Anti-NMDAR Encephalitis: A Multidisciplinary Approach to Identification of the Disorder and Management of Psychiatric Symptoms.

BACKGROUND: The novelty of anti-NMDA receptor encephalitis, for which somatic treatments have only recently been developed, has led to a lack of information on assessment and treatment of its variable behavioral manifestations. METHOD: In this article, we discuss 4 challenging cases of anti-NMDAR encephalitis, focusing on the importance of a multidisciplinary approach to identification and management of the disorder and the necessity of close collaboration in the acute hospital setting for management of the behavioral symptoms. CONCLUSION: The cases we discuss highlight some of the medication and nonpharmacologic treatment strategies that may facilitate management of psychiatric symptoms, both while the medical workup is ongoing and after the diagnosis has been confirmed.

Prolonged Hypercalcemia-Induced Psychosis.

Hypercalcemia is known to cause neuropsychiatric dysfunction including mood and cognitive changes and rarely, acute psychosis. High calcium levels can be a catalyst for neuronal demise, possibly due to glutaminergic excitotoxicity and dopaminergic and serotonergic dysfunction. While restoration of normal calcium levels or removal of a parathyroid adenoma has been shown to rapidly resolve neuropsychiatric symptoms, there have been rare reported cases of primary hyperparathyroid-related hypercalcemia with persistent symptoms of psychosis. In this case report, we will describe a patient with no past psychiatric history presenting with a protracted course of delirium and psychosis after a removal of a parathyroid adenoma which had caused prolonged exposure to hypercalcemia. The patient's psychosis was unresponsive to psychotropic medication and required inpatient psychiatric care after medical clearance. Per medical records, before the patient was ultimately lost to follow-up, she continued to suffer from psychotic symptoms for at least 8 months. We will discuss the patient's unusual hospital course and management and offer suggestions for future study.

Aspirin misuse: a case report.

Aspirin-use disorder is an underreported condition. Identification of the signs and symptoms of aspirin misuse are important in light of prevalent non-prescribed medicine/over-the-counter medication (NPM/OTC) misuse. We discuss here the case of a patient with a history of chronic aspirin misuse who presented to the emergency department with salicylate intoxication and described elation secondary to deliberate aspirin consumption. This case highlights the importance of screening for NPM/OTC medication misuse in at-risk populations.

Corrigendum to "A Case of Sporadic Creutzfeldt-Jakob Disease Presenting as Conversion Disorder".

[This corrects the article DOI: 10.1155/2017/2735329.].

Alprazolam-induced dose-dependent anorgasmia: case analysis.

BACKGROUND: Sexual dysfunctions are associated with multiple medical and psychiatric disorders, as well as pharmacotherapies used to treat these disorders. Although sexual dysfunctions negatively affect both quality of life and treatment adherence, patients infrequently volunteer these symptoms and clinicians do not pose directed questions to determine their presence or severity. This issue is especially important in psychiatric patients, for whom most common psychotropics may cause sexual dysfunctions (antidepressants, antipsychotics, anxiolytics and mood-stabilising agents). There is limited literature addressing benzodiazepines, and alprazolam in particular. AIMS: To report dose-dependent alprazolam anorgasmia. METHOD: Case analysis with PubMed literature review. RESULTS: A 30-year-old male psychiatric patient presented with new-onset anorgasmia in the context of asymptomatic generalised anxiety disorder, social anxiety, panic disorder with agoraphobia, obsessive-compulsive disorder, major depression in remission, and attention-deficit hyperactivity disorder treated with escitalopram 10 mg q.a.m., gabapentin 1000 mg total daily dose, lisdexamfetamine dimesylate 70 mg q.a.m., nortriptyline 60 mg q.h.s. and alprazolam extended-release 2.5 mg total daily dose. All psychotropic doses had been constant for >6 months excluding alprazolam, which was titrated from 1 mg to 2.5 mg total daily dose. The patient denied any sexual dysfunction with alprazolam at 1 mg q.d. and 1 mg b.i.d. Within 1 week of increasing alprazolam to 2.5 mg total daily dose, the patient reported anorgasmia. Anorgasmia was alprazolam dose-dependent, as anorgasmia resolved with reduced weekend dosing (1 mg b.i.d. Saturday/1.5 mg total daily dose Sunday). CONCLUSIONS: Sexual dysfunction is an important adverse effect negatively influencing therapeutic outcome. This case reports alprazolam-induced dose-dependent anorgasmia. Clinicians/patients should be aware of this adverse effect. Routine sexual histories are indicated. DECLARATION OF INTEREST: None.

Frontotemporal dementias: a review.

Dementia is a clinical state characterized by loss of function in multiple cognitive domains. It is a costly disease in terms of both personal suffering and economic loss. Frontotemporal dementia (FTD) is the term now preferred over Picks disease to describe the spectrum of non-Alzheimers dementias characterized by focal atrophy of the frontal and anterior temporal regions of the brain. The prevalence of FTD is considerable, though specific figures vary among different studies. It occurs usually in an age range of 35-75 and it is more common in individuals with a positive family history of dementia. The risk factors associated with this disorder include head injury and family history of FTD. Although there is some controversy regarding the further syndromatic subdivision of the different types of FTD, the three major clinical presentations of FTD include: 1) a frontal or behavioral variant (FvFTD), 2) a temporal, aphasic variant, also called Semantic dementia (SD), and 3) a progressive aphasia (PA). These different variants differ in their clinical presentation, cognitive deficits, and affected brain regions. Patients with FTD should have a neuropsychiatric assessment, neuropsychological testing and neuroimaging studies to confirm and clarify the diagnosis. Treatment for this entity consists of behavioral and pharmacological approaches. Medications such as serotonin reuptake inhibitors, antipsychotics, mood stabilizer and other novel treatments have been used in FTD with different rates of success. Further research should be directed at understanding and developing new diagnostic and therapeutic modalities to improve the patients' prognosis and quality of life.

Overlay of Late-Life Depression and Cognitive Impairment.

This article appraises several facets of the linkage between depression and cognitive impairment, including dementia, mild cognitive impairment, and vascular dementia. Potential mechanisms for this association are examined. This review was crafted to be extensive but not exhaustive. The authors searched PubMed, using the terms depression, late-life depression, cognitive impairment, and dementia. Articles included are seminal articles from the field as well as representative, heuristic studies. A link between depression and cognitive impairment was found. Depression likely serves as both a risk factor and a prodromal symptom of dementia. Mechanisms whereby depression could induce cognitive impairment include hippocampal atrophy, alterations in glucocorticoid secretion, cerebrovascular compromise, deposition of ß-amyloid plaques, chronic inflammation, apolipoprotein E status, and deficits of nerve growth factors. This article will benefit the practicing clinician by increasing awareness of the links between depression and dementia and encouraging greater emphasis on screening for cognitive impairment among individuals with depression or a history of depression.

A Case of Sporadic Creutzfeldt-Jakob Disease Presenting as Conversion Disorder.

Background. Creutzfeldt-Jakob disease is a rare disorder of the central nervous system. Its initial diagnosis may be obscured by its variable presentation. This case report illustrates the complexity of diagnosing this disease early in the clinical course, especially when the initial symptoms may be psychiatric. It offers a brief review of the literature and reinforces a role for consultation psychiatry services. Methods. PUBMED/MEDLINE was searched using the terms "Creutzfeldt-Jakob disease", "psychiatric symptoms", "conversion disorder", "somatic symptom disorder", "functional movement disorder", and "functional neurologic disorder". Case. The patient was a 64-year-old woman with no prior psychiatric history who was initially diagnosed with conversion disorder and unspecified anxiety disorder but soon thereafter was discovered to have Creutzfeldt-Jakob disease. Discussion. This case highlights the central role of psychiatric symptoms in early presentations of Creutzfeldt-Jakob disease. Still, few other cases in the literature report functional neurological symptoms as an initial sign. The consultation psychiatrist must remain alert to changing clinical symptoms, especially with uncharacteristic disease presentations.

Treatments for late-life bipolar disorder.

BACKGROUND: Bipolar affective disorder is not uncommon in the elderly; prevalence rates in the United States range from 0.1% to 0.4%. However, it accounts for 10% to 25% of all geriatric patients with mood disorders and 5% of patients admitted to geropsychiatric inpatient units. These patients often present a tremendous treatment challenge to clinicians. They frequently have differing treatment needs compared with their younger counterparts because of substantial medical comorbidity and age-related variations in response to therapy. Unfortunately, the management of geriatric bipolar disorder has been relatively neglected compared with the younger population. There continues to be a scarcity of published, controlled trials in the elderly, and no treatment algorithms specific to bipolar disorder in the elderly have been devised. OBJECTIVE: The goal of this article was to review the current literature on both the pharmacologic and nonpharmacologic management of late-life bipolar disorder. METHODS: English-language articles written on the treatment of bipolar disorder in the elderly were identified. The first step in data collection involved a search for evidence-based clinical practice guidelines in the Cochrane Database of Systematic Reviews (up until the third quarter of 2006). Systematic reviews were then located in the following databases: MEDLINE (1966-September 2006), EMBASE (1980-2006 [week 36]), and PsycINFO (1967-September 2006 [week 1]). Additional use was made of these 3 databases in searching for single randomized controlled trials, meta-analyses, cohort studies, case-control studies, case series, and case reports. "Elderly," used synonymously with "geriatric," was defined as individuals aged > or =60 years. However, to take into account ambiguity in the nomenclature, the key words aged, geriatric, elderly, and older were combined with words indicating pharmacologic treatments such as pharmacotherapy; classes of medications (eg, lithium, antidepressants, antipsychotics, anticonvulsants, benzodiazepines); and names of selected individual medications (eg, lithium, valproic acid, lamotrigine, carbamazepine, oxcarbazepine, topiramate, gabapentin, zonisamide, clozapine, risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole). These terms were then combined with the diagnostic terms bipolar disorder, mania, hypomania, depression, or bipolar depression. Finally, the terms ECT and psychotherapy were also queried in combination with indicators for age and diagnosis. A few articles on "older adults," usually defined as individuals aged 50 to 55 years, were also included. They may allow for possible extrapolation of data to the geriatric population. Additionally, several mixed-age studies were included for similar considerations. Case reports and case series were described for their potential heuristic value. RESULTS: Unfortunately, there is a considerable dearth of literature involving evidence-based clinical practice guidelines and even randomized controlled trials in elderly individuals with bipolar disorder. Available options for the treatment of bipolar disorder (including those for mania, hypomania, depression, or maintenance) in the elderly include lithium, antiepileptics, antipsychotics, benzodiazepines, antidepressants, electroconvulsive therapy (ECT), and psychotherapy. CONCLUSIONS: The data for the treatment of late-life bipolar disorder are limited, but the available evidence shows efficacy for some commonly used treatments. Lithium, divalproex sodium, carbamazepine, lamotrigine, atypical antipsychotics, and antidepressants have all been found to be beneficial in the treatment of elderly patients with bipolar disorder. Although there are no specific guidelines for the treatment of these patients, monotherapy followed by combination therapy of the various classes of drugs may help with the resolution of symptoms. ECT and psychotherapy may be useful in the treatment of refractory disease. There is a need for more controlled studies in this age group before definitive treatment strategies can be enumerated.

Placement of 19F into the center of GB1: effects on structure and stability.

A structural and thermodynamic characterization of 5F-Trp-substituted immunoglobulin binding domain B1 of streptococcal protein G (GB1) was carried out by nuclear magnetic resonance and circular dichroism spectroscopy. A single fluorine reporter atom was positioned at the center of the three-dimensional structure, uniquely poised to be exploited for studying interior properties of this protein. We demonstrate that the introduction of 5F-Trp does not affect the global and local architecture of GB1 and has no influence on the thermodynamic stability. The favorable properties of the fluorinated GB1 render this molecule a desirable model system for the development of spectroscopic methodology and theoretical calculations.

What are the causes of late-life depression?

Although depression in old age is less common than depression in younger populations, it still affects more than 1 million community-living older adults. Depression in late life has been associated with reduced quality of life and increased mortality from both suicide and illness. Its causes are multifactorial but are prominently related to both biologic and social factors. Psychological factors, although less studied in elders, are also important in understanding its cause. In this article, multiple facets of late-life depression are reviewed, including its clinical presentation, epidemiology, and biopsychosocial causes.

Valproic Acid-induced myoclonus in a demented patient: a case report.

Valproic acid and its derivatives are now commonly used to treat various psychiatric disorders in the elderly. Data indicates that the elderly patients are more susceptible to developing neuropsychiatric complications when treated with these medications. In this report, we describe the case of a 66-year-old woman with early-onset, Alzheimer's type dementia, who developed myoclonus when treated with a valproic acid preparation for behavioral disturbances associated with the dementia.

Chorea associated with gabapentin use in an elderly man.

BACKGROUND: Chorea is a hyperkinetic movement disorder characterized by irregular, flowing, nonstereotyped, random, involuntary movements. Huntington disease (HD) and drug-induced chorea account for >50% of adult-onset cases. Chorea associated with gabapentin, an anticonvulsant, has not been well documented. OBJECTIVE: The purpose of this article was to report a case of chorea that developed in an elderly man being treated with gabapentin for severe anxiety. CASE SUMMARY: A 75-year-old white man (height, 165.1 cm; weight, 65.8 kg; body mass index, 19.6 kg/m2) with anxiety disorder not otherwise specified was admitted to a geriatric medicine psychiatric unit in Connecticut because of worsening symptoms of anxiety affecting his cognitive ability. On evaluation, the patient had choreiform movements involving the neck, trunk, upper and lower extremities, and tongue. The patient reported that symptoms began after taking gabapentin 300 mg PO TID (prescribed by his geriatrician) for the treatment of anxiety. The patient had been taking gabapentin for >1 month when the symptoms first appeared. There was no known family history of HD, and patient workup was unremarkable for other conditions (eg, vascular disease of the brain, progressive dementia, infectious and metabolic disorders) that might present with chorea. The chorea lasted for ~4 months and resolved within 2 days after gabapentin discontinuation. CONCLUSION: This article reports a case of chorea in an elderly patient who was receiving gabapentin for the treatment of anxiety. After gabapentin discontinuation, the chorea resolved completely, indicating a probable adverse drug reaction.