Case Reports in Psychiatry最新文献

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.

This case report documents a rare presentation of obsessive-compulsive-like symptoms co-occurring with Capgras syndrome following surgical resection of a right-sided frontal lobe pleomorphic xanthoastrocytoma in a 13-year-old girl. The patient initially presented with headache and intractable vomiting, leading to the discovery of a right-sided frontal lobe tumor. Postoperatively, the patient exhibited cognitive and behavioral changes manifesting as misidentification beliefs regarding the identities of loved ones and associated distressing thoughts. Comprehensive psychiatric evaluation using validated assessment tools confirmed these presentations. This report contributes to understanding the complex interplay between neurological, psychiatric, and cognitive factors in the development of these rare postsurgical neuropsychiatric complications following frontal lobe tumor resection.

Objective: In the wider context of palliative care, problems faced by young people today, such as depression, mental illness, and suicide; are considered terminal problems, so they must be treated immediately and given appropriate intervention. Caution is needed in providing appropriate interventions for them, of course, interventions that are by their characteristics. Based on their character, they are a generation that is quite fragile and easily discouraged; on the other hand, they are a generation that is dynamic and passionate about creativity. There needs to be a match between what they need and what the intervention provides. One type of intervention in palliative care that has recently been offered is "rapid tele-psychotherapy" with single-session music therapy (RTP-SSMT), which is considered quite appropriate in responding to these challenges.

Method: I report the case of a 22-year-old broken-hearted girl with hopelessness, depression, and suicidal ideation.

Results: I describe the effectiveness of the implementation of RTP-SSMT in reducing the scales of hopelessness, depression, and suicidal ideation.

Significance of results: It can be concluded that the implementation of the RTP-SSMT for a broken-hearted girl with conditions of hopelessness, depression, and suicidal ideation who can be at risk for suicide can be said to be effective in alleviating these negative feelings. Aside from that, through this study, the biggest implication is that the RTP-SSMT intervention theory can be a choice for mental health workers who want to process assistance to patients/clients who experience hopelessness, depression, and suicidal ideation in someone who has experienced a breakup.

Background: Delusional infestation (DI), or delusional disorder, somatic type, is a rare psychiatric condition characterized by a fixed false belief of infestation despite lack of medical evidence. Patients frequently resist psychiatric care due to poor insight and somatic preoccupation, increasing the risk of delayed diagnosis and serious self-harm.

Case presentation: We report the case of a 60-year-old woman with no prior psychiatric history who presented with 11.5% total body surface area (TBSA) second- and third-degree self-inflicted burns resulting from attempts to eradicate perceived skin parasites. She reported a 2-year history of pruritus attributed to "shiny fiberglass bacteria," with associated tactile hallucinations. Extensive medical workup excluded underlying anatomic, inflammatory, or infectious etiologies. The psychiatry consultant diagnosed her with delusional disorder, somatic type. Treatment with low-dose risperidone and doxepin was initiated following empathic, nonconfrontational engagement. Her distress improved, and she demonstrated early signs of insight by the time of hospital discharge.

Conclusion: This case highlights the risk of severe self-injury in DI and underscores the need for timely psychiatric evaluation and a compassionate, collaborative approach. Reframing treatment goals to prioritize symptom relief over delusional challenge may enhance engagement and facilitate recovery.

Metachromatic leukodystrophy (MLD) is a rare, autosomal recessive disorder of lipid metabolism characterized by deficiency of arylsulfatase A (ARSA), which leads to an accumulation of sulfatides in central and peripheral nerve system and eventually to progressive demyelination. The adult form of MLD may be misinterpreted as a psychiatric disease, since behavioral signs may precede intellectual decline. Here we report the case of a 53-year-old woman initially admitted to a psychiatric ward with symptoms of depression. The behavioral changes were initially attributed to psychosocial stressors within the family, particularly long-term emotional abuse by the patient's former partner. However, detailed anamnesis with the patient's mother revealed progressive behavioral and cognitive decline, urinary and fecal incontinence, that is, features suggestive of an underlying neurological disorder. Notably, laboratory investigations recommended 6 years earlier had not been performed. Neurological examination revealed signs of a frontal syndrome, bilateral pyramidal tract involvement, and mild polyneuropathy. Magnetic resonance imaging (MRI) demonstrated abnormal white matter signal alterations. Further diagnostic investigations showed reduced serum ARSA activity, elevated urinary sulfatides, and a homozygous pathogenic variant in the ARSA gene, confirming the diagnosis of adult-onset MLD. The homozygous mutation indicated parental consanguinity, suggesting early trauma embedded within the family. This case underscores the complexity of diagnosing MLD and emphasizes the importance of integrating psychiatric, neurological, and systemic family perspectives in the diagnostic process of rare and slowly progressing illnesses.

Quetiapine, an atypical antipsychotic, is widely prescribed for psychiatric disorders, particularly schizophrenia, bipolar disorder, and depressive disorders with or without psychotic symptoms. While edema is more commonly associated with olanzapine and clozapine amongst second general antipsychotics, reports involving quetiapine-particularly the extended-release (XR) formulation-are rare. We describe the case of a 52-year-old woman with severe major depressive episode with psychotic features who was initiated on escitalopram and quetiapine immediate-release (IR) 100 mg/day, later switched to quetiapine XR 100 mg/day to improve adherence and reduce sedation. Ten days after the switch, she developed symmetrical bilateral lower limb pitting edema without systemic symptoms. Comprehensive cardiac, renal, hepatic, thyroid, and immunologic evaluations were unremarkable, and venous Doppler ruled out deep vein thrombosis. The edema resolved within 10 days of discontinuing quetiapine XR and recurred upon rechallenge. The Naranjo Adverse Drug Reaction Probability Score was 9, indicating a probable to definite association. Possible mechanisms include α1-adrenergic blockade, 5-HT2 receptor antagonism, and pharmacokinetic differences in XR formulations leading to sustained peripheral receptor occupancy. Literature review reveals few comparable reports, most involving higher doses or polypharmacy. This case highlights the importance of clinician awareness of quetiapine XR-associated edema, even at low doses, and supports dechallenge-rechallenge as a useful diagnostic approach to improve patient safety and adherence.