Cotard's syndrome with schizophreniform disorder can be successfully treated with electroconvulsive therapy: case report

We report a case of Cotard's syndrome associated with psychotic symptoms. A 27-year-old man was admitted to hospital with the diagnosis of schizophreniform disorder. His presenting symptoms, which had started 1 month before hospital admission, were somatic delusions of gastrointestinal and cardiovascular malfunction and the absence of a stomach, which resulted in a decrease in weight from 75 kg to 63 kg in 1 month. Cranial computed tomographic images showed dilatation of the lateral and third ventricles, whereas magnetic resonance imaging revealed central atrophy and lateral ventricle dilatation. Single- photon emission computed tomography demonstrated left temporal, left frontal and left parietal hypoperfusion. The patient did not respond to antipsychotic therapies, but he was successfully treated with electroconvulsive therapy. This report emphasizes that Cotard's syndrome may be accompanied by lesions of the left hemisphere and that electroconvulsive therapy could be the first-line therapy in such patients with psychotic disorder.     

Persistent psychotic disorder following bilateral mesencephalo-thalamic ischaemia: case report

A 38-year old male patient with no history of psychiatric illness developed a progressive psychotic disorder after bilateral (predominantly left) mesencephalo-thalamic cerebral ischaemia. The reason of the emergency hospitalization was the sudden onset of a confusional state, culminating in a fluctuating comatose status. The neurological examination found mild right hemiparesia, praxic disorders and reactive left mydriasis with paresia of the downward vertical stare, leading to the hospitalisation in the neurology department for suspicion of a cerebral vascular ischaemic accident. The psychiatric symptoms started with acoustic-verbal hallucinations, poorly structured paranoid delusions, progressively developed over two weeks, followed by behavioural disorders with psychomotor agitation and heteroaggressivity. The patient was transferred to the psychiatric department, because of the heteroaggressive risk and lack of morbid consciousness, in spite of recovering from the confusional status. An intensive psychiatric management was proposed, combining a psychotherapeutic approach with 4 mg of risperidone and adjustable doses of benzodiazepine according to the psychomotor agitation. During the next days, there was a net recovery of the behavioural disorders, in spite of the persistence of the ideas of persecution. All the neurological symptoms also decreased. An anomaly of the polygon of Willis was found on a cerebral arteriography (the posterior cerebral arteries had a foetal origin, dependent on carotidal axes and not on the vertebro-basilar system). The main emboligen risk factor was the presence of a permeable foramen ovale, discovered during a transoesophageal echography. The patient underwent a surgical correction of the permeable foramen ovale. The psychiatric hospitalization for three months was continued by ambulatory follow-up. The initial positive symptoms (delusions, acoustic-verbal hallucinations) progressively diminished while negative symptoms became predominant after few months. One year after the first hospitalization the patient presented a second psychotic decompensation, with delusions of persecution, jealousy and behavioural disorders with heteroaggressivity, that required an emergency psychiatric hospitalization. The wife of the patient decided to divorce, because she was "frightened by the threats of death" from her husband. A neurological assessment during the second hospitalization in psychiatry did not find new ischaemic lesions after the cardiac surgery for the permeable foramen ovale, nor relevant changes in cerebral perfusion. The final diagnosis after the psychiatric follow-up of 14 months was: psychotic disorder with delusional ideas, due to cerebral ischaemia (DSM IV). There are relatively few data in the literature regarding persistent psychotic disorders in the context of ischaemic mesencephalo-thalamic lesions. However, several authors support the hypothesis of a possible disconnection of the thalamic nuclei, the frontal lobes and limbic system as a risk factor or a triggering factor for psychotic disorders in cerebral ischaemia. Observations concerning the occurrence of psychotic disorders following cerebral--especially localised--ischaemia may help to better understand the neuro-physiological mechanisms triggering or accompanying the psychiatric symptomatology. The role of functional cerebral imagery in the detection of possible structural lesions related to clinical observations must be emphasised. The slow progression (over a year) to psychotic disorder with predominantly negative symptoms emphasized the importance for long-term prospective studies. Isolated clinical observations arouse the interest for a specific scale for psychotic disorders occurring after cerebral ischaemia, similar to existing specific scale for post-ischaemic depressive disorders. The necessity of systematic psychiatric examination and re-evaluations in thalamic cerebral ischaemia is to be highlighted, both for the differential diagnosis and for the early psychiatric care.     

A case of schizophreniform disorder in frontotemporal dementia (FTD)

The concept of frontotemporal lobar degeneration comprises a heterogenous group of cortical dementias, including frontotemporal dementia, as the major clinical variant. Because of their highly variable clinical presentation, to establish the diagnosis of frontotemporal dementia could be a diagnostic challenge for the clinician. Here we report a 53 years old caucasian male patient who was admitted for hospitalization due to acute severe schizophrenia-like symptoms. The leading symptomatology comprised acoustic and bizarre optical hallucinations with euphoria and self-overestimation. Remission of the psychotic symptoms demasked the clinical picture of a rapidly progressive frontotemporal dementia with marked apathy, indifference, emotional blunting, loss of insight, change of personality and typical cognitive impairment. The diagnosis was supported by the results of cerebral MRI and FDG-18 PET. This first clinical manifestation of a schizophrenia-like syndrome in the 6th life decade implicates frontotemporal dementia as an important differential diagnosis of schizophrenic disorders in late life. In addition of basically thinking about frontotemporal dementia, a detailed medical history, cognitive testing, neuroimaging and eventually the evaluation of the further disease course are necessary to establish a diagnosis of frontotemporal dementia.     

First-episode schizophreniform disorder: comparisons with first-episode schizophrenia

BACKGROUND: Schizophreniform disorder remains poorly understood and has been reported probably to be a heterogeneous group of psychotic disorders. METHOD: This study compared first-episode schizophreniform disorder (N=12) and schizophrenia (N=18) patients. The authors propose that schizophreniform disorder has a different type of onset and outcome than schizophrenia. Patients were given extensive assessments at initial evaluation, 6 month follow-up, and 24 month follow-up. Comparisons between the two groups were made on type of onset, demographic, clinical ratings and outcome variables. RESULTS: Patients with schizophreniform disorder compared to patients with schizophrenia were more likely to have an acute onset (P=0.003), and have recovered by 6 months (P=0.03). However, there were no differences in outcome at 24 months. Furthermore, all schizophreniform cases except for two were re-diagnosed at 24 months as having schizophrenia. CONCLUSIONS: The findings suggest that the initial differences of schizophreniform disorder compared to schizophrenia were not apparent at 24 months follow-up. Schizophreniform disorder did not emerge as a highly distinctive and stable form of psychosis that merits a diagnostic classification separate from schizophrenia.     

Limbic system dysfunction as a factor in some schizophreniform psychoses: case report and overview

A case is presented of a young woman whose schizophreniform psychosis was unresponsive to neuroleptic treatment, but who subsequently responded well to Carbamazepine. Several converging lines of investigation, suggesting an underlying Limbic System dysfunction, are discussed. Background to the Limbic System concept is provided.     

边缘型人格障碍一例

本病例共3次住精神病院,诊断均为“恶劣心境”及“抑郁症”,经详细收集病史及深入精神检查,更改诊断为“边缘型人格障碍”。这类病例在临床工作中并不少见,但由于医生对该病的临床特点缺乏认识,因此经常误诊为其他精神疾病。本病例的诊断过程颇有代表性,特做报道,以供借鉴。     

Pemoline-induced Tourette's disorder: a case report

The author describes the case of a 14-year-old boy who developed Gilles de la Tourette's disorder during pemoline therapy. Unlike other reported cases, the boy's tics did not remit after the pemoline was discontinued.     

Neuroendocrine dysfunction in schizophreniform disorder: correlation with six-month clinical outcome

The thyrotropin-releasing hormone (TRH) stimulation test and the dexamethasone suppression test (DST) were administered to 21 patients with schizophreniform disorder at the time of admission for acute illness: 9 showed dysregulation on one or the other test. Seventeen patients followed for 6 months were divided into two groups: those with persistent dysfunction and/or psychotic symptoms and those in full remission. Only 1 of 7 patients (14%) with persistent dysfunction in contrast to 7 of 10 patients (70%) in full remission revealed dysregulation on either test. Neuroendocrine challenges may be useful in the early assessment of first-break psychotic patients, and neuroendocrine dysregulation may be a predictor of episodic illness with a better prognosis.     

分裂样障碍患者的脑磁共振成像分析

目的　探讨分裂样障碍患者与正常对照者脑形态的差异。方法　采用三维磁共振成像技术测量64例(男女各32例)分裂样障碍患者和64名(男女各32名)对照组的脑形态,径线测量采用秋野等方法。结果　(1)两组男性比较:与对照组比较,患者组右侧颞叶长径小[ ( 63 4±1 5 )mm],海马角大[ (38 7±1 7)°];左侧海马长径小[ (39 4±0 7)mm],海马角大[ (38 6±1 5)°],均P<0 05。两侧半球比较,患者组右侧半球长径( 159 5±2 1 )mm、顶枕叶长径( 54 4±1 3 )mm均小于左侧[分别为(160 7±2 3)mm和(55 8±1 1)mm],而右侧半球横径[ ( 71 1±1 0 )mm]、颞叶长径[ (63 4±1 5)mm]和海马长径[ (40 7±0 8 )mm]则大于左侧[分别为( 69 8±1 0 )mm、( 62 0±1 2)mm、(39 4±0 7)mm;P<0 05]。(2)两组女性比较:患者组右侧半球高径[ (106 9±1 5)mm]、颞叶长径[ (61 6±1 2)mm]、顶枕叶长径[ (50 8±1 3)mm]和海马长径[ ( 39 9±0 8 )mm]均小于对照组[分别为(109 0±1 4)mm、(62 0±1 1)mm、(51 5±1 1)mm、(41 3±0 9)mm;均P<0 05]。两侧半球比较,患者组右侧额极长径[ ( 34 9±0 9 )mm]、额叶长径[ ( 60 7±0 9 )mm]和颞叶长径[ (61 6±1 2)mm]均大于左侧[分别为(33 6±0 8)mm、(59 6±0 8)mm、(59 9±1 3)mm],顶枕叶长径[ (50 8±1