Case Reports in Psychiatry最新文献

Objective: Risk for mood and behavioral activation (MBA) due to selective serotonin reuptake inhibitors (SSRIs) is multiply determined in persons with Prader-Willi syndrome (PWS) due to underlying epigenetic and pharmacogenomic factors that affect medication response. Further, age and molecular subtype of PWS are predisposing factors, as there is a >60% risk for bipolar disorder onset prior to age 30 among those with maternal uniparental disomy (mUPD). This article presents two cases of MBA due to sertraline prescribed to treat anxiety in these adults with PWS (mUPD). Methods: Literature review, clinical experience, and data from group home behavior logs inform this case report. The assent of the patients and the consent of their parents (legal guardians) were obtained for this publication. Results: In these two cases, the gradual onset of MBA occurred over 1 year as the dose of sertraline was increased causing irritability, sleep disturbance, increased intensity of hyperphagia, and other phenotypic behaviors. These clinical signs were attributed to the stress of COVID-19 shutdown that resulted in loss of community activities for work, socialization, leisure, and exercise. But after sertraline was discontinued, activation resolved. Mood-stabilizing medication was required for a return to baseline, as sertraline may have unmasked or exacerbated an underlying bipolar diathesis. Conclusion: Sertraline and other SSRI medications can cause MBA in patients with PWS at typical starting doses, although risk for adverse effects increases with higher doses. Age is a contributing factor. Knowing the genetic subtype of PWS is essential for making clinical decisions about pharmacotherapy, and results of pharmacogenomic testing may inform the selection of medication, dose, and schedule of administration.

Delusional misidentification syndromes (DMSs) are a group of disorders, characterized by consistent misidentification of individuals, locations, objects, or events. Four primary subtypes are recognized within this classification: Capgras syndrome, Frégoli syndrome, intermetamorphosis syndrome, and the syndrome of subjective doubles. We report a case of a woman with schizophrenia who experienced a strange delusion that her parents were her babies. This delusion did not arise from visual hallucinations of infants or from prosopagnosia. Furthermore, she denied experiencing auditory hallucinations related to the infants, suggesting that this delusion was not secondary to auditory hallucinations. The delusion that she had her infant was the delusion of maternity, and it was a form of delusional procreational syndrome that consists of sequential delusions in every possible stage of procreation. We concluded the delusion of misidentification that her parents were her own babies exhibited in this case was a subtype of intermetamorphosis syndrome coexisted with delusional procreation syndrome and her coping mechanisms shaped by underlying fears and inner wishes.

Introduction: This case highlights the unique challenge of difficult-to-treat depression (DTD), a complex condition that distinguishes itself from treatment-resistant depression (TRD) due to its multifaceted nature. DTD is characterized by comorbidities, childhood trauma, symptomatic variability, personal history, substance use, and adherence issues, presenting a significant clinical challenge. Unlike TRD, typically defined by the failure of at least two adequate pharmacological treatments, DTD requires a more comprehensive approach. Recent literature supports a multidisciplinary treatment strategy as the most effective in managing DTD. The patient's main concerns and important clinical findings: We present the case of a 63-year-old female patient with a long-standing history of unresolved depressive disorder despite multiple pharmacological treatments. Her primary concerns included severe anhedonia, persistent suicidal ideation, and impaired personal and familial functioning. The patient's history included prior failed treatments, highlighting the complexity of her case. Primary diagnoses, interventions, and outcomes: The patient was diagnosed with DTD. A personalized treatment plan was implemented, integrating a clearly defined multidisciplinary approach: pharmacotherapy, psychotherapy (with a focus on grief and trauma processing), and psychosocial support, including active family involvement through psychoeducation sessions. Neurostimulation techniques were discussed as a potential alternative but were not applied in this case. Over time, the patient demonstrated significant improvement, with a reduction in depressive symptoms, resolution of suicidal ideation, and enhanced personal and familial functioning. Conclusion: This case underscores the need for a personalized treatment approach for DTD that goes beyond pharmacotherapy to include psychotherapy, psychosocial support, and alternative options, such as neurostimulation when indicated. Active involvement of patients and their families is crucial, as evidenced by improvements in clinical and functional scores. Continuous monitoring and treatment adjustments based on objective measures (e.g., HRS-D, GAF, DTDQ) further optimize outcomes. The case exemplifies how an integrated treatment strategy can address the complexities of DTD, leading to long-term recovery and improved quality of life. The key takeaway is that managing DTD requires a comprehensive and individualized approach.

Persistent postural perceptual dizziness (PPPD) is a functional vestibular disorder that can cause significant distress and impairment. Evidence for effective PPPD treatment is still limited and among suggested treatment regimes there have been mixed findings regarding neurostimulation. We present a case report of electroconvulsive therapy (ECT) for an individual with severe PPPD. The patient was a middle-aged woman admitted for acute suicidal ideation in the setting of peripartum depression and PPPD, following several unsuccessful antidepressant trials and a prior suicide attempt. She provided voluntary consent for ECT during admission, and 10 acute bifrontal ECT treatments were completed. The patient was substantially improved in PPPD, depressive, and anxiety symptoms, as well as quality of life. ECT may be beneficial in addressing PPPD symptoms. Further research is needed regarding the role of neurostimulation in PPPD.

Background: Chromosome 4q deletion is a rare genetic disorder affecting an estimated 1 out of 100,000 people. It is characterized by microdeletions of the long arm of chromosome 4 with variable clinical presentations including heart defects, craniofacial and skeletal abnormalities, short stature, and developmental delays. While behavioral and psychiatric symptoms have been reported in a small number of patients with chromosome 4q deletions, none of these reports have described the hyperphagia or parasomnia symptoms that are presented in the current case. Case Presentation: A 7-year-old boy presented with a microdeletion of the long arm of chromosome 4 that resulted in psychiatric symptoms and neurodevelopmental delays. Notable manifestations included hyperphagia and parasomnias, in addition to aggression, functional encopresis, and speech delays. The boy's initial treatment was markedly delayed due to limited genetic testing at the age of 1 year, which led to a misdiagnosis of childhood aggression. This limited the care team involvement for neurologic evaluation and appropriate school interventions that would have otherwise been indicated. At inpatient admission, a multidisciplinary approach to diagnosis and treatment was adopted, encompassing pharmacological and behavioral interventions. The patient's attention-deficit/hyperactivity disorder (ADHD) was treated, and his individualized education plan included a functional behavioral assessment, as well as occupational therapy and speech and language services. Following a 4-day inpatient stay, the patient demonstrated a significant decrease in aggressive behaviors. Conclusion: Chromosome 4q deletion-related behaviors parallel those of children with autism spectrum disorder (ASD), and treatment is primarily focused on behavioral interventions. To successfully manage the psychiatric features of this complex condition, the involvement of a multidisciplinary team is recommended.

Obsessive-compulsive (OC) disorder (OCD) is a common and potentially disabling illness with a waxing and waning course. OCD significantly disrupts the quality of life. Selective serotonin reuptake inhibitors (SSRIs) are first-line pharmacological treatments for OCD and benefit up to half of the patients. Augmentation with low-dose antipsychotics is an evidence-based second-line strategy. Psychotherapy, including cognitive behavior therapy (CBT), is used both as first and second-line treatment. A significant portion of patients, however, do not respond to conventional treatments. We present a case series on the use of Endoxifen as an augmenting agent in patients with OCD and multiple psychiatric comorbidities who did not respond well to conventional pharmacotherapy.

This case study investigates the complex interplay between autism spectrum disorder (ASD) and maladaptive daydreaming (MD), focusing on the misinterpretation of stereotypical movements. The case investigates Liam, a 23-year-old male diagnosed with ASD in childhood. He sought reassessment due to suspicions that his "stimming" behaviors might be linked to MD rather than autism. We analyze Liam's freely reported experiences, self-reported scale scores, and the outcome of clinician-administered diagnostic interviews scored independently by two clinicians. Findings reveal that social communication problems were not present, negating the diagnosis of ASD, and behaviors previously attributed to ASD could be better construed as kinesthetic components of MD episodes. This case highlights the potential for misidentification of MD as ASD, mainly when stereotypical movements are present. The case study underscores the significance of awareness to MD in research and clinical settings. It also illuminates the critical importance of differential diagnosis in cases of ASD, as similar behavioral manifestations may stem from distinct underlying conditions. This study contributes to the emerging body of literature on the relationship between ASD and MD and calls for increased awareness among clinicians about the potential overlap in symptoms between these conditions. We discuss future research directions and implications for clinical practice.

Background: Rastafarianism maintains that cannabis is a sacred element of the religious practice, and followers of the religion traditionally engage cautiously with western medicine. This case involves Mr. I, a 72-year-old Rastafari male with acute myelogenous leukemia (AML) and hepatic decompensation, who developed delirium with psychotic features which were initially managed with quetiapine. His family expressed concerns with psychotropic medications and requested using dronabinol, a synthetic cannabinoid, to manage his symptoms considering the spiritual significance of cannabinoids in the Rastafari culture. The psychiatry team's dissenting recommendations regarding dronabinol was met with resistance, and the family voiced that they felt their religious beliefs were not being respected and considered bringing in their own marijuana products. Following an ethics consultation, a compromise was reached to trial low-dose dronabinol. However, Mr. I's symptoms worsened, prompting discontinuation of dronabinol and management with olanzapine. Discussion: This case exemplifies the complexities of clinical care when religious beliefs conflict with medical necessity. We discuss the limited indications for dronabinol and potential adverse effects on delirium's behavioral symptoms. Concerns about fungal sensitization from cannabinoid products in the context of immunosuppressive chemotherapy and the effects of cannabinoids on hepatic dysfunction are also explored. Moreover, we emphasize the importance of cultural sensitivity for Rastafari individuals who view marijuana as sacred and therapeutic. Balancing cultural and religious sensitivity with ethical, evidence-based medicine through a thorough discussion of risks and benefits is essential for optimal decision-making in such ethical dilemmas.

Psychosis after mild traumatic brain injury (TBI) can be rare, complex, and functionally impairing, often requiring inputs from various specialties. This usually entails separate visits and long wait times. We present the case of an elderly patient with schizophrenia-like psychosis after a mild TBI. Three years after the TBI, the treating physiatrist requested diagnostic clarifications and treatment recommendations from a brain medicine clinic (BMC), a novel integrated virtual clinic composed of neurology, psychiatry, and other brain-related disciplines. Six months later, the patient was overall improved, and her driver's license, which had been suspended 6 months after the TBI, was reinstated. We discuss diagnostic and treatment challenges of TBI. BMCs could provide timely, comprehensive, and efficient access to multispecialty care and resources for patients with complex brain disorders and minimize the artificial siloes in healthcare.

A 57-year-old woman with bipolar disorder (BD) was started on combination therapy with aripiprazole and lithium. At the same time, a community pharmacist administered follow-up through 24-h telephone services for the early detection of adverse events. Four days after starting therapy, the patient called a community pharmacy after working hours and mentioned the occurrence of disabilities, possibly due to adverse effects, including extrapyramidal symptoms (EPSs), to the pharmacist who received the forwarded call. The community pharmacist immediately called the hospital to report the patient's problems and suggested a decrease in doses or withdrawal of the suspected medications to the prescribing doctor. After several hours, the hospital called and informed the pharmacist that the doctor had instructed the patient to discontinue aripiprazole. The pharmacist immediately called the patient, explained the doctor's instructions, and found that the EPS symptoms improved gradually, except for difficulty speaking smoothly. Ultimately, valproic acid was prescribed instead of lithium, resulting in a dramatic improvement in speech difficulties. These results indicate that community pharmacist-administered follow-up and intervention, especially through 24-h telephone services, is crucial for drug safety management, such as early detection of adverse events caused by combination therapy in patients with BD.