Self-enucleation of the right eye by a 38-year-old woman diagnosed with schizoaffective disorder: a case report.

BACKGROUND: Autoenucleation is a rare form of self-mutilation typically associated with psychiatric disorders such as schizophrenia, substance-induced psychosis and bipolar disorder. The act is usually unilateral, although bilateral attempts are also well documented in the literature. CASE PRESENTATION: It is a case study involving a female patient (NN) diagnosed with schizoaffective disorder who self-enucleated her right eye following sexual intercourse with a fellow patient, and was forcefully prevented by staff from enucleating the second eye. We report recurrent episodes of her illness culminating in this severe act of self-mutilation. The motivational reasons behind this form of self-harm along with differential diagnosis and potential treatment options are discussed in the context of the available literature. CONCLUSION: Autoenucleation is commonly associated with religious and sexual delusions, and patients are thought to be at a greater risk of further self-harm. Timely antipsychotic treatment is likely to reduce the risk of such extreme forms of self-harm, although they can occur despite robust therapeutic intervention and treatment attempts. While self-inflicted eye injuries are rare, their prevention in what is typically a difficult patient group is fraught with challenges.

The German Multicentre Study on Multiple Chemical Sensitivity (MCS).

In this multicentre study on multiple chemical sensitivity (MCS) 291 consecutive environmental medicine (EM) outpatients were examined in several environmental medicine outpatient centres/units throughout Germany in 2000/2003. Of the EM outpatients, 89 were male (30.6%) and 202 were female (69.4%), aged 22-80 (mean 48 years, S.D.=12 years). The sample was representative for university-based environmental outpatient departments and represented a cross-sectional study design with an integrated clinical-based case-control comparison (MCS vs. non-MCS). Three classifications of MCS were used: self-reported MCS (sMCS), clinically diagnosed MCS (cMCS), and formalised computer-assisted MCS with two variants (f1MCS, f2MCS). Data were collected by means of an environmental medicine questionnaire, psychosocial questionnaires, the German version of the Composite International Diagnostic Interview (CIDI), and a medical baseline documentation, as well as special examinations in partial projects on olfaction and genetic susceptibility markers. The hypothesis guided evaluation of the project showed that the patients' heterogenic health complaints did not indicate a characteristic set of symptoms for MCS. No systematic connection could be observed between complaints and the triggers implicated, nor was there any evidence for a genetic predisposition, or obvious disturbances of the olfactory system. The standardised psychiatric diagnostics applying CIDI demonstrated that the EM patients in general and the subgroup with MCS in particular suffered more often from mental disorders compared to an age and gender matched sample of the general population and that in most patients these disorders commenced many years before environment-related health complaints. Our results do not support the assumption of a toxicogenic-somatic basis of the MCS phenomenon. In contrast, numerous indicators for the relevance of behavioural accentuations, psychic alterations or psychosomatic impairments were found in the group of EM-outpatients with subjective "environmental illness".

Palinacousis leading to the diagnosis of temporal lobe seizures in a patient with schizophrenia.

Palinacousis is a rarely reported symptom of temporal lobe dysfunction. Especially in psychiatric patients it may be misdiagnosed if it is not differentiated from the auditory hallucinations of psychotic illness. We report the case of a 20-year-old patient with the previously established diagnosis of paranoid schizophrenia who presented with the symptom of palinacousis. She was not psychotic at that time, her only complaints being recurrent auditory sensations. Repeated EEG recordings showed a left temporal theta focus with spikes. The diagnosis of temporal lobe seizures was made. Treatment with carbamazepine led to complete recovery.

Working memory deficiencies in adults associated with low-level lead exposure: implications of neuropsychological test results.

BACKGROUND: Although lead exposure has steadily decreased in the last few years, some lead is still used in the metal processing industry, mostly for wall paints and plumbing. Recent studies on children showed neurobehavioral effects of low-level exposure, but little is known about the neurocognitive effects of lead concentrations in the upper reference range on adults. METHODS: The neuropsychological effects of lead exposure were examined in 39 adult outpatients at the Unit of Environmental Medicine (UEM), University Hospital, Aachen, Germany. All patients underwent a comprehensive medical examination, including psychiatric. Venous blood and urine samples were collected and tested for heavy metals and selenium. Since the neuropsychological examination was not expected to reveal any severe abnormalities, only specific attentiveness functions were analyzed (alertness, working memory, flexibility, intermodal comparison) since these areas were the likeliest to show objectifiable effects. The tests were conducted using a standardized computerized battery. RESULTS: Lead blood levels ranged from 1 to 65.6 microg/l (mean 27.4 +/- 16.2 microg/l). Although the neuropsychological test results of all patients were within the normal range, there were significant correlations between blood lead levels and the speed of information processing for working memory. CONCLUSIONS: The results indicate working memory dysfunctions in adults, the severity of which correlates directly with blood lead levels, supporting the hypothesis that increased blood lead levels can also be associated with measurable neurocognitive abnormalities.

Environmental factors as delusional contents in patients with schizophrenia.

In a series of 50 consecutive cases in the outpatients' unit of Environmental Medicine (UEM) at the University Hospital of Aachen, Germany, five patients with the diagnosis of schizophrenia presented delusions of being poisoned by environmental factors. This case report illustrates the clinical features of the paranoid type of schizophrenic psychoses. Schizophrenia represents an important differential diagnosis in the interdisciplinary diagnosis and management of health problems attributed to environmental factors.

From psychosurgery to neuromodulation: deep brain stimulation for intractable Tourette syndrome.

Tourette syndrome is a neuropsychiatric disorder characterized by motor and vocal tics. It is often associated with depression, obsessive-compulsive symptoms, self-injurious behaviour and attention deficit-hyperactivity disorder (ADHD). In intractable patients, neuromodulation using deep brain stimulation (DBS) has widely replaced psychosurgery. Three different key structures are defined for DBS, the medial portion of the thalamus, the globus pallidus internus and the anterior limb of the internal capsule/nucleus accumbens. This is a comprehensive overview on the effect of DBS on motor and non-motor symptoms using different case series and two larger studies.

[Psychiatric disorders of environmental outpatients--results of the standardized psychiatric interview (CIDI) from the German multi-center study on Multiple Chemical Sensitivity (MCS)]. / Psychische Störungen bei Umweltambulanzpatienten--Ergebnisse der standardisierten psychiatrischen Diagnostik (CIDI) aus der deutschen Multizenterstudie zur Multiplen Chemikaliensensitivität (MCS).

BACKGROUND: A nationwide, environmental outpatient-based multi-center two-phase study on Multiple Chemical Sensitivity (MCS) was conducted from 1999 until 2004. The aim of the study was to characterize more precisely the health-complaints relevant for the MCS-phenomenon. A standardized psychiatric interview (CIDI), used to identify frequency, character and duration of psychiatric disorders and their chronological relation to the environment-related health complaints of the patients, formed part of the extensive diagnostic procedure. METHOD: 251 (86.3%) of the 291 attendees of the environmental outpatient departments in Aachen, Berlin, Bredstedt, Freiburg, Giessen and Munich, were examined using the German version (M-CIDI/DIA-X) of the Composite International Diagnostic Interview. RESULTS: 83.7% (lifetime prevalence rate) fulfilled the diagnostic criteria of at least one psychiatric disorder, with the 12-month and 4-week prevalence rates being 76.5% and 64.5%, respectively. Environmental outpatients, in all prevalence periods, had significantly higher rates of psychiatric disorders than the comparable general population. Somatoform disorders were most frequently diagnosed, followed by depressive and phobic disorders. For 81.2% of the patients the psychiatric disorder started long before the environment-related health complaints (average 17 years). CONCLUSIONS: This study confirms the results of earlier studies, i.e. that patients with environment-related health complaints suffer from psychiatric disorders more frequently than the general population. The high environmental outpatients really suffer from psychosomatic complaints, but attribute the causes to the environment. Application of specific therapeutic regimen is recommended for those patients, whose psychiatric disorders are safeguarded diagnostically and for whom a relevant exposure is unlikely.