Case Reports in Psychiatry最新文献

We report a 58-year-old woman with bipolar I disorder on long-term lithium and aripiprazole who developed a progressive asymmetric resting tremor and rigidity. Despite stopping both agents, the tremor persisted for more than a year. Dopamine transporter imaging showed reduced uptake in the left putamen, confirming idiopathic Parkinson's disease (PD) with superimposed drug-induced parkinsonism (DIP). Management included discontinuing lithium, switching aripiprazole to quetiapine to limit motor worsening, and starting carbidopa-levodopa. Motor symptoms improved, but hypomanic symptoms emerged and required psychiatric dose adjustments, while apathy remained prominent. The case illustrates diagnostic overshadowing in bipolar disorder (BD) and highlights two practical lessons. When parkinsonian signs are atypical or persist after medication changes, consider idiopathic PD rather than attributing symptoms to side effects. Care is best delivered through close collaboration between psychiatry and neurology to balance dopaminergic therapy with mood stabilization.

Background: Clozapine has shown to be effective as an off-label treatment for aggressive behavior in patients with borderline personality disorder (BPD) and mild intellectual disability (MID). However, there is a lack of empirical evidence for its efficacy in these patient populations and results are so far heterogeneous.

Case presentation: A 40-year-old woman diagnosed with BPD and MID with severe and treatment-resistant aggressive behavior was treated off-label with clozapine. A carefully administered treatment with slow titration led to a significant reduction in self-aggressive behavior and termination of aggressive behavior towards others over a 26-week observation period.

Conclusions: Our case highlights the potential efficacy of clozapine as an off-label treatment for severe and treatment-resistant aggressive behavior in patients with combined BPD and MID. Clozapine should be considered as a therapeutic option in severe and complex cases.

Despite the robust body of evidence supporting the efficacy and safety of electroconvulsive therapy (ECT) in the treatment of severe psychiatric disorders, this procedure remains at the center of social debate, often influenced by historical prejudice. Such misconceptions have contributed to restricted access, which typically occurs either through costly private practice or in large academic centers within the public health system. Among the clinical conditions for which ECT is considered a first-line treatment, malignant catatonia stands out-a rare and potentially fatal syndrome characterized by psychomotor disturbances and severe autonomic instability. If not treated promptly, its mortality rate may reach up to 50%. This case report describes the successful treatment of malignant catatonia in a patient with schizophrenia, in whom ECT sessions were administered intermittently and without a subsequent maintenance phase during inpatient care at a specialized psychiatric hospital affiliated with the Unified Health System in the state of São Paulo, Brazil. After 10 sessions, there was complete remission of the catatonic state, followed by hospital discharge for outpatient follow-up. After 16 months, the patient maintained psychiatric stability, medication adherence, and partial independence in daily activities, with no new episodes of psychiatric decompensation. The case underscores the effectiveness of ECT in achieving remission of a rare and potentially life-threatening disorder.

Background: Clozapine-associated myocarditis (CAM) is the most common inflammatory adverse effect under clozapine treatment. In the absence of equally effective therapeutic alternatives for treating treatment-resistant schizophrenia (TRS), clinicians are often faced with the question of whether to rechallenge clozapine in patients who have experienced CAM. However, there is a lack of standardized protocols and published case reports of successful clozapine rechallenge following CAM.

Case presentation: A 40-year-old patient diagnosed with paranoid schizophrenia experienced CAM during his first clozapine treatment. Four years later, he was successfully rechallenged using a recently published standardized protocol involving a very slow titration schedule.

Conclusions: Our case adds to the limited number of published cases of successful clozapine rechallenge following CAM. It is the first published case report to use the rechallenge protocol recently published by Qubad et al. (2024), thereby contributing to the development of standardized protocols for the safe and successful clozapine rechallenge following CAM.

Background: Individuals with schizophrenia appear to experience differences in dreaming compared to control populations-the small amounts of research that does exist demonstrates abnormalities such as simpler dreams that are more bizarre and with greater negative content than those of controls. Dream-related psychopathology remains insufficiently described however-particularly experiences in which patients believe their dreams are externally generated or controlled. Such phenomena extend classically described first rank symptoms-such as thought insertion and passivity phenomena-into the domain of sleep mentation. This case presents a patient who describes a delusional belief that an external agent can directly infiltrate his nocturnal state to insert dreams themselves.

Case presentation: A 34-year-old male patient with schizophrenia was admitted to the inpatient unit for commencement of clozapine following poor response to multiple antipsychotic agents. While admitted, he described a new delusional belief that a Central Intelligence Agency (CIA) agent was infiltrating his dreams at night and inserting externally created dreams. This symptom did not respond to ongoing clozapine uptitration and community follow-up suggests an ongoing limited response.

Conclusions: This patient describes a novel symptom not previously described in the literature to the best of the authors knowledge and neither appears consistent with other commonly described sleep related phenomenon nor first rank symptoms. As such, we use the term "dream insertion" to describe the phenomenon noted in the case report and suggest an expanded inquiry into the oneiric effects of schizophrenia to enhance understanding and management of such symptoms.

Introduction: Nearly one-fourth of individuals diagnosed with schizophrenia may experience symptoms of gender dysphoria. Patients may identify with a gender other than the gender assigned at birth before or after psychotic disorder onset. In either case, the presence of both psychosis and gender dysphoria may complicate evaluation and treatment.

Case: We present the case of a 45-year-old patient with a past psychiatric history of paranoid schizophrenia who was assigned male at birth and began to identify as a woman in her youth around the age when her psychosis first developed. During the admission discussed in this report, the patient identified as a man during a period with frank psychotic symptoms but preferred feminine clothing and structured the clothes to create the appearance of female anatomy. Later in admission, as psychosis resolved with pharmacologic treatment, the patient began to identify as a woman and adopted a traditionally feminine name and female-coded dress. Psychiatric assessment, record-gathering, and psychological assessment were completed to better understand her perspective on self and others and the historical context of her symptoms and gender identity.

Conclusion: This case highlights the risk of assessing gender identity in patients with active thought disorders. Patients' perspectives on gender and presentation may shift during periods of psychosis compared to periods of remission. Assessment and treatment of gender dysphoria is possible and beneficial in patients with psychotic disorders, but physicians must be cautious about diagnosing and treating gender dysphoria during active psychosis.

Clozapine, a gold standard for treatment-resistant schizophrenia, is associated with a range of adverse effects, including the rare but serious risk of pulmonary embolism (PE). The management of such complications, particularly in the absence of clear guidelines for preventive anticoagulation, poses significant challenges. We present a case of a male (in his late 30s) with schizophrenia who developed recurrent thromboembolic events during clozapine therapy. Despite the occurrence of a second PE, clozapine therapy was continued successfully with concurrent anticoagulation. This case highlights the need for individualized treatment strategies and underscores the critical gap in evidence regarding preventive anticoagulation in patients with clozapine.

Background: Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an autoimmune disorder marked by prominent neuropsychiatric symptoms. It is typically first encountered by psychiatrists because psychotic symptoms can be early signs of the condition. In recent years, this form of encephalitis has been established as a distinct diagnostic entity in neurology and psychiatry. Furthermore, as an organic and autoimmune psychosis, it is considered a differential diagnosis of schizophrenia and schizoaffective disorders.

Clinical presentation: We report the case of a 25-year-old male who presented with a first episode of psychosis. During his stay, the patient exhibited severe cognitive deficits (disorientation, confusion, memory issues), movement disorders (dysarthria, perioral dyskinesia leading to speech difficulties), a decreased level of consciousness, and a catatonic state complicated by a malignant neuroleptic syndrome. The patient also experienced epileptic seizures and had unstable vital signs. An electroencephalogram (EEG) revealed an extreme delta brush pattern (specific for anti-NMDAR encephalitis), and CSF analysis showed an elevated immunoglobulin G (IgG) index. Based on these findings, anti-NMDAR autoimmune encephalitis was suspected 17 days after admission but not yet confirmed. The patient was treated with oral corticosteroids followed by plasmapheresis and showed significant improvement. At discharge, he was alert, oriented, cooperative, and not psychotic, with only mild cognitive defects. Days after discharge, anti-NMDAR IgG antibodies were detected in his CSF, confirming the diagnosis.

Clinical presentation: This case underscores the importance of considering anti-NMDAR autoimmune encephalitis as a differential diagnosis in patients with no personal or family psychiatric history who develop subacute psychotic symptoms (lasting less than 3 months) along with fluctuating neuropsychiatric signs. Conducting an EEG, cerebral MRI, and CSF analysis to confirm or exclude the condition, followed by early immunosuppressive treatment, is crucial for improving prognosis.

Possession state is a disorder of consciousness with substitution of the personality, which is claimed to be a spirit, a deity, a dead person or some other power. In rural Nepal these experiences are normalised and Hindu communities often attribute psychological conditions to a supernatural cause. We report the case of a 30-year-old woman who presented with acute-onset symptoms characterised by episodes of altered consciousness, vocalisations suggestive of religious chants, and deity-associated behaviour, probably influenced by local suggestions of divine possession. Additional notable features included similar presentations among a family member and seeking help from traditional healers prior to psychiatric consultation. Medical examinations and investigations were normal. Specific cultural and religious manifestations posed challenges to clinical interpretation. The patient responded well to combined pharmacotherapy and supportive psychotherapy during her brief hospital stay, with cessation of possession episodes. This case report highlights the importance of cultural competence in Nepalese forensic psychiatric evaluations, particularly in the context of possession states, while examining the application of mental health legislation in traditional cultural settings.

A 36-year-old African American male with sickle cell disease (SCD), osteomyelitis, major depressive disorder (MDD), and alcohol use disorder presented with active suicidal ideation following a suicide attempt via increasing alcohol consumption. Diagnostic evaluation suggested MDD. Within the hospitalization, he was also diagnosed with comorbid obsessive-compulsive disorder. Pharmacologic treatment was initiated with sertraline titrated to 150 mg daily, and his pain was managed with buprenorphine-naloxone 1 mg twice daily, meloxicam 15 mg daily, and acetaminophen 650 mg every 6 h as needed. He also engaged in individual and group psychotherapy, including interventions from psychology and occupational therapy teams, and completed a comprehensive safety plan. Early in the hospitalization, the patient began to share his experiences of mistrust in the healthcare system and stigma as a black patient with SCD. The approach of open dialogue (OD) was then introduced which consisted of providers openly sharing their assessments with the patient present and allowing the patient to provide reflections to further promote transparency and collaboration with patient care. Upon discharge, the patient shared positive feedback on this approach. The patient expressed appreciation for the transparency and collaborative nature of the discussions, which helped to build rapport and reduce mistrust in healthcare institutions. This case illustrates the potential for integrating OD principles to promote transparency and collaborative decision making that could help mitigate the detrimental effects of stigma and structural racism for black patients with SCD. Developing and testing standardized OD protocols could potentially further enhance patient-centered care and reduce healthcare disparities.