonin is involved in filtering of auditory stimuli. Cochlear input is processed through complex interactions between serotonergic, glutamatergic, and GABAergic neurotransmitter systems. Options for treatment of tinnitus include selective serotonin reuptake inhibitors (SSRIs); however in rare instances this symptom may occur as a side effect of this class of medications. Case Presentation. A 50-year-old woman developed bilateral tinnitus after several weeks of being treated with sertraline 50 mg. She had been on a long-standing daily dose of aspirin 325 mg which had been discontinued shortly before starting sertraline. Medical work-up was negative for her symptom. Shortly after discontinuation of the medication, her tinnitus subsided completely. Discussion. Tinnitus is a rare side effect of sertraline and may be related to particular distribution of serotonin receptor subtypes within the auditory system, and serotonergic agents may reinforce or desensitize the activity of different receptors. Also, there may be a priming effect of salicylate agents on the auditory system, predisposing particular patients to be more sensitive to how auditory stimuli are processed. Christopher W. T. Miller Copyright © 2016 Christopher W. T. Miller. All rights reserved. Delirious Mania Associated with Autoimmune Gastrothyroidal Syndrome of a Mid-Life Female: The Role of Hashimoto Encephalopathy and a 3-Year Follow-Up including Serum Autoantibody Levels Thu, 01 Sep 2016 09:57:37 +0000 We report the case study of a 57-year-old Caucasian female with steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT), commonly termed Hashimoto encephalopathy (HE). This presentation includes one of the longest lasting follow-up studies of HE considering the neuropsychiatric symptoms (here delirium, mania, and EEG-slowing) and their relation to serum autoantibody levels. Antithyroid-peroxidase autoantibodies, the hallmark of autoimmune thyroiditis, were found in the serum and also in the cerebrospinal fluid. Diagnostic analyses found no evidence of limbic encephalopathies characterized by serum antibodies against intracellular, synaptic, or further cell surface antigenic targets, neoplasm, and connective tissue or vasculitis diseases. A potential contribution of bipolar disorder and metabolic encephalopathies due to severe hypothyroidism, glucocorticoid treatment, accelerated thyroid hormone replacement therapy, or vitamin B deficiency is critically discussed. Another special feature of this case report is the linkage of HE to an autoimmune polyendocrine syndrome (type 3B) affecting the gastroduodenum in addition to the thyroid gland. Udo Bonnet, Claudia Selle, and Ralf Kuhlmann Copyright © 2016 Udo Bonnet et al. All rights reserved. Medial Cranial Fossa Meningioma Diagnosed as Mixed Anxiety Disorder with Dissociative Symptoms and Vertigo Mon, 29 Aug 2016 14:16:27 +0000 Meningiomas are mostly benign tumors of the meninges that may stay clinically silent or present first with psychiatric symptoms only. We present a case of medial cranial fossa meningioma that was first diagnosed as mixed anxiety disorder with dissociative symptoms and vertigo. In light of the intact neurological and vestibular system examination, our patient’s vertigo and depersonalization were firstly addressed as psychosomatic symptoms of the psychiatric syndrome. Despite decreased anxiety and improved mood, dissociative symptoms and vertigo were resistant to treatment which prompted further research yielding a left hemisphere localized meningioma. Resection of meningioma resulted in full remission of the patient proving it to be responsible for the etiology of the psychiatric syndrome and vertigo. We suggest that brain imaging should be performed for patients with late-onset (>50 years) psychiatric symptoms and those with treatment resistance. It is important to keep in mind always that medically unexplained symptoms may become explicable with detailed assessment and regular follow-up of the patient. Emin Mehmet Ceylan, Bariş Önen Ünsalver, and Alper Evrensel Copyright © 2016 Emin Mehmet Ceylan et al. All rights reserved. Two Sudden and Unexpected Deaths of Patients with Schizophrenia Associated with Intramuscular Injections of Antipsychotics and Practice Guidelines to Limit the Use of High Doses of Intramuscular Antipsychotics Mon, 15 Aug 2016 08:10:19 +0000 Intravenous haloperidol has been associated with torsades de pointes (TdP). These two sudden deaths were probable adverse drug reactions (ADRs) following intramuscular (IM) antipsychotics. The autopsies described lack of heart pathology and were highly compatible with the possibility of TdP in the absence of risk factors other than the accumulation of antipsychotics with a high serum peak after the last injection, leading to death within hours. The first case was a 27-year-old African-American male with schizophrenia but no medical issues. His death was probably caused by repeated IM haloperidol injections of 10 mg (totaling 35 mg in 2 days). The second case involves a 42-year-old African-American female with metabolic syndrome. Her probable cause of death was the last ziprasidone IM injection of 20 mg in addition to (1) three extra haloperidol doses (2 hours before the ziprasidone injection, 5 mg oral haloperidol; approximately 21 hours earlier, 5 mg oral haloperidol; and 2 days prior, one 10 mg IM haloperidol injection), (2) 10 mg/day of scheduled oral haloperidol for 6 days before death, and (3) a long-acting paliperidone injection of 156 mg 18 days before death. The study of haloperidol glucuronidation and its impairment in some African-Americans is urgently recommended. Nasratullah Wahidi, Katie M. Johnson, Allen Brenzel, and Jose de Leon Copyright © 2016 Nasratullah Wahidi et al. All rights reserved. Successful Treatment of Suspected Cannabinoid Hyperemesis Syndrome Using Haloperidol in the Outpatient Setting Thu, 11 Aug 2016 10:58:32 +0000 Chronic use of cannabis can result in a syndrome of hyperemesis characterized by cyclical vomiting without any other identifiable causes. Cannabinoid hyperemesis syndrome (CHS) is seldom responsive to traditional antiemetic therapies. Despite frequent nausea and vomiting, patients may be reluctant to discontinue use of cannabis. We report a case of severe, refractory CHS with complete resolution of nausea and vomiting after treatment with haloperidol in the outpatient setting. After review of the literature, we believe this is the first reported successful outpatient treatment of CHS and suggests a potential treatment for refractory patients. Jennifer L. Jones and Karen E. Abernathy Copyright © 2016 Jennifer L. Jones and Karen E. Abernathy. All rights reserved. Effectiveness of Simple Individual Psychoeducation for Bipolar II Disorder Sun, 31 Jul 2016 07:05:31 +0000 Several studies have proven the effectiveness of psychoeducation in bipolar II disorder patients; however, simpler psychoeducation is needed in daily medical practice. Therefore, we devised a simple individual psychoeducation program, which involved 20-minute sessions spent reading a textbook aloud in the waiting time before examination. Here, we report a successful case of simple individual psychoeducation with a patient with bipolar II disorder, a 64-year-old woman who had misconceptions surrounding her mood due to 24 years of treatment for depression. Her perception of mood state, particularly mixed state, was dramatically changed, and her quality of life was improved after the simple individual psychoeducation. This case suggests that the simple individual psychoeducation could be effective for bipolar II disorder by improving understanding of the disease and by meeting different individual needs. Yuka Saito-Tanji, Emi Tsujimoto, Reiko Taketani, Ami Yamamoto, and Hisae Ono Copyright © 2016 Yuka Saito-Tanji et al. All rights reserved. Acute Psychosis as Major Clinical Presentation of Legionnaires’ Disease Thu, 28 Jul 2016 07:22:51 +0000 We report a case of a 61-year-old woman who presented with acute psychosis as a major manifestation of Legionnaires’ disease in the absence of other neuropsychiatric symptoms. Clinical history revealed dry cough and nausea. Observation showed fever and auscultation crackles in the lower lobe of the right lung. Laboratory testing demonstrated elevated C-reactive protein and lung chest radiograph showed patchy peribronchial and right lower lobe consolidation. Soon after admission, she started producing purulent sputum. Epidemiological data suggested Legionella pneumophila as possible cause of the clinical picture that was confirmed by urinary antigen detection and polymerase chain reaction of the sputum. She was treated with levofloxacin 750 mg/day for 10 days with complete remission of pulmonary and psychiatric symptoms. She has not had further psychotic symptoms. Ricardo Coentre, Amílcar Silva-dos-Santos, and Miguel Cotrim Talina Copyright © 2016 Ricardo Coentre et al. All rights reserved. Clozapine Can Be the Good Option in Resistant Mania Mon, 25 Jul 2016 09:35:23 +0000 Bipolar mood disorder is a mental disorder with a lifetime prevalence rate of about 1% in the general population and there are still a proportion of individuals who suffer from bipolar mood disorders that are resistant to standard treatment. Reporting clozapine responsive mania that was not responding to two previous consecutive atypical antipsychotics and one typical antipsychotic was aimed at. A 17-year-old male manic patient was admitted into the psychiatry inpatient department and was nonresponsive to Risperidone 12 mg daily for 4 weeks, Olanzapine 30 mg daily for 3 weeks, and Haloperidol 30 mg daily for 3 weeks, along with valproate preparation 1500 mg daily. He was started on clozapine as he was nonresponsive to Lithium in previous episodes and did not consent to starting Electroconvulsive Therapy (ECT). He responded adequately to 100 mg clozapine and 1500 mg valproate preparation and remission happened within 2 weeks of starting clozapine. Clozapine can be a good option for resistant mania and further RCT based evidences will strengthen the options in treating resistant mania. S. M. Yasir Arafat, S. M. Atikur Rahman, Md. Maruful Haque, Mohsin Ali Shah, Sultana Algin, and Jhunu Shamsun Nahar Copyright © 2016 S. M. Yasir Arafat et al. All rights reserved. Valproic Acid Induced Hyperammonemia in a Long Time Treated Patient Tue, 19 Jul 2016 08:23:58 +0000 We report a case of a patient who had been on long time valproic acid for treatment of bipolar affective disorder. While being an inpatient, serology ammonia level testing revealed a very high ammonia level despite being asymptomatic. Dual therapy of carnitine and lactulose was provided to the patient for treatment of the hyperammonemia. It should also be noted that, during this treatment, valproic acid was not stopped. Consequently, this case illustrates that patients can present asymptomatically despite very high ammonia levels and hyperammonemia can occur in chronic valproic acid despite not increasing the dose of the medication and psychiatrists do not need to discontinue valproic acid in the presence of elevated levels of ammonia if the patient shows no signs of encephalopathy or delirium. Rohit Aiyer, Margaret Seide, and Robert G. Stern Copyright © 2016 Rohit Aiyer et al. All rights reserved. Dandy-Walker Malformation Presenting with Psychological Manifestations Thu, 14 Jul 2016 12:54:27 +0000 Dandy-Walker malformation, which is a congenital malformation of the cerebellum, is documented in literature to be associated with psychotic symptoms, obsessive compulsive symptoms, mood symptoms, hyperactivity, and impulsive behavior. The pathogenesis of psychiatric symptoms in Dandy-Walker malformation is thought to be due to disruption of the corticocerebellar tracts, resulting in what is known as cerebellar cognitive affective syndrome. We present a case of Dandy-Walker malformation presenting with psychiatric symptoms. This case highlights the necessity to be aware of psychiatric manifestations of cerebellar disease as it has an impact on the diagnosis and treatment. Yasodha Maheshi Rohanachandra, Dulangi Maneksha Amerasinghe Dahanayake, and Swarna Wijetunge Copyright © 2016 Yasodha Maheshi Rohanachandra et al. All rights reserved. Generalized Anxiety Disorder and Hypoglycemia Symptoms Improved with Diet Modification Thu, 14 Jul 2016 09:34:40 +0000 Observational evidence suggests that a relationship may exist between high glycemic index diets and the development of anxiety and depression symptoms; however, as no interventional studies assessing this relationship in a psychiatric population have been completed, the possibility of a causal link is unclear. AB is a 15-year-old female who presented with concerns of generalized anxiety disorder and hypoglycemia symptoms. Her diet consisted primarily of refined carbohydrates. The addition of protein, fat, and fiber to her diet resulted in a substantial decrease in anxiety symptoms as well as a decrease in the frequency and severity of hypoglycemia symptoms. A brief return to her previous diet caused a return of her anxiety symptoms, followed by improvement when she restarted the prescribed diet. This case strengthens the hypothesis that dietary glycemic index may play a role in the pathogenesis or progression of mental illnesses such as generalized anxiety disorder and subsequently that dietary modification as a therapeutic intervention in the treatment of mental illness warrants further study. Monique Aucoin and Sukriti Bhardwaj Copyright © 2016 Monique Aucoin and Sukriti Bhardwaj. All rights reserved. Bilateral Orchidopexy in a Hypochondriacal (Somatic Symptom Disorder) Patient and Determination of Fitness for Bilateral Orchidectomy Mon, 11 Jul 2016 13:07:03 +0000 Introduction. DSM-5 identifies two disorders: somatic symptom disorder and illness anxiety disorder, to replace hypochondriasis in DSM-IV. Patients with both disorders are intensely anxious about the possibility of an undiagnosed illness or devote excessive time and energy to health concerns and are not easily reassured. Both disorders cause considerable distress and life disruption, even at moderate levels. However, hypochondriasis (DSM-IV) is an indication for neither orchidopexy nor orchidectomy. This is the rationale for this report which is the first of its kind to the best of available literature. This is an original case report of interest to a particular clinical specialty of mental health but it will have a broader clinical impact across medicine. Case Presentation. A 30-year-old black male presented to a primary care clinic with multiple internet searches on the topic of testicular pain and its differential diagnosis. He had a bilateral orchidopexy for a suspected torsion. He was referred to mental health unit, to determine fitness for further surgery. Conclusions. If hypochondriasis is suspected in a medical or surgical inpatient, a psychological medicine consultation should be performed, to elucidate the diagnosis, to avoid unnecessary procedures, and to optimize patient’s care. A. U. Nwaopara and Erefagha Leonardo P. Allagoa Copyright © 2016 A. U. Nwaopara and Erefagha Leonardo P. Allagoa. All rights reserved. Paliperidone Induced Hypoglycemia by Increasing Insulin Secretion Sun, 10 Jul 2016 14:03:28 +0000 We report the case of a 41-year-old woman with schizophrenia who developed persistent hypoglycemia following paliperidone administration. After discontinuing paliperidone, the hypoglycemia resolved, but symptoms of diabetes emerged. Therefore, it appears that the hypoglycemia induced by paliperidone may mask symptoms of diabetes. Paliperidone may induce hypoglycemia by increasing insulin secretion. This report could help elucidate the relationship between atypical antipsychotics and glucose metabolism. Tsubasa Omi, Keisen Riku, Motoyuki Fukumoto, Koji Kanai, Yumi Omura, Hiromune Takada, and Hidenori Matunaga Copyright © 2016 Tsubasa Omi et al. All rights reserved. Lessons Learned and Questions Raised by an Atypical Case of Clozapine-Induced Myocarditis Tue, 05 Jul 2016 09:59:53 +0000 A Caucasian male in his early twenties suffering from treatment resistant schizophrenia was started on clozapine. After three days he developed tachycardia, a common side effect of clozapine induction. He had one temperature spike (38.9°C) on day ten after induction but remained clinically well. An ECG and blood tests were normal. Due to persistent tachycardia and an episode of collapse whilst seated on day 12, he was admitted to hospital for further investigation. A diagnosis of myocarditis was confirmed as a result of elevated cardiac enzyme levels and an echocardiogram. Following withdrawal of clozapine, supportive management, and initiation of cardiac medication, the patient made a successful recovery. He will be followed up with the cardiology team to ensure that his heart function returns to normal. Given the incidence of clozapine-induced myocarditis, the associated mortality risk, and diagnostic difficulties, this case raises questions about whether a formal system for identifying myocarditis should be adopted. Charles H. Earnshaw, Lucy Powell, and Owen Haeney Copyright © 2016 Charles H. Earnshaw et al. All rights reserved. Bupropion Induced Hyponatremia in an Elderly Patient: A Case Report and Review of the Literature Tue, 28 Jun 2016 08:36:50 +0000 We present the case of a 72-year-old female with a major depressive episode who developed hyponatremia associated with bupropion. In reviewing the literature, there are only a few case reports which pertain to this topic. The clinical symptoms of hyponatremia can be misinterpreted as a worsening of the primary psychiatric illness and can lead to potentially serious consequences if not fully evaluated. We recommend that clinicians should be well aware of this side effect and that sodium levels should be checked within the first 2 weeks after initiating treatment in patients, especially those with additional risk factors for hyponatremia, such as older age, female sex, diuretic use, low BMI, and unexplained mental status changes at any time during treatment with antidepressants. The risk for hyponatremia associated with mirtazapine appears to be low and its use can be helpful in patients who have developed hyponatremia induced by other antidepressants and who experienced symptoms of weight loss and insomnia. Sahil Munjal and Yvette Smolin Copyright © 2016 Sahil Munjal and Yvette Smolin. All rights reserved. Loxapine and Cyproheptadine Combined Limit Clozapine Rebound Psychosis and May Also Predict Clozapine Response Tue, 28 Jun 2016 08:15:43 +0000 Clozapine has been consistently shown to be superior to other antipsychotics in the treatment of psychosis. However, clozapine usage has been limited due to required routine blood monitoring and the potential for life threatening side effects. We report a case of a 66-year-old female patient, who developed clozapine-induced agranulocytosis after 10 weeks of clozapine treatment and was subsequently successfully treated with a combination of loxapine and cyproheptadine. The combination is thought to mimic the pharmacological profile of clozapine, rendering it as a possible alternative to traditional clozapine treatment. Lila Aboueid and Richard H. McCarthy Copyright © 2016 Lila Aboueid and Richard H. McCarthy. All rights reserved. First-Episode of Synthetic Cannabinoid-Induced Psychosis in a Young Adult, Successfully Managed with Hospitalization and Risperidone Sun, 26 Jun 2016 12:22:20 +0000 Synthetic cannabinoids- (SCs-) induced psychosis is a growing public health concern. 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 psychotic symptoms, presenting with first-episode psychosis in the context of progressive, acutely worsening, disorganized, psychotic thoughts and behaviors following prolonged use of SCs. We also discuss relevant literature on SCs-induced psychosis, highlighting its prevalence, presentation, diagnosis, and recommended management. It is important to diagnose and treat SCs-induced psychosis as early and efficiently as possible, in order to alleviate symptoms while limiting functional impairment and emotional distress to the patient. Aaron J. Roberto, Aileen Lorenzo, Kevin J. Li, Jonathan Young, Abhishek Mohan, Subhash Pinnaka, and Kyle A. B. Lapidus Copyright © 2016 Aaron J. Roberto et al. All rights reserved. Flakka-Induced Prolonged Psychosis Wed, 22 Jun 2016 09:39:56 +0000 In South Florida, there has been a highly addictive new synthetic drug flooding the streets for people looking for a cheap high. Alpha-PVP, better known as Flakka, is an illegal substance that sells on the streets for as little as $5 a hit and delivers an instant high that can last from hours to days with lingering effects for weeks after it has been ingested. Although people use Flakka for its potential euphoric high, symptoms are known to easily escalate into frightening delusions, paranoid psychosis, extreme agitation, and a multitude of other altered mental states. According to the National Institute on Drug Abuse, Florida appears to be the nation’s hot spot for reports of Flakka. In this case report, a 17-year-old female with no prior psychiatric diagnosis presents to the hospital under a 72-hour involuntary placement for altered mental status with agitation and psychotic behaviors. After multiple days of symptomatic treatment with benzodiazepines and antipsychotics, the patient became coherent enough to give a history of a “friend” putting Flakka in her food at school as a joke. Although she continues to have residual symptoms including psychomotor agitation and slowing of cognition, she was alert, oriented, and able to be discharged home with proper follow-up. Craig Crespi Copyright © 2016 Craig Crespi. All rights reserved. Valproate Induced Hypertensive Urgency Wed, 15 Jun 2016 11:29:28 +0000 Valproate is a medication used in the treatment of seizures, bipolar disorder, migraines, and behavioral problems. Here we present a case of an 8-year-old boy who presented with hypertensive urgency after initiation of valproate. Primary treatment of his hypertension was ineffective. Blood pressure stabilization was achieved following discontinuation of valproate. Clinicians should be aware of the risk of developing hypertensive urgency with administration of valproate. Mauran Sivananthan and Sarah Mohiuddin Copyright © 2016 Mauran Sivananthan and Sarah Mohiuddin. All rights reserved. Psychosis or Obsessions? Clozapine Associated with Worsening Obsessive-Compulsive Symptoms Mon, 30 May 2016 14:02:33 +0000 One underrecognized adverse event of clozapine is the emergence or worsening of obsessive-compulsive symptoms (OCS). OCS, particularly violent thoughts, can be inaccurately described as psychosis and result in a misdiagnosis. We report a case of a 42-year-old man, initially diagnosed with schizoaffective, who was placed on clozapine for the management of “violent delusions.” However, clozapine led to a worsening of these violent thoughts resulting in suicidal ideation and hospitalization. After exploration of the intrusive thoughts and noting these to be egodystonic, clearly disturbing, and time consuming, an alternative diagnosis of obsessive-compulsive disorder (OCD) was made. Clozapine was inevitably discontinued resulting in a significant reduction of the intrusive thoughts without emergence of psychosis or adverse events. While an overlapping phenomenology between OCD and psychotic disorders has been described, clozapine and other antiserotonergic antipsychotics have been implicated with the emergence or worsening of OCS. Unique to our case is that the patient’s obsessions had been treated as psychosis leading to the inadequate treatment of his primary illness, OCD. This case highlights the potential for OCD to masquerade as a psychotic disorder and reminds clinicians that clozapine may worsen OCS. Jonathan G. Leung and Brian A. Palmer Copyright © 2016 Jonathan G. Leung and Brian A. Palmer. All rights reserved. A Recommendation for the Management of Illness Anxiety Disorder Patients Abusing the Health Care System Wed, 25 May 2016 12:15:04 +0000 Introduction. Illness anxiety disorder (IAD) entails a preoccupation with having a serious, undiagnosed illness in which somatic symptoms are, if present, mild in intensity (American Psychiatric Association, 2013). Case Report. This is a case of seventy-three-year-old Saudi man who started visiting the primary health care center around twenty-five years ago. With concerns of having cancer, the patient continuously visited the hospital, costing over $170,000. Throughout this period, the patient has been exposed to extensive unnecessary imaging studies and laboratory tests that have effects on his life in all aspects with such concerns. Five years ago, a family doctor has put an end to that by directing the patient to the right path. The doctor made several actions; most importantly, he directed the patient to a cognitive behavioral therapy which significantly improved a range of hypochondriacal beliefs and attitudes. This patient’s case demonstrates the fundamental importance of a proper health system that limits such patients from abusing the health system and depleting the medical resources. Moreover, this case emphasizes the important role of the family physician who can be the first physician to encounter such patients. Thus, proper understanding of the nature of such disorder is a key element for better diagnosis and management. Mohammad Almalki, Ibrahim Al-Tawayjri, Ahmed Al-Anazi, Sami Mahmoud, and Ahmad Al-Mohrej Copyright © 2016 Mohammad Almalki et al. All rights reserved. Differential Diagnosis of an Elderly Manic-Depressive Patient with Depersonalization and Other Symptoms Wed, 18 May 2016 14:30:25 +0000 The case study of an elderly man having persecutory delusions and bizarre complaints at the first psychiatric interview is reported. The patient complained: “I have no sense of time” and “I have no sense of money.” He refused nursing care. He had delusions centered on himself including that of his own death, which were difficult to diagnose but suggested the possibility of Cotard’s syndrome. We assumed that the man was depressed and treated him for depression. However, as a result of this treatment he became temporarily manic but finally recovered completely. After his recovery, we learnt the patient’s past history of hospitalization for psychiatric problems, and based on that history he was diagnosed as suffering from a bipolar I disorder. The lack of typical symptoms of depression and the remarkable depersonalization and derealization in this patient made it difficult to infer a depressive state. Nevertheless, being attentive to his strange feelings related to the flow of time would have helped us to make an accurate diagnosis earlier. Shigehiro Ogata, Yu Itohiya, Yuri Sakamoto, Yuki Sato, Yudai Suyama, Hidenori Atsuta, and Ken Iwata Copyright © 2016 Shigehiro Ogata et al. All rights reserved. Topiramate-Induced Persistent Eyelid Myokymia Tue, 17 May 2016 06:48:16 +0000 Background. Topiramate (TPM) is a psychotropic drug, which is used mainly as an antiepileptic drug and now over the years is used for a wider range of indications, including migraine prophylaxis and binge eating disorders. Although ocular side effects of Topiramate have been frequently reported, neuroophthalmologic manifestations such as myokymia are rarely reported. Case Presentation. This case report presents a case of a 47-year-old woman who had begun TPM for binge eating problem. She developed unilateral long standing lower eyelid twitching, which progressed to upper eyelid and eyebrow at the same side. The patient was not a smoker or excessive alcohol or caffeine abuser. Increasing the resting time and changing life style made no significant changes in her eyelid twitching. There was no definite evidence by neuroimaging and clinical or laboratory evaluations causing eyelid myokymia. The symptoms resolved with discontinuation of TPM. Conclusion. Although eyelid myokymia is a benign and self-limited condition, it sometimes becomes a source of distress in chronic long standing cases. Physicians should be aware of the neuroophthalmologic side effects of this drug. Mohammadrasoul Khalkhali Copyright © 2016 Mohammadrasoul Khalkhali. All rights reserved.