Sertraline alleviated osmophobia caused by partial hypopituitarism with isolated ACTH deficiency

Objective

Hyperosmia may be an early manifestation of hypocortisolism and may be mistakenly diagnosed as osmophobia. However, sertraline therapy incidentally alleviated the phobic symptoms and hindered accurate diagnosis.

Case report

A 41-year-old man was diagnosed as having osmophobia. Initial sertraline treatment relieved the symptoms, but its cessation resulted in recurrence of osmophobia. Endocrinological examinations revealed severe hypocortisolism and partial hypopituitarism with isolated adrenocorticotropic hormone deficiency. After prednisolone supplementation, his condition dramatically improved.

Conclusion

We recommend that, before intervention with selective serotonin reuptake inhibitors is performed, the hypothalamic–pituitary–adrenal axis be evaluated in psychiatric patients presenting with co-occurring olfactory change.     

Is interictal EEG activity a biomarker for mood disorders in temporal lobe epilepsy?

Objective

Psychiatric comorbidities are frequent in temporal lobe epilepsy (TLE), and symptoms of these comorbidities may be related to epilepsy activity. Here we evaluated interictal EEG activity in TLE patients with or without psychiatric comorbidities.

Methods

A cohort study of 78 patients with TLE, with evaluation of wake/sleep interictal scalp EEG. All subjects were submitted to a psychiatric structured clinical interview (SCID) for the diagnosis of lifetime psychiatric comorbidities. Three major diagnostic categories were studied: mood disorders, anxiety disorders, and psychosis. We then evaluated differences in interictal EEG activity between patients with and without these psychiatric comorbidities.

Results

Infrequent EEG interictal spikes, defined as less than one event per minute, were significantly associated with mood disorders in TLE (p = 0.02).

Conclusions

Low intensity seizure disorder has been associated with a decrease in interictal EEG discharges and with an increase in psychiatric symptoms in TLE, a phenomenon known as forced normalization. In our study, we observed a low interictal spike frequency on EEG in TLE patients with mood disorders.

Significance

A low spike index might be a neurophysiological marker for depression in temporal lobe epilepsy.     

Mental disorders in leprosy: An underdiagnosed and untreated population

Objective

To describe the frequency of psychiatric comorbidities in leprosy patients and check if they had been previously diagnosed and were in psychiatric care.

Method

The study was conducted with a sample of 120 leprosy patients being treated at two reference hospitals for leprosy in Salvador, Bahia, Brazil. Survey participants were more than 18 years of age, had a confirmed diagnosis of leprosy and was undergoing antimicrobial treatment. Patients were evaluated face-to-face with a socio-demographic questionnaire and the Mini-International Neuropsychiatric Interview (MINI-Plus) in Portuguese. The period of data collection was between October 2009 and June 2012.

Results

The assessment using the MINI-Plus showed that 34 (28.3%) patients did not receive any psychiatric diagnosis and 86 (71.7%) met the criteria for at least one. Of these 86 patients, 25 (20.8%) had one diagnosis, 26 (21.7%) had two diagnoses and the rest, 35 (29.2%), had three or more psychiatric diagnoses. All patients with a moderate or high risk of suicide had one or more psychiatric comorbidities.

Conclusion

Leprosy patients have a high prevalence of psychiatric comorbidities. Furthermore, most of them had no previous psychiatric diagnosis and the majority was not undergoing treatment.     

Influence of attention-deficit/hyperactivity disorder on binge eating behaviors and psychiatric comorbidity profile of obese women

Objective

Previous studies have reported higher prevalence rates of attention-deficit/hyperactivity disorder (ADHD) both in eating disorders (ED) and in obese patients. We compared the psychiatric comorbidity profile of obese ADHD women with non-ADHD obese women and how ADHD symptoms impact in binge eating behaviors.

Design

Cross-sectional study of a clinical sample.

Subjects

171 adult women were evaluated at a specialized clinic in obesity and ED.

Measurements

Participants complete a semi-structured interview and psychopathology rating scales. A hierarchical regression model was employed to predict binge eating behavior.

Results

Obese ADHD patients had a larger number of psychiatric comorbidities (p < 0.001), especially Substance Abuse Disorders, and higher scores on psychopathology rating scales (p < 0.05). The highest prediction for binge eating in the regression model was the presence of depressive symptoms, followed by ADHD inattention symptoms and trait-impulsivity.

Conclusion

ADHD should be routinely evaluated in obese since it is related with more severe psychopathology. Depressive symptoms can predict the presence of binge eating in obese patients.     

Triiodothyronine may be possibly associated with better cognitive function and less extrapyramidal symptoms in chronic schizophrenia

Objective

Many chronic inpatients with schizophrenia demonstrate enduring psychiatric symptoms and various side effects of antipsychotic drugs. Several biological markers such as prolactin, thyroid hormones and brain-derived neurotrophic factor (BDNF) are reportedly associated with psychiatric symptoms and/or antipsychotic side effects in patients with schizophrenia but to date findings are inconsistent. The objective of the present study was to comprehensively investigate the association of psychiatric and extrapyramidal symptoms with hormones and BDNF in chronic schizophrenia.

Methods

In this study, 93 chronic inpatients with schizophrenia were comprehensively investigated in order to examine the association of psychiatric and extrapyramidal symptoms with prolactin, thyroid hormones (free triiodothyronine (T₃), free thyroxine (T₄), thyroid stimulating hormone), cortisol and BDNF. Symptoms were assessed via the Positive and Negative Syndrome Scale (PANSS), Mini-Mental State Examination (MMSE), and drug-induced extrapyramidal symptoms scale (DIEPSS).

Results

Multiple regression analyses revealed that antipsychotic dose was the only variable that predicted significant variance in PANSS positive subscale scores, that BDNF and free T₃ predicted significant variance in MMSE scores, and that prolactin and free T₃ predicted significant variance in DIEPSS scores.

Conclusion

These findings suggest that BDNF, free T₃, and prolactin may be associated with cognitive function and/or extrapyramidal symptoms in patients with chronic schizophrenia. Notably, free T₃ may be possibly associated with better cognitive function and less extrapyramidal symptoms, although our cross-sectional study could not reveal a causal relationship.     

Influence of psychiatric comorbidities in migraineurs in the emergency department

Objective

To examine how psychiatric comorbidities in migraineurs in the emergency department (ED) affect healthcare utilization and treatment tendencies.

Method

This is a cross-sectional analysis of 2872 patients who visited our ED over a 10-year period and were given a principal diagnosis of migraine.

Results

Compared to migraineurs without a psychiatric comorbidity, migraineurs with a psychiatric comorbidity had about three times more ED visits, six times more inpatient hospital stays and four times more outpatient visits. Migraineurs with psychiatric comorbidities received narcotics in the ED more often than migraineurs without psychiatric comorbidities (P<0.0001). In addition, migraineurs with psychiatric disorders were more likely to have a computed tomography scan of the head [Risk Ratio (RR) 1.42 (95% confidence interval (CI)=1.28–1.56, P<0.001)] or a magnetic resonance image of the brain [RR 1.53 (95% CI=1.33–1.76, P<0.001)] than patients without a psychiatric disorder when visiting our hospital center.

Conclusions

Migraineurs with psychiatric comorbidity who visit the ED have different healthcare utilization tendencies than migraineurs without psychiatric comorbidity who visit the ED. This is seen in the frequency of ED visits, outpatient visits and inpatient stays, in the medications administered to them and in the radiology tests they undergo.     

Challenges in managing a mother with a dual diagnosis of peripartum cardiomyopathy and paranoid schizophrenia — a case report

Introduction

Psychotic illness has a low incidence in the puerperal period. Peripartum cardiomyopathy as a complication of pregnancy is also rare.

Clinical case

We report a case where the above two conditions occurred simultaneously in a patient and posed significant difficulties in the clinical management. She was diagnosed as having paranoid schizophrenia and peripartum cardiomyopathy. Many of the antipsychotics were contraindicated, and electroconvulsive therapy could not be administered due to the added risks involved with regard to anesthesia. She was therefore managed with clonazepam and olanzapine.

Discussion

This case highlights the challenges in a patient with a psychiatric illness presenting with comorbid physical illness.     

Do motor subtypes of delirium in child and adolescent have a different clinical and phenomenological profile?

Objective

To explore the frequency of different motor subtypes of delirium in children and adolescents and to study the relationship of motor subtypes with other symptoms, etiology and outcome of delirium.

Methods

Forty-nine consecutive patients, aged 8–19 years, diagnosed as having delirium as per DSM-IV-TR were assessed on Delirium Rating Scale-Revised 98 (DRS-R-98), amended Delirium Motor Symptom Scale (DMSS), delirium etiology checklist and risk factors for delirium. Different motoric subtypes of delirium were compared with each other for symptoms of delirium as assessed by DRS-R-98, risk factors, etiology and outcome.

Results

More than half (53%) of patients were classified as having hyperactive delirium, this was followed by the mixed (26.5%) and the hypoactive (16%) subtype. When the different subtypes were compared with each other, the 3 motor subtypes did not differ from each other in terms of frequency and severity of other symptoms except for minor differences. Hallucinations are more common in patients with hyperactive and mixed subtype. There is no significant difference in the outcome of delirium across different subtypes.

Conclusion

Unlike in adults, motoric subtypes of delirium in child and adolescents do not differ from each other with respect to other symptoms, risk factors and outcome.     

Patients with psychogenic non-epileptic seizures referred to a tertiary epilepsy centre: patient characteristics in relation to diagnostic delay

Objective

This clinical study examines patient and seizure characteristics of patients with psychogenic non-epileptic seizures (PNES) in a tertiary epilepsy centre. The main focus was whether a new subgroup of PNES patients emerged with a relatively short referral time and possible specific characteristics.

Methods

All PNES patients referred to a specialist program in our centre between mid 2007 and mid 2009 were consecutively included. This yielded a study cohort of 90 patients.

Results

The majority of the patients have a patient history with many medical symptoms and they were or had been in treatment by a medical specialist. Furthermore diffuse psychological/psychiatric symptoms and subsequent treatments are also remarkably common, in general without a clear psychological diagnosis. The average time between seizure onset and referral to an epilepsy centre is remarkably low (4.29 years). About 50% of the patients were referred within 2 years of seizure onset. This ‘active high speed referral group’ had significantly more previous psychological complaints, significantly more previous psychological/psychiatric treatments and a trend towards more previous medical investigations.

Conclusion

There seems to be a new subgroup of PNES patients with a short referral time, characterized by a more active attitude towards examination of the symptoms in combination with an active attitude to apply for treatment. However, the PNES cohort as a whole is characterized by having somatoform symptoms based on a process of somatization.     

Manifestaciones neurológicas de los mixomas cardiacos. Experiencia en un centro de referencia

Introduction

Cardiac myxoma is an important but uncommon cause of stroke in younger patients. Few published case series analyse the frequency and clinical presentation of neurological complications in patients with myxoma.

Objective

To list all neurological complications from cardiac myxoma recorded in our hospital in the past 28 years.

Patients and methods

We retrospectively reviewed the neurological manifestations of cardiac myxoma in patients treated in our hospital between December 1983 and March 2012.

Results

Of the 36 patients with cardiac myxoma, 8 (22%) presented neurological manifestations. Half were women and mean age of patients was 52.4 ± 11.6 years. Sudden-onset hemiparesis was the most frequent neurological symptom (63%). Established ischaemic stroke was the most common clinical manifestation (75%), followed by transient ischemic attack. The most commonly affected territory corresponded to the middle cerebral artery. Myxoma was diagnosed by echocardiography in all cases. Mean myxoma size was 4.1 cm and most of the tumours (63%) had a polypoid surface. All tumours were successfully removed by surgery. There were no in-hospital deaths.

Conclusions

Cardiac myxomas frequently present with neurological symptoms, especially ischaemic events (established stroke or transient ischaemic attack), in younger patients with no cardiovascular risk factors. The anterior circulation is more frequently affected, especially the middle cerebral artery. Echocardiography can facilitate prompt diagnosis and early treatment of the lesion.     

Sleep disturbances in a clinical forensic psychiatric population

Objective

Poor sleep is known to cause detrimental effects on the course of diverse psychiatric disorders and is a putative risk factor for hostility and aggression. Thus, sleep may be crucial in forensic psychiatric practice. However, little is known about the prevalence of sleep disturbances in these complex psychiatric patients.

Methods

In this study we investigated the presence of sleep disorders and subjective sleep quality using the Sleep Diagnosis List (SDL), the Pittsburgh Sleep Quality Index (PSQI), interviews addressing the causes of sleep complaints, and file information on sleep medications in 110 patients admitted to a forensic psychiatric hospital.

Results

Almost 30% of the participants suffered from one or more sleep disorders, especially insomnia. An even larger proportion of the participants (49.1%) experienced poor sleep quality. Interestingly, patients with an antisocial personality disorder or traits were particularly dissatisfied with their sleep. The most common causes of sleep problems were suboptimal sleep hygiene, stress or ruminating, negative sleep conditioning, and side effects of psychotropic medication. Of the poor sleepers, 40.7% received a hypnotic drug.

Conclusion

Despite intensive clinical treatment, sleep problems are experienced by a large number of forensic psychiatric patients. It would be worthwhile to examine the effects of pharmacological and non-pharmacological sleep interventions on both psychiatric symptoms and reactive aggressive behavior in forensic patients.     

Diagnostic problems and delay of diagnosis in amyotrophic lateral sclerosis

Objective

Initial symptoms of amyotrophic lateral sclerosis (ALS) mimic several neurological syndromes that may decelerate a correct diagnosis. The aim of our study was to investigate if diagnostic and therapeutic parameters have influence on the time of diagnosis.

Methods

We retrospectively reviewed the medical records of 100 consecutive ALS patients focusing on clinical and diagnostic data, the timing of diagnosis and treatments attributed to the onset of symptoms of ALS.

Results

Among 100 consecutive patients with ALS, 12% underwent surgery due to symptoms retrospectively attributable to ALS. The comparison of duration from first symptoms to correct diagnosis showed a significant difference between operated and non-operated patients. 35% of all ALS patients had bulbar onset symptoms. The mean time from first symptoms to diagnosis was 9 months in this group. In patients without bulbar onset it was 16.4 months which also represents a significant difference. In 44% of patients other diagnoses were considered and medically treated previous to correct diagnosis, but there was no significant delay of diagnosis.

Conclusion

Our study confirms that diagnosis of ALS is still a common clinical problem and shows the need of sensitive and specific diagnostic tests.     

Delirium during psychiatric admission increases mortality in psychiatric patients during and after hospitalization. A nationwide study from 1995 through 2012

Objective

Delirium is a common acute neuropsychiatric disorder caused by a variety of physical insults. It is commonly associated with a variety of serious adverse outcomes, including elevated mortality. There are few studies of delirium occurring in psychiatric patients, including its mortality. The aim was to determine the psychiatric diagnostic profile of Danish psychiatric inpatients diagnosed with delirium and to compare standardized mortality ratio (SMR) in this group with the Danish population and general psychiatric inpatients from 1995 through 2012.

Methods

All first time ICD-10 diagnoses of delirium among psychiatric inpatients were identified in the nationwide Danish Psychiatric Central Research Register (DPCRR) from 1995 through 2012.

Results

A total of 7179 persons diagnosed with delirium were identified in the DPCRR between 1995 and 2012. Of these patients 40.8% had more than one diagnosis of delirium during the period. We identified three distinct groups, based on the first delirium-diagnosis; unspecified delirium (76.9%), comorbid delirium–dementia (19.8%), and drug-related delirium (3.3%). Use of sedative-hypnotics was noted in 46% of those with drug-related delirium. The SMR of delirious psychiatric inpatients compared to all psychiatric inpatients was stable at 1.7 throughout the time period.

Conclusion

Delirium occurring in psychiatric inpatients is associated with elevated mortality. Sedative-hypnotic agents are commonly involved in drug-related delirium. Particular preventative effort is warranted for patients with a previous history of delirium, as we found approximately 40% with more than one episode of delirium.     

Newly diagnosed multiple sclerosis in state of Qatar

Background

Epidemiologic studies on multiple sclerosis (MS) are well-documented in the western population but to a lesser extent in Arab world.

Objective

To study the demographics, clinical aspects, radiologic and laboratory features along with the degree of disability inflicted, and factors affecting disease progression and outcome of newly diagnosed MS patients at our institution.

Methods

Data from all newly diagnosed MS patients fulfilling McDonald criteria from January 01, 2005 to December 31, 2010 were collected and analyzed.

Results

A total of 142 patients were identified, in which 82 (58%) were Qataris, and 90 (64%) females. Mean age was 31 years, and mean duration of symptoms was 24 days (median 15 days). Most common symptoms were sensory (63%), followed by visual (45%) and motor (43%). Mean EDSS was 2.3 at presentation. Treatment was given to 127 (89%), and relapse observed in 49%. Gadolinium enhancing lesions on follow-up MRI brain and relapsing remitting MS were associated with increased radiologic disease burden, while weakness at onset, EDSS of ≥2.5 and ≥3 clinical relapse was associated with clinical disease progression.

Conclusion

MS in Qatar is an emerging disorder especially in the native population. The pattern of disease differs from other Middle Eastern countries by its milder clinical and aggressive radiologic disease presentation.     

Visual and auditory hallucinations revealing cerebellar extraventricular neurocytoma: uncommon presentation for uncommon tumor in uncommon location

Objective

Visual and auditory hallucinations in relation to a cerebellar tumor are rarely reported in children. Primary origin of extraventricular neurocytoma (EVN) in the cerebellum is very rare.

Clinical Presentation

We report on a case of a cerebellar EVN in a 13-year-old girl with the initial symptoms of psychiatric manifestations for more than 2 months. Magnetic resonance imaging of the brain revealed a patchy enhanced tumor in the paramedian left cerebellar region. No obstructive hydrocephalus was noted.

Intervention

Total surgical removal of the tumor was performed. The tumor was initially diagnosed as an oligodendroglioma. After special immunohistochemical studies, the final definitive diagnosis was an EVN without isocitrate dehydrogenase mutation.

Conclusion

EVNs located in the cerebellum are extremely rare. We discuss the clinical symptoms and histological–immunohistochemical features of this rare tumor in that rare location.     

Rapid eye movement sleep behavior disorder in treatment-naïve Parkinson disease patients

Objective

Rapid eye movement (REM) sleep behavior disorder (RBD) is a risk factor for dementia in Parkinson disease (PD) patients. The objectives of our study were to prospectively evaluate the frequency of RBD in a sample of treatment-naïve, newly diagnosed PD patients and compare sleep characteristics and cognition in RBD and non-RBD groups.

Methods

Fifty-seven newly diagnosed PD patients were consecutively recruited in a university medical center. All patients underwent two overnight polysomnography (PSG) sessions and were diagnosed with RBD according to the International Classification of Sleep Disorders, Second Revision criteria. Daytime sleepiness was measured in a multiple sleep latency test (MSLT). Cognition was assessed in a standard neuropsychologic examination.

Results

Seventeen PD patients (30%) met the criteria for RBD. The RBD patients and non-RBD patients did not significantly differ in mean age, gender ratio, disease duration, motor symptom subtype and severity, total sleep time, percentage of REM sleep, apnea–hypopnea index, mean oxygen saturation, and importantly cognitive performance. However, non-RBD patients had a significantly shorter mean daytime sleep latency than RBD patients (15 vs 18 min, respectively; P = .014).

Conclusion

A high frequency of RBD was found in our sample of 57 newly diagnosed PD patients. At this stage in the disease, RBD was not found to be associated with other sleep disorders or cognitive decline. Follow-up is needed to assess the risk for developing dementia in early-stage PD patients with RBD.     

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.     

Psychiatric aspects of Wilson disease: a review

Objective

To review the current evidence about psychiatric symptoms in Wilson's disease (WD).

Method

We searched Ovid, PsychInfo, CINHAL and PubMed databases from May 1946 to May 2012 using the key words Wilson('s) disease in combination with psychiatry, psychiatric, psychosis, schizophrenia, depression, mania, bipolar, mood, anxiety, personality and behavior.

Results

Psychiatric symptoms occur before, concurrent with or after the diagnosis and treatment for WD. Thirty to forty percent of patients have psychiatric manifestations at the time of diagnosis, and 20% had seen a psychiatrist prior to their WD diagnosis. When psychiatric symptoms preceded neurological or hepatic involvement, the average time between the psychiatric symptoms and the diagnosis of WD was 864.3 days. The prevalence of psychiatric disorders in WD patients varies wildly (major depressive disorder, 4–47%; psychosis, 1.4–11.3%). Certain gene mutations of ATP7B may correlate with specific personality traits.

Conclusions

Psychiatric manifestations represent a significant part of the clinical presentation of WD and can present at any point in the course of the illness. Psychiatric manifestations occurring without overt hepatic or neurologic involvement may lead to misdiagnosis. A better understanding of the psychiatric presentations in WD may provide insights into the underlying mechanisms of psychiatric disorders.