Psychiatry research case reports最新文献

Menopause represents a physiological phase in the woman aging process that marks the end of fertility, but also increases vulnerability for physical and mental symptoms and represents a risk for onset or exacerbation of psychiatric disorders. We aim to present a case of menopause-associated psychosis and also conduct a literature review emphasizing the pathophysiology hypotheses and management particularities. We present a case of a 51-years-old woman who had her first episode of psychosis at menopausal transition period, with the need of hospitalization for stabilization and further etiologic study. Beyond the psychotic symptoms, she experienced several menopause-associated symptoms that caused incapacity. She became stabilized with paliperidone 9 mg/day, olanzapine 2.5 mg/day and lorazepam 2.5 mg/day but did not return to her premorbid functioning. Months later she developed depressive and cognitive symptoms, in relation to negative symptoms and antipsychotics side-effects, which improved after the switch to cariprazine 4.5 mg/day. Postmenopausal women represent an especially vulnerable group for psychosis and the side effects associated with antipsychotic treatment. Therefore, antipsychotics with elevated risk for extra-pyramidal side-effects should be avoided or used with caution and augmentation with selective estrogen-receptor modulators might be a valuable choice for eligible patients. The understanding of underlining mechanisms involved and potential additional risk factors for menopause-associated psychosis is essential for the prevention and early treatment and can promote advances in etiologic theories, treatment approaches, and overall women's health. Furthermore, there is a need for guidelines that provide a concise and precise description of experimental evidence and support for clinical practices. This should include prescribing information that takes hormone levels into account and clinical trials with postmenopausal women. Further studies in psychosis should start investigating and aggregating data according not only to sex, but also to hormonal status.

There is limited literature outlining the practical management of severe health anxiety in patients attending specialist physical health settings (in this case, diabetes mellitus-Type 1, T1DM). This case outlines how a patient engaged in a multi-modal care plan involving a shared formulation, blended-care cognitive behavioural therapy (BCCBT) and pharmacotherapy. BCCBT is the combination of face-to-face CBT and internet-delivered CBT (iCBT) into one integrated treatment protocol. It also highlights some of the barriers to his care. The patient made gradual and significant improvements; and on completion reported better function at work, reduced health checking behaviours and decreased functional impacts of somatic pain. The patient was male, in his early 30′s, with a history of T1DM since childhood. He presented to the hospital outpatient endocrine clinic. Online mental health screening revealed clinical range levels on validated measures of both general anxiety and health-related anxiety. He was referred to our health anxiety clinic and met criteria for Somatic Symptom Disorder (SSD).

Background

Assessment of Posttraumatic Stress Disorder (PTSD) symptoms in individuals with dementia is difficult due to diagnostic challenges like an incomplete self-report, interference of neuropsychiatric symptoms and overlapping comorbid psychiatric symptoms.

Objective

These diagnostic challenges are articulated here and an in-depth evaluation of assessment of PTSD in dementia is given.

Method

A qualitative case design was used including an 88 years old woman, living in a nursing home, with moderate-severe dementia and suspected PTSD. The TRAuma and DEmentia(TRADE)-interview, a semi-structured tool to diagnose PTSD in dementia, was assessed independently by two psychologists, followed by a debriefing in which the outcomes were discussed with the use of informant measures (Neuropsychiatric Inventory-Nursing Home (NPI-NH), the Gerontological Personality Disorders Scale (GPS), Levels of Personality Functioning Scale-Brief Form 2.0 (LPFS-BF 2.0) and Personality Inventory DSM-5-Brief Form (PID5-BF).

Results

TRADE-interview indicated PTSD triggered by a cycling accident with agitation as a neuropsychiatric symptom. Personality assessment indicated features of a cluster C personality disorder (PD) with core features of negative affectivity and detachment. In the debriefing psychologists reported three challenges: attributing symptoms to the past traumatic event, interference of neuropsychiatric symptoms and overlap in symptoms between PTSD and PDs.

Conclusions

Distinguishing PTSD symptoms in those with dementia from neuropsychiatric and PD symptoms requires careful evaluation of all symptoms present. The TRADE-interview can be helpful, but sometimes additional resourcefulness and good clinical considerations are advised.

Background

The pathogenic hexanucleotide repeat expansion in chromosome 9, the C9orf72 mutation, represents the most common genetic cause of frontotemporal dementia (FTD) and amyotrophic lateral sclerosis (ALS). Psychiatric symptoms, especially psychosis, are common in FTD secondary to C9orf72 mutation, and cases of psychosis have been reported in expansion carriers before the onset of prototypical cognitive symptoms. This can create diagnostic challenges due to their homology to primary psychiatric disorders. Although the mechanisms underlying the presence of psychotic symptoms in pre-symptomatic C9orf72 mutation-carriers are unclear, there is potential for the mutation to play a role in the development of prodromal psychiatric symptoms in ALS-FTD spectrum disorders.

Case report

We report the case of a 39-years old patient admitted to a psychiatric inpatient unit due to an inaugural atypical psychotic syndrome, with persecutory delusions, auditory hallucinations, prominent critical judgement impairment and behavioural symptoms. The patient had a previous history of an anxiety disorder and had severe extrapyramidal symptoms associated with dopamine D2-receptor antagonists. The family history was remarkable for a first-degree relative with C9orf72-positive FTD. Cognitive impairment was not detected in bedside screening tests and brain computed tomography showed no major abnormalities. We ordered genetic testing, which confirmed a heterozygous pathogenic expansion of C9orf72. The patient was treated with oral aripiprazole, with partial response. Follow-up and further neuropsychological assessment could not be obtained as the patient suddenly died, 10 days after discharge.

Discussion

This case highlights the need of addressing the current literature gaps on the clinical significance of C9orf72 pathological repeat expansion in patients with a positive family history of ALS-FTD who present with psychosis but have no cognitive or neuroimaging abnormalities. The threshold to order a genetic test or the implications of a positive test in terms of risk stratification and follow-up remain unsolved. Although no specific treatment for psychosis in C9orf72 carriers is currently available, a correct diagnosis can have prognostic and intervention implications and may contribute to the understanding of different disease trajectories and distinct clinical phenotypes, ultimately leading to the development of more accurate tools for disease staging and therapeutic strategies.

Olfactory reference syndrome (ORS) is a relatively unknown psychiatric condition characterized by recurrent and unremitting preoccupations with producing an unpleasant bodily odor. As a result, patients with ORS experience significant distress and social impairment. Although reports of ORS have been published globally since the 1800s, its prevalence remains unknown, potentially due to patients’ feelings of embarrassment and shame. The classification of ORS in the Diagnostic and Statistical Manual of Mental Disorders (DSM) has also been controversial. While some classify ORS as a subtype of delusional disorder, others correlate the condition to social anxiety disorder (SAD). Due to the absence of explicit diagnostic criteria for ORS, treatment options have varied, ranging from selective serotonin reuptake inhibitors (SSRIs) to antipsychotic medications. Herein, we present a case of a 60-year-old patient with a relevant past medical history of ORS, major depressive disorder, and generalized anxiety disorder. We successfully treated their ORS symptoms by adding as-needed lorazepam to their medication regimen before social interactions.

Approximately one-third of patients with major depression do not improve sufficiently even after multiple trials of otherwise effective antidepressant treatments, meeting criteria for treatment-resistant depression (TRD). The phenomenon of TRD remains poorly understood, as it can be attributed to a myriad of diverse factors, including pharmacogenetic variations and underdiagnosed or untreated comorbid psychopathology. This series of six case reports from an innovative second-opinion consultation program brings into focus some of the most prevalent psychiatric comorbidities in TRD: anxiety disorders, “double depression” (a combination of dysthymia and major depressive disorder), and personality psychopathology and discusses implications for their assessment and treatment. It also highlights the benefits of incorporating psychological testing in second-opinion evaluations toward increased accuracy and reliability of assessment of co-occurring psychiatric disorders. This enhanced approach to re-evaluation of patients with TRD may lead to more highly personalized treatment recommendations and better treatment outcomes.

We report the first case of new-onset mania and psychosis post heterologous bivalent booster vaccination (corresponding to the 4th mRNA vaccine) in Singapore, to our knowledge. The COVID-19 pandemic has significantly impacted mental health, and studies have shown that COVID-19 infections can be directly or indirectly associated with neuropsychiatric symptoms. While mRNA vaccines are highly effective in preventing severe illness and death from COVID-19, there are case reports describing associated neuropsychiatric manifestations following COVID-19 vaccination, but none reported post heterologous bivalent boosting yet. This report centers on an immunocompetent man in his 40s who developed manic and psychotic symptoms temporally after receiving his first Moderna/Spikevax bivalent COVID-19 vaccine, with a lack of other contributing biological and psychological factors. He previously received three doses of the Pfizer-BioNTech/Comirnaty vaccine with no significant side effects. The manic and psychotic symptoms included elevated mood, increased irritability, psychomotor agitation, increased energy, decreased need for sleep, increased distractibility, grandiosity, and paranoid delusions. Following the development of these symptoms, he was hospitalized and treated with Olanzapine, after which his symptoms resolved. He recovered well, with no relapse of symptoms after discontinuation of Olanzapine and after discharge from the hospital. While vaccination is generally considered safe, a small minority of individuals may experience significant psychiatric adverse reactions following COVID-19 booster vaccination, perhaps a higher immunogenic risk if one received heterologous bivalent boosting, a suspicion raised in this case report.  This warrants further systematic study as COVID-19 evolves from being a pandemic to an endemic infection internationally.

Background

Psychosis in children and adolescents is devastating to those affected. The addition of comorbid medical comorbidities can further complicate presentation and management. Additionally, there is growing literature about a possible link between psychosis and COVID-19.

Case Presentation

The authors present a case of a 16-year-old Irish/Nigerian male with first episode psychosis admitted to a child and adolescent psychiatric inpatient unit in Ireland. The patient had a complex medical history of glcose-6-phosphate dehydrogenase deficiency, narcolepsy, and co-infection of coronavirus disease 2019 (COVID-19). The presence of multiple co-morbidities made management challenging. Additionally, culturo-religious factors arose which arose as barriers to the therapeutic relationship between the patient and his family.

Conclusions

This case highlights the complexity of managing psychosis in an adolescent with multiple serious medical comorbidities. Further research exploring the relationship between medical comorbidities and psychosis is warranted to improve patient outcomes.

Drug-induced pancreatitis is an uncommon but not usually life-threatening adverse reaction to various medications, including several antipsychotics. We are reporting here on the first such case due to a long-acting antipsychotic, paliperidone palmitate, in a patient with schizophrenia that had been stabilised using this medication for more than a year. A subsequent re-challenge led to a second episode of acute pancreatitis, making the aetiological correlation with paliperidone palmitate more definite. Both episodes were resolved with conservative treatment.

Background

Epilepsy and psychotic disorders have a bidirectional correlation that is established in the literature. Psychosis of epilepsy (POE) describes a group of psychoses such as interictal and postictal psychosis. We present a case of overlapping symptoms of postictal and interictal psychosis making diagnostic clarification difficult.

Case

A 58-year-old female with a history of epilepsy since childhood, blunt traumatic brain injury, glioma status post right temporoparietal craniotomy and resection, HIV on HAART, depression, and alcohol use disorder, presented to the emergency room with hallucinations, paranoia, delusions, and agitated behavior after a seizure. The patient had an increase in seizure frequency over the past 9 months, now having one seizure a week. The disorientation, agitation, and hallucinations would resolve spontaneously in a short period of time but have persisted after recent seizures. Recent MRI revealed focal cortical and subcortical encephalomalacia with gliosis in the right superior temporal gyrus extending into the lingual gyrus and mesial temporal sclerosis. EEG showed multifocal 1 Hz sharp discharges in a ratio of 3:1 coming from the right temporal region, not correlated to any tonic-clonic events.

Conclusion

This case has risk factors and presenting features for both interictal and postictal psychosis making accurate diagnostic clarification difficult during their stay. Differentiating between various POE can prove challenging as the evidence-based management differs. When an antipsychotic needs to be provided, we recommend risperidone as a suitable option given its relative safety in both seizure disorders and traumatic brain injuries secondary to neurosurgery.