Case Reports in Psychiatry最新文献

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.

Background: Challenging behaviours (CBs) are common in patients with intellectual disabilities (IDs) and diagnosing an underlying primary psychiatric disorder is often difficult. Even though many respond to non-pharmacological or pharmacological interventions persistent aggressive and self-injurious behaviour occur and no treatment-resistant guideline exists. We aim to present clinical scenarios regarding patients with ID and persistent CB with or without a primary psychiatric disorder where clozapine could be considered.

Case presentation: We present five patients with ID with persistent CB with or without a primary psychiatric disorder treated with clozapine. Four of the five patients responded well to clozapine treatment with markedly decreased CB, and two patients had reduced psychotic- or affective symptoms. Side-effects were mild and manageable. Haematological monitoring was performed with a point-of-care (POC) test device.

Conclusions: We show that clozapine can be efficacious in persistent CB and/or treatment-resistant psychiatric symptoms in patients with ID. Monitoring and managing side-effects were possible.

Impact and implications: We suggest that clozapine should be considered in patients with ID regardless of a primary psychiatric disorder when CB does not respond to non-pharmacological and first line pharmacological treatment. It is possible to monitor and manage side-effects with a systematic approach including the use of POC testing.

Deliberate self-harm (DSH) is defined as the intentional infliction of physical injury on oneself without the intent to end one's life. Common behaviors associated with DSH include cutting with a knife or razor, scratching or hitting oneself, and intentional drug overdose. Additionally, these behaviors may encompass restricting food intake and engaging in other risk-taking activities, such as driving at high speeds and participating in unprotected sexual activities. DSH is a strong indicator of suicide risk, particularly in individuals with schizophrenia. The death of Vincent Van Gogh on July 29, 1890, at the age of 37, following a firearm-related suicide attempt, is a compelling example. This occurred a year after his infamous act of self-inflicted ear mutilation, underscoring the increased suicide risk among individuals with a history of significant self-mutilation. We report a similar case of a patient who presented with superficial new cuts on a broken index finger of the left upper limb. Further assessment revealed schizoaffective disorder, which required close monitoring and management. There is a need to enhance the knowledge of identifying those at an elevated risk of self-harm and, whenever feasible, to implement appropriate harm-reduction strategies.

Background: Catatonia is a multifaceted disorder marked by diminished motor activity and communication, and often accompanied by heightened agitation and cognitive confusion. While historically associated with schizophrenia, recent revisions in the DSM-5 have broadened its connections to various mental and physical health disorders. The lorazepam challenge test (LCT) is used to diagnose and treat catatonia. This case challenges the traditional manifestation of catatonia and the timeline of the LCT. Case: The case discussed involves a young man whose primary manifestation was cognitive impairment, ultimately diagnosed as catatonia through a traditional 2 mg LCT. Although his initial response to the LCT was negative, a marked reduction of symptoms was observed hours later. Discussion: Timely diagnosis of catatonia led to symptom improvement and reduced hospitalization. This case challenges the conventional assessment timeline and highlights the need for further understanding of catatonia's pathophysiology and treatment response. It underscores the diagnostic challenges posed by catatonia's cognitive and ambiguous presentation. Conclusion: The response to lorazepam, its dosage, and timing remain enigmatic, accentuating the knowledge gap in catatonia research. Further investigations are required to unravel the intricacies of catatonia's manifestation, diagnosis, and treatment response.

Managing aggressive behaviors in patients with substance use disorders (SUDs), particularly when accompanied by comorbid psychiatric disorders, presents considerable challenges. Clozapine is an atypical antipsychotic known for its effectiveness in treatment-resistant schizophrenia with evidence in support of its ability to reduce violent and aggressive behaviors. This case report describes two patients who were treated with clozapine and showed reduction in violent behaviors, as well as improvement in addiction issues during their stay in a secure rehabilitation center. This observation suggests that clozapine may offer considerable benefits in managing aggression in SUD patients with co-occurring psychiatric illness and highlights the need for further research to assess its broader applicability in complex cases beyond treatment resistant schizophrenia.

Catatonia is a complex psychomotor syndrome associated with several psychiatric disorders, including schizophrenia and autism. It is also associated with neurologic conditions such as encephalitis and epilepsy. Catatonia has also been described in genetic syndromes such as Down Syndrome. Catatonia presents with two main subtypes. Retarded catatonia is characterized by stupor, immobility, mutism, rigidity, and withdrawal, as well as negativism, posturing, and echolalia/echopraxia. Excited catatonia is primarily characterized by psychomotor agitation and occasionally self-injurious behaviors. Though the pathophysiology of catatonia remains poorly understood, treatment with benzodiazepines is effective in many cases, with electroconvulsive therapy indicated in cases of poor response. Rett syndrome is an X-linked neurodevelopmental disease associated with mutations in methyl-CpG-binding protein 2 and is characterized by regression of spoken language and purposeful hand skills, gait abnormalities, and stereotyped hand movements. Herein we describe a case of catatonia associated with Rett syndrome in a 17-year-old female. Her presentation was notable for hyperactivity, impulsive behaviors, agitation, self-injurious behaviors, and aggression. The patient had limited response to multiple medication trials. Initially she had a positive response to treatment with lorazepam, with later waning efficacy despite dose escalation. The patient was admitted to the inpatient psychiatry and completed an index course of 13 ECT treatments followed by maintenance ECT, completing 30 treatments in total. Treatment resulted in significant improvements in self-injurious behaviors, agitation, and overall engagement. In conclusion, catatonia should be considered in individuals with Rett syndrome who present with agitation and self-injury to aid in overall symptom improvement and outcome.

Background: Neuroleptic malignant syndrome (NMS) is an idiosyncratic and life-threatening side effect that usually occurs in response to dopamine receptor antagonist medications. Despite increased awareness, the diagnosis of NMS remains challenging due to its wide differential diagnoses, which can lead to delayed treatment and increased mortality or premature reinitiation of the causative agent, culminating in recurrent NMS, a phenomenon with limited reports. This case presents a patient who experienced three episodes of NMS within 1 year, all triggered by risperidone. Case Presentation: A 58-year-old male patient with schizophrenia presented to the emergency department of a university hospital in Northern Iran, due to decreased consciousness, fever, and rigidity. Initial laboratory results showed elevated creatine phosphokinase (CPK) at 14,949 U/L. He had two previous episodes of rhabdomyolysis and hospitalization in the past year. Review of prior hospital records indicated treatment for rhabdomyolysis with symptoms consistent with NMS, without making this diagnosis. Conclusion: In any patient treated with dopaminergic drugs who suffer from mental status changes, muscle stiffness, high fever, and dysautonomia, especially who have complications such as rhabdomyolysis, kidney failure, seizures, leukocytosis, and increased CPK and lactate dehydrogenase (LDH), the possibility of NMS should be considered.

Background: Othello syndrome (OS) is a rare psychiatric disorder characterized by delusional jealousy and unfounded suspicions of infidelity. It has been associated with neurological diseases such as Parkinson's disease (PD), particularly in patients receiving dopamine agonists (DAs). Case Presentation: A 69-year-old man with a longstanding diagnosis of PD developed OS after transitioning from levodopa/carbidopa to ropinirole due to intolerance. Six months after initiating ropinirole, the patient began experiencing intense, delusional beliefs regarding his wife's fidelity, despite no cognitive decline or psychiatric history. The delusional symptoms significantly strained his marital relationship. Clinical Findings and Diagnostic Assessment: Neurological examination remained consistent with PD, and no structural brain abnormalities were observed on magnetic resonance imaging (MRI). The temporal association between ropinirole use and symptom onset led to the diagnosis of ropinirole-induced OS. Ropinirole was gradually discontinued over 4 weeks, and quetiapine was introduced. The patient showed substantial improvement in psychiatric symptoms with resolution of delusional beliefs and restoration of spousal rapport. Conclusion: This case highlights the potential for DAs, including ropinirole, to induce OS in PD patients. Clinicians should remain vigilant for psychiatric side effects during PD treatment and consider timely intervention, including medication adjustment and antipsychotic therapy, to prevent severe psychosocial consequences.

Delayed posthypoxic leukoencephalopathy (DPHL) is a rare diagnosis that may present similarly to other more common neurological conditions, such as catatonia. While often seen with carbon-monoxide poisoning, it can also be due to anoxia due to other causes, such as drug overdose or cardiac arrest. Due to the delayed nature of its symptoms and overlap with other conditions, it can be initially misdiagnosed. We present a 50-year-old female patient with a history of depression who was found unresponsive, hypoxic, and febrile at her home for an unknown amount of time. The initial concern was for sepsis. Initial computed tomography (CT) of the head and magnetic resonance imaging (MRI) of the brain were normal. The patient had rhabdomyolysis with secondary renal failure, shock liver, and acute pancreatitis. Once medically stabilized, her cognition returned to a normal baseline. However, 10 days into her hospitalization, her mental state deteriorated, displaying symptoms of mutism, stupor, staring, decreased oral intake, and perseveration. Catatonia, secondary to a major depressive episode, was suspected. Lorazepam was titrated upward without result. Lack of response to lorazepam prompted a repeat brain MRI, revealing diffuse white matter changes in the frontal, temporal, parietal, and occipital lobes of both hemispheres. A diagnosis of DPHL was made. She was then started on carbidopa/levodopa 25/100 mg with improvement and was discharged to a rehabilitation facility.

Background: Body integrity dysphoria (BID) is a rare disorder, in which individuals experience a persistent desire to become physically disabled, often through limb amputation. It is now included within the International Classification of Diseases 11th Revision (ICD-11), and this is one of the first case reports to describe the application of these new diagnostic criteria. This also raises the question of treatment pathways for individuals with the disorder, with recognition bringing legitimacy to patients' experience, and responsibility to professionals. Case Presentation: We describe the experience of a 50-year-old man with a long standing desire for his leg to be amputated. He described frustration with the support available, and shame associated with accessing this. After discussions in an online forum he caused dry ice burns to his leg, which resulted in a below-knee amputation. The patient was satisfied with this outcome. All the essential features of ICD-11 diagnostic requirements for BID were met, as well as a number of additional clinical features. Conclusions: New diagnostic criteria appeared both accurate and acceptable to our patient. This formal recognition of the diagnosis presents a new challenge to services about how best to support individuals, and whether there needs to be development of clinical guidance to support clinicians.