Olanzapine treatment of premenstrual onset psychosis: a case report

Objective

Premenstrual onset psychosis is a rare condition of unknown etiology for which no treatment trials have been conducted and whose existence as a definitive diagnosis continues to be debated. The literature includes individual case reports and small case series, leaving psychiatrists to make decisions about prescribing antipsychotic agents on a case-by-case basis. Moreover, researchers continue to debate the efficacy of antipsychotic agents in the treatment of premenstrual onset psychosis.

Method

Case report.

Results

We report the case of a 17-year-old female with recurrent premenstrual onset psychosis that was successfully treated with olanzapine monotherapy (20 mg/day).

Conclusion

These findings may serve as a reminder to physicians to rethink the suitability of a more traditionally accepted diagnosis, including premenstrual exacerbation of bipolar disorder or schizophrenia, and the potentially important role of antipsychotic agents, especially prolactin-sparing ones, in premenstrual onset psychosis.     

Psychotic episode secondary to metronidazole use

Objective

Psychosis is a recognized but often forgotten side effect of many commonly prescribed medications.

Method

A case of psychosis in a 27-year-old female related to metronidazole treatment is presented along with review of possible mechanisms.

Results

The onset and resolution of psychosis appeared to coincide with metronidazole treatment.

Conclusions

Clinicians should be aware of medication-related psychosis.     

Identification and comparison of adverse events for preparations of IVIG in patients with neuromuscular diseases

Objective

Risk factors for adverse events in intravenous immunoglobulin (IVIG) therapy are uncertain. We sought to determine the associations of IVIG-related adverse events in patients with neuromuscular disorders.

Patients and methods

We determined the prevalence of adverse events with the use of different forms of IVIG in a tertiary care patient population with neuromuscular diseases. A retrospective assessment for over two decades of patient care was performed.

Results

Adverse events occurred in 43% of patients over time and during 10% of infusions. Prevalence of adverse events, especially headache, was higher for lyophilized forms of IVIG, and increased with cumulative IVIG delivery. Fortunately, serious adverse events were rare for all IVIG preparations. Discontinuation of IVIG therapy occurred most commonly due to perceived inefficacy or adverse events with lyophilized forms of IVIG.

Conclusion

IVIG is generally well tolerated and only rarely associated with serious adverse events, but lyophilized forms of IVIG may be associated with greater prevalence of adverse events in patients with neuromuscular diseases.     

Spinal intramedullary tuberculosis: A series of 15 cases

Objectives

Spinal intramedullary tuberculosis is a rare disease. This study aims to acquaint readers with its clinicoradiological features and emphasizes the importance of early treatment in intramedullary spinal tuberculosis.

Materials and methods

Retrospective analysis was conducted from 1985 to 2006 over a period of 21 years and data were retrieved from patient records at our institute (single centre study). Clinicoradiological and pathological data were reviewed along with final outcome at discharge and analyzed. Results: Fifteen patients were analyzed. Mean age of presentation was 31 years (range: 18–45 years), with average duration at presentation being 11 months (2–24 months). Common locations: dorsal region: 7 cases, cervical: 5 cases, cervicodorsal: 2 cases and dorsolumbar region: 1 case. Sensori-motor involvement was noted in fourteen patients. Bowel and bladder involvement was seen in ten patients while one patient had respiratory distress. Only 40% of patients had secondary involvement of spine while the rest of the cases were having primary spinal intramedullary tuberculosis. Three patients had previous history of tubercular meningitis, while one patient had old pulmonary tuberculosis. There were one case each of cervical node involvement and intracranial granuloma. Twelve patients underwent surgery while others were conservatively managed, all patients received antitubercular therapy for 18 months.Nine of the twelve operated patients showed improvement in motor power, while two of the conservatively managed patients improved. Patients presenting late had a poorer outcome.

Conclusion

Spinal intramedullary tuberculosis is a non-malignant, treatable lesion giving a good outcome on management. Surgically managed patients showed a better outcome.     

Psychosis in a cocaine-dependent patient with ADHD during treatment with methylphenidate

Objective

The objective was to report a case of experienced psychosis during the treatment with methylphenidate (MPH) in a cocaine-dependent adult treated for attention-deficit/hyperactivity disorder (ADHD) with comorbid cocaine dependence.

Conclusion

ADHD is a frequent comorbidity in substance use disorder (SUD) patients. MPH may be effective in treating ADHD symptoms in SUD patients, thus preventing possible adverse outcomes. Cocaine-induced psychosis may be a risk factor for development of psychosis in the presence of a concurrent treatment with MPH.     

A review of the interplay between tuberculosis and mental health

Aims

Tuberculosis and mental illness share common risk factors including homelessness, HIV positive serology, alcohol/substance abuse and migrant status leading to frequent comorbidity. We sought to generate a comprehensive literature review that examines the complex relationship between tuberculosis and mental illness.

Methods

A literature search was conducted in MedLine, Ovid and Psychinfo, with further examination of the references of these articles. In total 316 articles were identified. It was not possible to conduct a formal meta-analysis due to the absence of randomised controlled data.

Results

Rates of mental illness of up to 70% have been identified in tuberculosis patients. Medications used in the treatment of common mental illnesses, such as depression, may have significant interactions with anti-tuberculosis agents, especially isoniazid and increasingly linezolid. Many medications used in the treatment of tuberculosis can have significant adverse psychiatric effects and some medications such as rifampicin may reduce the effective doses of anti-psychotics y their enzyme induction actions. Treatment with agents such as cycloserine has been associated with depression, and there have been reported cases of psychosis with most anti-tuberculous agents. Mental illness and substance abuse may also affect compliance with treatment, with attendant public health concerns.

Conclusions

As a result of the common co-morbidity of mental illness and tuberculosis, it is probable that physicians will encounter previously undiagnosed mental illness among patients with tuberculosis. Similarly, psychiatrists are likely to meet tuberculosis among their patients. It is important that both psychiatrists and physicians are aware of the potential for interactions between the drugs used to treat tuberculosis and psychiatric conditions.     

Paranoid psychosis and cognitive impairment associated with hepatitis C antiviral therapy

Objective

To report a case of paranoid psychosis and cognitive impairment associated with Hepatitis C virus (HCV) antiviral therapy.

Methods

Case report.

Results

A 55-year-old male presented with paranoid psychosis and cognitive impairment, 4 months after initiating interferon-based HCV antiviral therapy. His psychosis resolved with discontinuation of therapy and initiation of risperidone, but his cognitive impairment persisted. His psychosis also re-emerged months later when attempting to titrate down his risperidone. Brain MRI demonstrated bilateral asymmetric subcortical and deep white matter changes, which were non-specific but may have rendered him susceptible to neuropsychiatric sequelae of antiviral therapy.

Conclusion

This case emphasizes the importance of neuropsychiatric screening and monitoring of patients being treated with interferon-based therapy for HCV, particularly if there is evidence of previous neurologic disease.     

A systematic review of clinical outcomes, perioperative data and selective adverse events related to mild hypothermia in intracranial aneurysm surgery

Background

In the last two decades, mild intraoperative hypothermia has become widely accepted as a protective therapy in neurosurgery. However, its effect in intracranial aneurysm surgery remains unclear.

Objective

The purpose of this study was to assess the perioperative effects and selected adverse events associated with intraoperative mild hypothermia in aneurysm surgery and to compare those with events in normothermic surgery.

Methods

Three literature databases, namely the Cochrane Library, PubMed and EMBASE, were searched for randomised controlled trials (RCTs) of aneurysm surgery that compared intraoperative mild hypothermia and normothermia from January 1965 to August 2010. Three RCTs were identified. We extracted the following information: author names and publication year; clinical outcome (number of deaths and Glasgow outcome scales); perioperative data (number of moderate or severe intraoperative brain swelling occurrences, hypertensive episodes, ruptured or leaking aneurysms, volume of blood loss during surgery, duration of temporary clipping, and number of patients who received protective drugs, who required rewarming and who were intubated); number of adverse events (cerebral infarctions, brain swelling, myocardial ischaemia or infarction, congestive heart failure, meningitis or ventriculitis and pneumonia). Except for author names and publication year, the data were pooled to perform a mean effect size estimate. The effects of intraoperative mild hypothermia were then analysed.

Results

The number of patients requiring rewarming in the mild hypothermia group was significantly greater than in the normothermia group (odds ratio, 33.89; 95% confidence intervals, 3.61–318.36). There were no other statistically significant differences.

Conclusion

Based on available RCTs, especially involving surgery of low-grade aneurysms, intraoperative mild hypothermia showed no advantages compared with normothermia.     

A functional polymorphism in estrogen receptor alpha gene is associated with Japanese methamphetamine induced psychosis

Background

A recent study reported an association between rs2234693, which influences enhancer activity levels in estrogen receptor alpha gene (ESR1), and schizophrenia. This study reported that schizophrenic patients with the CC genotype have significantly lower ESR1 mRNA levels in the prefrontal cortex than patients with other genotypes. The symptoms of methamphetamine induced psychosis are similar to those of paranoid type schizophrenia. Therefore, we conducted an association analysis of rs2234693 with Japanese methamphetamine induced psychosis patients.

Method

Using rs2234693, we conducted a genetic association analysis of case-control samples (197 methamphetamine induced psychosis patients and 197 healthy controls). The age and sex of the control subjects did not differ from those of the methamphetamine induced psychosis patients.

Results

We detected a significant association between ESR1 and methamphetamine induced psychosis patients in allele/genotype-wise analysis. For further interpretation of these associations, we performed single marker analysis of subjects divided by sex. Rs2234693 was associated with male methamphetamine induced psychosis.

Discussion

Our results suggest that rs2234693 in ESR1 may play a role in the pathophysiology of Japanese methamphetamine induced psychosis patients.     

Cenesthopathy in adolescence: An appraisal of diagnostic overlaps along the anxiety–hypochondriasis–psychosis spectrum

Objective

To discuss the diagnostic validity of unusual bodily perceptions along the spectrum from age-specific, often transitory and normal, to pathological phenomena in adolescence to hypochondriasis and finally to psychosis.

Methods

Critical literature review of the cornerstone diagnostic groups along the spectrum embracing anxiety and cenesthopathy in adolescence, hypochondriasis, and cenesthopathy and psychosis, followed by a discussion of the diagnostic overlaps along this spectrum.

Results

The review highlights significant overlaps between the diagnostic cornerstones. It is apparent that adolescents with unusual bodily perceptions may conceptually qualify for more than one diagnostic group along the spectrum. To determine whether cenesthopathies in adolescence mirror emerging psychosis, a number of issues need to be considered, i.e. age and mode of onset, gender, level of functioning and drug use. The role of overvalued ideas at the border between hypochondriasis and psychosis must be considered.

Conclusion

As unusual bodily symptoms may in some instances meet formal psychosis risk criteria, a narrow understanding of these symptoms may lead to both inappropriate application of the new DSM-5 attenuated psychosis syndrome and of treatment selection. On the other hand, the possibility of a psychotic dimension of unusual bodily symptoms in adolescents must always be considered as most severe expression of the cenesthopathy spectrum.     

How psychotic-like are paranormal beliefs?

Background and objectives

Paranormal beliefs and Psychotic-like Experiences (PLE) are phenotypically similar and can occur in individuals with psychosis but also in the general population; however the relationship of these experiences for psychosis risk is largely unclear. This study investigates the association of PLE and paranormal beliefs with psychological distress.

Methods

Five hundred and three young adults completed measures of paranormal beliefs (Beliefs in the Paranormal Scale), psychological distress (General Health Questionnaire), delusion (Peters et al. Delusions Inventory), and hallucination (Launay-Slade Hallucination Scale) proneness.

Results

The frequency and intensity of PLE was higher in believers in the paranormal compared to non-believers, however psychological distress levels were comparable. Regression findings confirmed that paranormal beliefs were predicted by delusion and hallucination-proneness but not psychological distress.

Limitations

The use of a cross-sectional design in a specific young adult population makes the findings exploratory and in need of replication with longitudinal studies.

Conclusions

The predictive value of paranormal beliefs and experiences for psychosis may be limited; appraisal or the belief emotional salience rather than the belief per se may be more relevant risk factors to predict psychotic risk.     

Psicosis epiléptica periictal,una causa de psicosis reversible

Introduction

Epileptic psychoses are categorised as peri-ictal and interictal according to their relationship with the occurrence of seizures. There is a close temporal relationship between peri-ictal psychosis and seizures, and psychosis may present before (preictal), during (ictal) or after seizures (postictal). Epileptic psychoses usually have acute initial and final phases, with a short symptom duration and complete remission with a risk of recurrence. There is no temporal relationship between interictal or chronic psychosis and epileptic seizures. Another type of epileptic psychosis is related to the response to epilepsy treatment: epileptic psychosis caused by the phenomenon of forced normalisation (alternative psychosis), which includes epileptic psychosis secondary to epilepsy surgery. Although combination treatment with antiepileptic and neuroleptic drugs is now widely used to manage this condition, there are no standard treatment guidelines for epileptic psychosis.

Clinical cases

We present 5 cases of peri-ictal epileptic psychosis in which we observed an excellent response to treatment with levetiracetam. Good control was achieved over both seizures and psychotic episodes. Levetiracetam was used in association with neuroleptic drugs with no adverse effects, and our patients did not require high doses of the latter.

Conclusions

Categorising psychotic states associated with epilepsy according to their temporal relationship with seizures is clinically and prognostically useful because it provides important information regarding disease treatment and progression. The treatment of peri-ictal or acute mental disorders is based on epileptic seizure control, while the treatment of interictal or chronic disorders has more in common with managing disorders which are purely psychiatric in origin. In addition to improving the patient's quality of life and reducing disability, achieving strict control over seizures may also prevent the development of interictal psychosis. For this reason, we believe that establishing a treatment protocol for such cases is necessary.     

Rapid relapse in depression following initialization of oral contraception with ethinyl estradiol and chlormadinone acetate

Objective

Female sexual hormones (estrogens and gestagens) may affect neurocognitive functioning and mood. Thus, the use of oral hormonal contraceptives (OHC) bears the risk of psychiatric adverse drug reactions such as depression and psychosis. However, the available empiric evidence regarding this connection is conflicting, and, moreover, female sex hormones seem to feature also mood-stabilizing and antidepressive effects. Hence, individual susceptibility factors and preparation-specific pharmacologic properties might play a pivotal role in the development of mood disturbances related to OHC. Single case reports provide empiric data for further systematic approaches.

Methods

A clinical case is presented and discussed.

Results

A 36-year-old female patient with recurrent major depressive disorder developed rapid relapse in depression after initialization of OHC with ethinyl estradiol 30 μg/chlormadinone acetate 2 mg. This OHC combination was described to particularly feature positive effects on depressive mood.

Conclusions

OHC may induce serious mood disturbances and should be administered with care, particularly in patients with affective disorders.     

Limbic encephalitis and psychosis

Objective

To report a case of limbic encephalitis (LE) presenting with psychosis.

Method

Case report.

Results

A woman with LE initially presented with acute psychotic symptoms. Magnetic resonance imaging (MRI) showed hyperintensity in bilateral temporal lobes. Paraneoplastic and autoimmune antibodies were negative, but symptoms resolved after starting methylprednisolone.

Conclusion

A greater awareness for and knowledge of LE among all disciplines could help early recognition and management of LE and avoid permanent behavioral deficits.     

Substance use disorders among treatment naïve first-episode psychosis patients

Objectives

To examine the prevalence of substance use among treatment naïve patients with first episode psychosis presenting to a psychiatry outpatient clinic in India.

Methods

The study sample consisted of 139 first episode treatment naïve patients with psychosis from in and around Bangalore, a city in South India. Self as well as informant-reported data on type, use and duration of substance use as well as the severity of psychotic symptoms were collected using structured instruments. Urine toxicology screen was also conducted for six common drugs of abuse. Breath alcohol analysis was performed in all patients.

Results

Acute and transient psychosis was the most common diagnosis (42.4%). Overall, 20% of the population reported current substance use disorder (excluding nicotine). Current alcohol dependence was diagnosed among 17.3%, whereas cannabis dependence in 3.6%. Life time as well as current use of cannabis was less than 6%. While one patient reported inhalant abuse none reported use of amphetamine or opioids. There was very high concordance between reported drug use and urine toxicology screen.

Conclusion

The use of illicit drugs is substantially less among first episode drug naïve patients with psychosis in an Indian urban clinical setting compared to rates reported from developed countries like North America, Canada and UK.     

Functional network connectivity in the behavioral variant of frontotemporal dementia

Introduction

The aim of this study was to investigate, using resting state (RS) functional magnetic resonance imaging (fMRI), the functional connectivity within and among brain networks in patients with the behavioral variant of frontotemporal dementia (bvFTD), compared with healthy controls and patients with probable Alzheimer's disease (pAD).

Methods

Twelve bvFTD patients were compared with 30 controls and 18 pAD patients. Functional connectivity within the salience, default mode (DMN), executive (EXN), attention/working memory (ATT/WM), and dorsal attentional networks was assessed using independent component analysis. The temporal associations among RS networks (RSNs) were explored using the functional network connectivity toolbox.

Results

A decreased dorsal salience network (DSN) connectivity, mainly involving the anterior cingulum, was observed in bvFTD versus controls and pAD. BvFTD was also characterized by a decreased ventral salience network connectivity in the basal ganglia, and divergent connectivity effects versus controls in the dorsolateral prefrontal cortex (decreased) and precuneus (enhanced) within the right ATT/WM network. The dorsal attentional network had a decreased connectivity with the DMN and EXN in bvFTD versus controls, and a decreased connectivity with the DSN versus pAD.

Conclusions

RSN functional abnormalities occur in bvFTD, involving not only the salience network, but also the DMN and fronto-parietal network associated with ATT and WM modulation. The pattern of functional changes differs from that seen in pAD. The altered interactions among RSN observed in bvFTD and pAD may provide a new venue to explore the functional correlates of cognitive abnormalities in neurodegenerative and psychiatric disorders.     

Increased serum Dickkopf-1 levels in drug-abusing psychotic patients

Background

Dickkopf-1 (DKK1) is an inhibitor of the canonical Wnt pathway, which is known to be impaired in both psychotic and neurodegenerative disorders. Here, we examined serum DKK1 levels as an indicator of ongoing neurodegeneration in psychotic patients, with or without a recent or current history of drug abuse.

Methods

We measured serum DKK1 levels by ELISA in 22 inpatients with psychosis and no history of drug abuse, 22 with psychosis and drug abuse, and 16 controls. We rated psychopathology using the following rating scales: the Positive and Negative Syndrome Scale (PANSS); the Clinical Global Impressions (CGI) severity scale; and the Global Assessment of Functioning (GAF) scale. Extrapyramidal motor symptoms were assessed by the Simpson-Angus Neurological Rating Scale (NRS).

Results

Inpatients with psychosis and comorbid substance abuse showed significantly higher serum DKK1 levels than inpatients with psychosis and no comorbid substance abuse or controls. Comorbid patients had earlier onset, longer duration of psychosis, and more severe extrapyramidal motor symptoms. However, we did not find any significant correlation between DKK1 levels and rating scale scores.

Conclusion

Psychosis led to elevated serum DKK1 levels, and substance abuse led to a further increase. Knowing that there is a correlation between brain and blood levels of DKK1, we speculate that the observed increase in DKK1 levels reflects drug-induced neurotoxicity in our patients.     

Adverse events and deterioration reported by participants in the PACE trial of therapies for chronic fatigue syndrome

Objective

Adverse events (AEs) are health related events, reported by participants in clinical trials. We describe AEs in the PACE trial of treatments for chronic fatigue syndrome (CFS) and baseline characteristics associated with them.

Methods

AEs were recorded on three occasions over one year in 641 participants. We compared the numbers and nature of AEs between treatment arms of specialist medical care (SMC) alone, or SMC supplemented by adaptive pacing therapy (APT), cognitive behaviour therapy (CBT) or graded exercise therapy (GET). We examined associations with baseline measures by binary logistic regression analyses, and compared the proportions of participants who deteriorated by clinically important amounts.

Results

Serious adverse events and reactions were infrequent. Non-serious adverse events were common; the median (quartiles) number was 4 (2, 8) per participant, with no significant differences between treatments (P = .47). A greater number of NSAEs were associated with recruitment centre, and baseline physical symptom count, body mass index, and depressive disorder. Physical function deteriorated in 39 (25%) participants after APT, 15 (9%) after CBT, 18 (11%) after GET, and 28 (18%) after SMC (P < .001), with no significant differences in worsening fatigue.

Conclusions

The numbers of adverse events did not differ significantly between trial treatments, but physical deterioration occurred most often after APT. The reporting of non-serious adverse events may reflect the nature of the illness rather than the effect of treatments. Differences between centres suggest that both standardisation of ascertainment methods and training are important when collecting adverse event data.