Understanding the Complexity of Early-Onset Dementia.

Dementia, particularly Alzheimer's disease, affects millions globally, with its prevalence increasing notably with age. Early-onset Alzheimer's disease, however, affects individuals under 65 years old. Unfortunately, diagnosing dementia in patients under 65 years old is quite challenging and is often delayed, missed, or wrong. Thus, we present the case of a 60-year-old female, with a medical history of hypothyroidism and presumed dementia on donepezil, who presented to the emergency department for agitation, dramatic change in personality and behavior, as well as cognitive decline that started in her late 50s. We discuss the importance of performing a thorough history and physical examination, as well as a comprehensive workup for patients who present with dramatic changes in behavior due to the wide range of potential diagnoses. While certain reversible causes, such as hypothyroidism, nutritional deficiencies, and polypharmacy, can be promptly identified and treated, chronic neurocognitive disorders such as Alzheimer's disease demand a timely evaluation for early multidisciplinary treatment to enhance patient outcomes.

Neuropsychiatric Manifestations of Arteriovenous Malformation: A Case of Acute Mania.

Current literature shows very few case reports about manic symptoms arising in patients with arteriovenous malformations and no other predisposing factors, where these cases presented with mania before the initiation of treatment. We report a rare case of a 46-year-old male patient, with a history of a left arteriovenous malformation (AVM) status post radiation treatment with associated seizures, who presented to the emergency department of a local hospital with acute mania and other behavioral changes. The patient had manic symptoms, including mood lability, impulsivity, insomnia, decreased appetite, jealous delusions, pressured speech, and suicidal ideations. The patient's escitalopram dose for depression was reduced from 20 mg to 10 mg, and valproate was started during admission. After a three-day hospital admission, his psychiatric symptoms gradually improved. He was subsequently discharged home with additional instructions to follow up with his neurologist. In this case report, we show that organic manic disorder should be considered in any manic patient who presents outside the usual age of onset for idiopathic manic-depressive disease, lacks a family or personal history of affective disturbance, or exhibits concomitant neurologic deficits. In addition, we emphasize that distinguishing between primary psychiatric conditions and those secondary to medical causes for patients who present with acute mania can significantly impact the care a patient receives and can make a difference in their psychiatric and medical prognosis.

A Case of 'Neptune's Fix Elixir': The Dangerous Consequences of Unregulated Use of Tianeptine in Over-the-Counter Products.

Tianeptine is an atypical tricyclic antidepressant approved for the treatment of major depressive disorder in some European, Asian, and Latin countries. Along with its serotonergic properties, tianeptine also acts as a full agonist at the mu-opioid receptor, creating sensations of euphoric highs and significant risks of addiction and withdrawal. For this reason, along with increased reports of adverse effects and fatalities, tianeptine has not been approved in the US. Despite this, tianeptine continues to be accessible through unregulated online stores and small retailers under street names such as Zaza, Tia, Tianna, 'gas-station dope', and a product not mentioned in the literature previously: Neptune's Fix Elixir. In this report, we discuss the case of a 34-year-old male who presented to the ED via EMS after being found unresponsive secondary to the ingestion of Neptune's Fix Elixir, whose main active ingredient is tianeptine.

Agranulocytosis Associated With Psychiatric Polypharmacy: Lessons Learned From a Clinical Case.

Psychiatric polypharmacy involves the use of two or more psychotropic medications to manage a mental and emotional condition. The prevalence of psychotropic polypharmacy has been increasing since the 1990s and has been attributed to the rise in multiple psychiatric conditions presenting in one patient. However, as the prevalence of polypharmacy increases to maximize therapeutic advantages, so does the adverse effect profile of those drugs used in combination, leading to very life-threatening effects such as agranulocytosis. Thus, we report a case of agranulocytosis secondary to polypharmacy in a patient with a history of multiple complex psychiatric conditions.  The patient is a 20-year-old female with a past medical history of major depressive disorder, borderline personality disorder, post-traumatic stress disorder, anxiety disorder, hypothyroidism, and ulcerative colitis. Her psychiatric conditions were managed with multiple medications including chlorpromazine, and clozapine was recently added a month prior to admission. Upon admission, the patient was hemodynamically stable and febrile, with complaints of generalized body aches and myalgia. Laboratory results showed profound leukopenia with a white blood cell count of 1.0x103/uL and a neutrophil number of 0.02x103/uL. The patient was admitted to the hospital for neutropenic sepsis and was aggressively treated with intravenous antibiotics. Her clozapine and chlorpromazine were discontinued. In this report, we discuss the association between chlorpromazine and clozapine use and agranulocytosis, emphasizing the importance of regular monitoring and heightened awareness for patients on these medications. This case also underscores the necessity for cautious polypharmacy medication management in individuals with complex psychiatric conditions, highlighting the potential life-threatening consequences of polypharmacy in this population.

Urinary Retention Following Methamphetamine and Cannabis Abuse in a 33-Year-Old Male.

Urinary retention is described as an inability to voluntarily empty the bladder, with potential etiologies including mechanical obstruction and neurologic dysfunction. Abused substances like methamphetamine and cannabis can induce this dysfunction. We report a case about a patient with no prior psychiatric history with concomitant methamphetamine and cannabis use, presenting with an acute delirious state and urinary retention. Due to the multifactorial nature and acuity of a patient's presentation, clinicians should be aware of the potential for substance abuse to impact bladder function and consider this in patients who present with urinary symptoms, including urinary retention.

Opioid Use in Pelvic Fractures: The Impact of Opioid Prescribing Laws in Pennsylvania.

Pennsylvania's Prescription Drug Monitoring Program (PDMP) was established in 2016, but its impact on opioid use for pelvic fractures is understudied. We compared opioid use in 277 pelvic fracture cases between two periods: 2015-2017 (T1) and 2018-2020 (T2). Outcomes included daily inpatient morphine milligram equivalents (MME), long-term opioid use (LOU) 60-90 days post-discharge, and intermediate-term opioid use (IOU) 30-60 days post-discharge. T1 and T2 had comparable baseline characteristics. T2 was associated with a decrease in average daily inpatient MME (58.6 vs 78.5, P = .02), particularly in younger patients. Regression analyses showed age and Injury Severity Score (ISS) were significant predictors for daily inpatient MME, while time period was not. Geriatric patients in T2 had significantly decreased IOU (30% vs 9%, P = .05). Pelvic fracture type and daily MME predicted IOU, while pelvic fracture type predicted LOU. This study suggests a modest impact of these laws, but further study is needed.

Cognitive Impairment in a 64-Year-Old Male: Dilemmas With Differential Diagnosis for Patients With Dementia.

Dementia is characterized by cognitive impairment and difficulties in executive functioning. It is an umbrella term for different subtypes that should be differentiated using a meticulous review of the patient's history, physical exam, and work-up. Posing difficulties in diagnosis, findings at times may be inconclusive. We report a case of a depressed patient on hemodialysis for end-stage renal disease (ESRD) who presents with an acute agitated episode following a visual hallucination that he has been experiencing intermittently for six months, along with a three- to four-year history of cognitive impairments. Our differential diagnosis includes vascular dementia, dementia with Lewy bodies, pseudodementia, dialysis dementia, and early-onset Alzheimer's. In this case, the findings of a normal mini-mental status exam (MMSE) and mental status exam (MSE) do not correlate with a working diagnosis. Due to persistent dilemmas in diagnosing early neurocognitive impairment, continued monitoring and re-assessment are necessitated for efficient management of psychiatric patients with cognitive decline.

Priapism in a 31-Year-Old Male With Paranoid Schizophrenia.

Priapism is a painful and emergent side effect that has been linked to some antipsychotics and other psychiatric medications, most often trazodone. This is thought to be due to some level of alpha-1 adrenergic blockade by these medications. Aripiprazole is an atypical antipsychotic with notably weak alpha-1 adrenergic antagonism. Thus, we report on a unique case of aripiprazole-induced priapism in a patient with schizophrenia and recurrent episodes of antipsychotic-induced priapism. This study offers insight into the potential mechanism of aripiprazole-induced priapism and offers alternative medications, such as olanzapine and lumateperone, to treat the patient's ongoing psychotic disorder.

Exploring the Link Between Pancreatic Neuroendocrine Tumors and Depression: A Case Study.

This case probes the potential temporal relationship between pancreatic neuroendocrine tumor (PNET) and depression. This patient has chronic symptoms of depression with no formal diagnosis until within a year of doctors suspecting her diagnosis of pancreatic cancer. An excisional biopsy confirmed a grade 1 neuroendocrine tumor (NET) in the pancreas, and postoperative psychiatric consultation confirmed continued elevated depression. This report presents an illustrative example of the ongoing research questions surrounding the relationship between the timing of a depression diagnosis and a PNET diagnosis. The depression-before-diagnosis relationship in pancreatic cancer patients is an observation that warrants further studies as depression could be a valuable early warning sign of pancreatic cancer.

The Catastrophic Effects of Psychogenic Polydipsia: A Case Report.

Patients with hyponatremia are at risk of severe complications including seizures, coma, and death. Psychiatric patients are particularly susceptible to death from hyponatremia due to the association between psychiatric conditions and psychogenic polydipsia, characterized by water intoxication. We report a case of a schizophrenic patient who presented with altered mental status, leading to a differential diagnosis narrowed through clinical investigations to include hypovolemic hyponatremia, syndrome of inappropriate antidiuretic hormone secretion (SIADH), and psychogenic polydipsia. This case underscores the need to inquire about schizophrenic patients' water intake, advocating for a standardized approach. The timely diagnosis of disorders causing electrolyte abnormalities can prevent severe complications and aid in the management of psychiatric patients.

Moon Rock Cannabis-Induced Psychosis and New-Onset Seizures in a 20-Year-Old Male.

"Moon rock" cannabis is a type of new and highly potent preparation of cannabis, which is made of a strain of cannabis dipped in hash oil and sprinkled with kief crystals, effectively increasing the concentration of δ-9-tetrahydrocannabinol (THC), the main psychoactive compound in cannabis, well beyond what is naturally found in the cannabis plant. The use of increasingly potent forms of cannabis has far-reaching health implications, including psychiatric and neurologic effects, which are not yet fully understood. This case report summarizes existing knowledge of the association of cannabis use with psychosis and seizures and describes a novel case of "moon rock" cannabis-induced psychosis and new-onset seizures.

Insights Into the Association Between Myasthenia Gravis and Depression: A Clinical Case Study.

Myasthenia gravis (MG) is a serious and debilitating autoimmune disease characterized by muscle weakness, shortness of breath, and issues affecting the eyes, limbs, throat, and speech. Given the intense physical toll of the disease, it is unsurprising that higher rates of depression are observed among MG patients. We present a case involving a 30-year-old female patient who was admitted to the hospital for MG exacerbation and had a psychiatric consultation for worsening depression symptoms. The patient acknowledged symptoms of sad mood, crying spells, anhedonia, fatigue, insomnia, and inappropriate guilt. She admits to psychosocial stressors of her declining health, recent job loss, and low self-esteem due to weight gain. Past medical history includes a thymectomy and a total thyroidectomy that caused postsurgical-acquired hypothyroidism. She is currently on prednisone and pyridostigmine for her MG. The patient has many potential causes of her increased depressive symptoms, including her medications, psychosocial stressors, and her past medical history, in addition to her MG. However, the literature shows higher incidence rates of depression in MG patients compared to both healthy controls and controls with other comparable chronic conditions, as well as shows a positive association between increased depressive symptoms and MG severity. Thus, these findings prompt the consideration of possible physiological interplay between the two diseases and encourage further research into the association between MG and depression.

Prevalence and Predictors of Long-term Opioid Use After Pelvic Fractures.

BACKGROUND: Opioids are effective in short-term pain treatment; however, their long-term effectiveness is unconfirmed. Many patients are exposed to opioids after pelvic injuries with little known about persistent use afterward. We assessed the prevalence and predictors of long-term opioid use following pelvic fractures. MATERIALS AND METHODS: This retrospective study enrolled 277 patients with acute pelvic fractures over five years. Daily and total morphine milligram equivalents (MME) were calculated. The primary outcome was long-term opioid use (LOU) defined as ongoing opioid use 60-90 days post-discharge. The secondary outcome was intermediate-term opioid use (IOU) defined as ongoing opioid use 30-60 days post-discharge. Univariable and logistic regression analyses were performed. RESULTS: Median (interquartile range) total inpatient opioid MME was 422 (157-1667) with a median daily MME of 69 (26-145). Long-term opioid use occurred in 16%, and IOU occurred in 29%. Univariable analysis found that total and daily inpatient opioid use were each significantly associated with LOU (median MME, 1241 vs 371; median MMEs, 127.7 vs 59.2, respectively) and IOU (median MME, 1140 vs 326; median MMEs, 111.8 vs 57.9, respectively). Logistic regression analysis found daily inpatient MME ≥50 (odds ratio [OR] 3.027, 95% confidence interval [CI] 1.059-8.652]) and pelvic fracture type (Tile B/C) (OR 2.992 [CI 1.324-6.763])were independent predictors of LOU. CONCLUSION: Total and daily inpatient opioid use were significantly associated with LOU and IOU. Patients who received ≥50 MME/inpatient day had a higher likelihood of LOU. This study seeks to inform clinical decisions for pain management to prevent adverse outcomes.

Cannabis use and medication nonadherence in bipolar disorder: A nationwide inpatient sample database analysis.

BACKGROUND: Medication nonadherence among bipolar disorder (BD) is often linked with comorbid substance use disorders. This study aims to investigate cannabis use disorder (CUD) association with medication noncompliance in hospitalized BD patients. METHODS: Using data on 266,303 BD hospitalizations between 2010 and 2014 from the US Nationwide Inpatient Sample database, we obtained medication noncompliance rates stratified by demographics and CUD. Logistic regression was used to evaluate factors associated with medication noncompliance. RESULTS: Overall mean age, the prevalence of CUD, and medication nonadherence were 41.58 (± 0.11) years, 15.0% and 16.1%, respectively. There were 56.6% females in the overall population. There was a significant difference in the characteristics of those in the medication nonadherence vs adherence groups, including age, sex, race, comorbid substance use, income, insurance type, hospital region, and hospital teaching status (p < 0.001). After adjusting for other variables using multivariate analysis, there remained a statistically significant association of medication nonadherence in BD hospitalization and CUD (OR 1.42, 95% CI 1.36-1.48). LIMITATION: Confounding multiple substance use could not be accounted for, and the retrospective nature of the database which includes only inpatients is prone to possible selection and reporting bias. CONCLUSION: CUD statistically predicts increased rates of medication nonadherence among patients with BD. Given the possible association of CUD with medication nonadherence among BD patients, collaborative work between general adult psychiatry and addiction services is imperative in improving the management outcome of patients with BD and comorbid CUD.

Does Cocaine Use Increase Medication Noncompliance in Bipolar Disorders? A United States Nationwide Inpatient Cross-Sectional Study.

Introduction Medication noncompliance among bipolar disorder (BD) is often linked with comorbid substance use disorders. This study aims to investigate cocaine use (CU) association with medication noncompliance in hospitalized BD patients. Methods Using data on 266,303 BD hospitalizations between 2010-2014 from the US Nationwide Inpatient Sample database, we obtained medication noncompliance rates stratified by demographics and cocaine use. Logistic regression was used to evaluate factors associated with medication noncompliance. Results Overall mean age, the prevalence of CU, and medication noncompliance were 41.58 (+0.11) years, 8.34%, and 16.08%, respectively. More than half of BD patients with comorbid CU were between 40-64 years (54.4%), while more male patients with BD were in the CU group (53.9%). With univariable logistic regression, CU (odds ratio [OR]: 1.77, 95% CI: 1.66-1.88) increased the odds of medication noncompliance among BD patients, and after adjusting for other variables there was sustained increased odds (adjusted odds ratio [aOR]: 1.40, 95% CI: 1.32-1.50). Conclusion This study showed that CU is associated with medication noncompliance among hospitalized BD patients. This highlights the importance of addressing CU among BD patients. Given the possible association of CU with medication noncompliance among BD patients, collaborative work between general adult psychiatry and addiction services is imperative in improving the management outcome of BD patients with comorbid CU.

The Effectiveness of Electroconvulsive Therapy on Catatonia in a Case of Anti-N-Methyl-D-Aspartate (Anti-NMDA) Receptor Encephalitis.

Catatonia is a symptom seen in a variety of neuropsychiatric conditions, including anti-N-Methyl D-aspartate receptor (NMDAR) encephalitis. When associated with anti-NMDAR encephalitis, catatonia is resistant to standard therapy. However, electroconvulsive therapy (ECT) has shown promising success in management. This case report presents a 25-year-old African American female who presented to the emergency room with nervousness, sweating, insomnia, and visual and auditory hallucinations. She was treated symptomatically for anxiety but returned to the hospital after she continued to experience worsening symptoms. Her anxiety worsened, and she became more agitated, warranting an extensive workup, including magnetic resonance imaging (MRI) and electroencephalogram (EEG), which showed normal findings. She also had an anti-NMDA receptor antibodies titer done, which showed a positive titer result. She was treated with intravenous steroids, intravenous immunoglobulin G (IgG), plasma exchange, and rituximab, which did not improve her symptoms, and she was discharged home after a prolonged hospital stay. On follow-up visits, she reported worsening confusion, aggression, and suicidal behaviors. The patient was readmitted, during which she experienced catatonia and psychiatric symptoms, and her anti-NMDAR titer had increased to 1:1280. Further treatments with intravenous steroids, intravenous IgG, plasma exchange, and rituximab, including haloperidol and clonazepam, failed to improve her condition. However, her condition improved remarkably following treatment with 12 rounds of ECT. No randomized control trial has been done to demonstrate the effectiveness of ECT in the treatment of anti-NMDAR encephalitis despite various reports of the effectiveness of this treatment modality. This case report adds to the growing clinical evidence in support of the use of ECT in anti-NMDAR encephalitis patients with catatonia. ECT can be incorporated as standard protocol in the treatment of catatonia and associated psychiatric symptoms when managing a patient with anti-NMDAR encephalitis associated with catatonic features.

A Retrospective Review of the Clinical Significance of the Outcome Questionnaire (OQ) Measure in Patients at a Psychiatric Adult Partial Hospital Program.

Introduction Outcome Questionnaire (OQ) measure is becoming a more popular assessment tool for monitoring treatment progress in psychiatry at different settings including inpatient and outpatient settings. It can also be used in non-clinical populations. However, little is known about the evaluation of this tool in the Adult Partial Hospital Program (PHP). Methods We conducted a study among patients in an Adult PHP where we extracted data from the OQ analysis program recorded for patients from January 1, 2015 to July 31st, 2020. Results We studied a total of 742 patients among which 509 (68.4%) were males. The mean age was 38.58 ± 14.86 years. Most of the patients had depressive disorder (56.9%). The mean numbers of days on admission were 17.37 ± 25.29 days. There is a consistent decrease in the total score average OQ score from initial to final measure with the year 2019 being 31.99 followed by 2017 (30.05) then 2020 (29.56) then 2015/2016 (28.38) and 2018 (27.27) p < 0.001. Also, for treatment progress it was observed that in years 2015/2016, there was significant improvement in 71.67% of the patients; in 2017, there was significant improvement in 78.53% of the patients; in 2018, there was significant improvement in 77.71% of the patients; while in 2019, there was significant improvement in 76.05% of the patients, and in 2020, there was significant improvement in 70.18% of the patients. Conclusion The direct benefit of the OQ measure to patients is to provide objective measurements of assessing clinical improvement or deterioration in the treatment progress of their clinical condition. Our study has proved that this is a useful tool to assess such in the Adult PHP.

Neuroleptic Malignant Syndrome After Re-introduction of Atypical Antipsychotics in a COVID-19 Patient.

We present a case of neuroleptic malignant syndrome (NMS) in a 46-year-old white female from a state psychiatric hospital who also tested positive for coronavirus-2019 (COVID-19) (severe acute respiratory syndrome coronavirus, SARS-CoV-2) infection after re-introduction of her home antipsychotics medication. She presented with confusion and altered mental status likely secondary to delirium from COVID-19 infection. Clozapine and risperidone were initially held on admission and restarted after continuing agitation on day two. She began to have increased restlessness with rising creatinine kinase (CK) levels, peaking on day seven with sudden fever, hypertension, and tachycardia. The diagnosis of NMS was confirmed, antipsychotic medication was held, and appropriate treatment was administered. The mechanism explaining the occurrence of NMS in COVID-19 patients is still unclear, but COVID-19 infection may be a risk factor for this presentation. The mechanism of SARS-CoV-2 as a risk factor for NMS is still uncertain and needs to be investigated further. However, if their infection status is known, patients should be given neuroleptics with caution and carefully considered for the development of this rare condition.

Illness Anxiety Disorder: A Case Report and Brief Review of the Literature.

Illness anxiety disorder (IAD) is defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V) as the preoccupation with having or acquiring a serious illness, in the absence of somatic symptoms (or, if present, symptoms that are only mild in severity). Patients with IAD experience persistent anxiety or fear of having or acquiring a serious illness, which adversely affects their daily life. They remain unsatisfied with their physician's reassurances to the contrary, mainly because their distress is created by the anxiety of the meaning, significance, and cause of the complaints and not necessarily due to the physical presentations. IAD remains a huge burden on both the health facility and for the managing healthcare provider. In this report, we present the case of a patient with IAD, which has been managed for the past five years with recurrent visits to the physician with no resolution of signs and symptoms. Despite extensive medical workup over this period, which repeatedly showed normal test results, the patient continued to have anxiety over his ill health and complained of recurrent mild somatic symptoms. After his most recent appointment, he got very upset and booked a flight to his home country to have a second opinion to validate his illness. Physicians are encouraged to build a therapeutic alliance with patients with IAD, rather than ordering expensive or unnecessary diagnostic tests or treatment.

Seasonal Trends in Hospitalization of Attempted Suicide and Self-Inflicted Injury in United States Adults.

Introduction  Suicide is the 10th leading cause of death in the United States (US) and the prevalence continues to increase. It is estimated that there is an average of 25 attempted suicides for every suicide death in the US, and the economic burden of suicide and attempted suicide is high. Identification of those at risk for suicide and attempted suicide can help with early and prompt intervention. Studies in Europe and Asia have shown that there is a relationship between seasonal patterns and suicidal risk. However, little is known about seasonal patterns of suicidal attempts in the US. Therefore, our study aimed to assess seasonal patterns by days of the week and months of the year in the US. Methods Hospitalized adult patients with suicide attempts and self-inflicted injury were identified using the discharge data from the National Inpatient Sample (NIS) from January 1, 2010 to December 31, 2014. We looked at the seasonal trends of patients with attempted suicide and self-inflicted injury by weekday vs weekend and month of the year over the five-year study period. We also assessed two groups, male and female with attempted suicide and compared trends and contributing risk factors over the study period using Student's t-test and chi-square test. Results A total of 249,845 patients with attempted suicide and self-inflicted injury were reported during the study period with a prevalence rate increase of 15%, among which 70% were males, 65.5% white and 38.8% were age 40-64 years. An overall prevalence rate of about 168-200 per 100,000 hospitalizations was reported. There was a higher admission rate on weekends as compared to weekdays (190-300 vs 150-178 per 100,000 hospitalizations). Attempted suicide and self-inflicted injury admissions peaked during the months of July and August with a peak period range of 200-230 per 100,000 hospitalizations in a year. Conclusion The prevalence of attempted suicide is steadily rising. Awareness of the seasonal and epidemiological trends of attempted suicide and self-inflicted injury is a very important step towards developing effective strategies to prevent suicide and attempted suicide.