A general clinical overview of the non-motor symptoms in Parkinson's disease: Neuropsychiatric symptoms.

The heterogeneity of non-motor features observed in people with Parkinson's disease (PD) is often dominated by one or more symptoms belonging to the neuropsychiatric spectrum, such as cognitive impairment, psychosis, depression, anxiety, and apathy. Due to their high prevalence in people with PD (PwP) and their occurrence in every stage of the disease, from the prodromal to the advanced stage, it is not surprising that PD can be conceptualised as a complex neuropsychiatric disorder. Despite progress in understanding the pathophysiological mechanisms underlying the neuropsychiatric signs and symptoms in PD, and better identification and diagnosis of these symptoms, effective treatments are still a major unmet need. The impact of these symptoms on the quality of life of PwP and caregivers, as well as their contribution to the overall non-motor symptom burden can be greater than that of motor symptoms and require a personalised, holistic approach. In this chapter, we provide a general clinical overview of the major neuropsychiatric symptoms of PD.

Deliberate self-harm in a patient with hyperthyroidism with acute psychosis.

A woman in her 30s with underlying Graves' disease, who recently completed radioactive iodine treatment, presented with 2 weeks of acutely altered behaviour associated with auditory hallucinations and religious preoccupations. Laboratory investigation demonstrated elevated free thyroxine levels and suppressed thyroid-stimulating hormone levels. Additionally, there was a presence of antithyroid peroxidase antibodies consistent with autoimmune thyroid disease. She responded to antipsychotics and achieved biochemical euthyroidism. Subsequently, antipsychotic was tapered off during outpatient follow-up at the patient's own request, with supplement thyroxine continuing. After 1 week, acute hallucinations and religious preoccupations re-emerged, driving her to inflict self-injuries by swallowing coins and nails and banging her head against the wall, sustaining laceration wounds. Furthermore, she hammered a roofing nail into the external genitalia, embedded in the symphysis pubis. After supplemental thyroxine was stopped and olanzapine was started, she achieved biochemical euthyroid followed by remission of psychosis within 1 week. This case illustrates the importance of elucidating organic causes of psychosis as they are easily and swiftly reversible.

Are we facing a crashing wave of neuropsychiatric sequelae of COVID-19? Neuropsychiatric symptoms and potential immunologic mechanisms.

The coronavirus disease 19 (COVID-19) pandemic is a significant psychological stressor in addition to its tremendous impact on every facet of individuals' lives and organizations in virtually all social and economic sectors worldwide. Fear of illness and uncertainty about the future precipitate anxiety- and stress-related disorders, and several groups have rightfully called for the creation and dissemination of robust mental health screening and treatment programs for the general public and front-line healthcare workers. However, in addition to pandemic-associated psychological distress, the direct effects of the virus itself (several acute respiratory syndrome coronavirus; SARS-CoV-2), and the subsequent host immunologic response, on the human central nervous system (CNS) and related outcomes are unknown. We discuss currently available evidence of COVID-19 related neuropsychiatric sequelae while drawing parallels to past viral pandemic-related outcomes. Past pandemics have demonstrated that diverse types of neuropsychiatric symptoms, such as encephalopathy, mood changes, psychosis, neuromuscular dysfunction, or demyelinating processes, may accompany acute viral infection, or may follow infection by weeks, months, or longer in recovered patients. The potential mechanisms are also discussed, including viral and immunological underpinnings. Therefore, prospective neuropsychiatric monitoring of individuals exposed to SARS-CoV-2 at various points in the life course, as well as their neuroimmune status, are needed to fully understand the long-term impact of COVID-19, and to establish a framework for integrating psychoneuroimmunology into epidemiologic studies of pandemics.

Diet and Psychosis: A Scoping Review.

INTRODUCTION: Schizophrenia spectrum disorders (SSD) represent a cluster of severe mental illnesses. Diet has been identified as a modifiable risk factor and opportunity for intervention in many physical illnesses and more recently in mental illnesses such as unipolar depression; however, no dietary guidelines exist for patients with SSD. OBJECTIVE: This review sought to systematically scope the existing literature in order to identify nutritional interventions for the prevention or treatment of mental health symptoms in SSD as well as gaps and opportunities for further research. METHODS: This review followed established methodological approaches for scoping reviews including an extensive a priori search strategy and duplicate screening. Because of the large volume of results, an online program (Abstrackr) was used for screening and tagging. Data were extracted based on the dietary constituents and analyzed. RESULTS: Of 55,330 results identified by the search, 822 studies met the criteria for inclusion. Observational evidence shows a connection between the presence of psychotic disorders and poorer quality dietary patterns, higher intake of refined carbohydrates and total fat, and lower intake or levels of fibre, ω-3 and ω-6 fatty acids, vegetables, fruit, and certain vitamins and minerals (vitamin B12 and B6, folate, vitamin C, zinc, and selenium). Evidence illustrates a role of food allergy and sensitivity as well as microbiome composition and specific phytonutrients (such as L-theanine, sulforaphane, and resveratrol). Experimental studies have demonstrated benefit using healthy diet patterns and specific vitamins and minerals (vitamin B12 and B6, folate, and zinc) and amino acids (serine, lysine, glycine, and tryptophan). DISCUSSION: Overall, these findings were consistent with many other bodies of knowledge about healthy dietary patterns. Many limitations exist related to the design of the individual studies and the ability to extrapolate the results of studies using dietary supplements to dietary interventions (food). Dietary recommendations are presented as well as recommendations for further research including more prospective observational studies and intervention studies that modify diet constituents or entire dietary patterns with statistical power to detect mental health outcomes.

Changing the treatment paradigm for Parkinson's disease psychosis with pimavanserin.

Introduction: Parkinson's disease psychosis (PDP) may affect up to 60% of patients with Parkinson's disease over the course of their disease, and is associated with poor prognosis, including increased risks of mortality and nursing home placement. PDP treatments have been limited to off-label use of atypical antipsychotics, most of which pose risks of worsened motor symptoms and other potential adverse events (AEs) due to their dopamine receptor blockade and additional off-target receptor affinities. Pimavanserin is a highly selective 5-HT2A inverse agonist and poses no known risks for worsening of parkinsonism or other off-target receptor AEs. Pimavanserin is the first and only medication approved for PDP treatment. Areas covered: This review covers estimated prevalence, clinical characteristics, diagnostic criteria, and risk factors for PDP; the hypothetical progression of PDP; management of PDP including use of antipsychotics; pharmacology and clinical trial data on pimavanserin; and expert opinion on PDP treatment. The NLM/PubMed database was searched for papers using the search terms of "PDP" AND "treatment" AND "pimavanserin" for the last 10 years. Expert opinion: The recent insights into PDP pathophysiology and approval of the only medication specifically to treat PDP are key advances that should improve the recognition, diagnosis, and management of PDP.

ACTH-producing thymic neuroendocrine tumor initially presenting as psychosis: A case report and literature review.

A 32-year-old woman was referred to our hospital because of severe psychosis and was found to have an ectopic ACTH-producing thymic neuroendocrine tumor. Laboratory data revealed an elevated serum cortisol and plasma ACTH level, hypokalemia, and metabolic alkalosis. Chest computed tomography (CT) revealed an anterior mediastinal mass and multiple pulmonary nodules. As the patient was unable to communicate because of her consciousness disturbance, she was managed with artificial ventilation and deep sedation. Metyrapone and potassium supplementation were administered, and steroid psychosis gradually improved. Thoracic surgery was performed and the histopathological diagnosis was thymic neuroendocrine tumor with positive anti-ACTH immunohistochemical staining. Here we present details of the case and review the literature.

Integration and Extension of Specialty Mental Healthcare Services to Community Practice in Parkinson Disease.

Parkinson disease (PD) is a progressive neurodegenerative disease with a higher prevalence of neuropsychiatric symptoms compared with the general population. Symptoms such as anxiety, depression, psychosis, impulse control disorders, and cognitive impairment cause a greater worsening of quality of life than even the motor symptoms that define PD. Despite the ubiquity and impact of neuropsychiatric symptoms, specialty mental healthcare is not routinely available, accessible, or integrated in most neurology practices. Currently, training in PD-specific mental healthcare is not standard in most programs, and the need for subspecialty-trained, mental healthcare providers will only increase over time, as the prevalence of PD will more than double by 2060. Many barriers limit extension of mental healthcare into existing models of integrated or multidisciplinary care and the community at large. Foundations and professional societies have played an important role in raising awareness of mental healthcare needs in PD; however, their initiatives to promote integrated or multidisciplinary care have traditionally focused on disciplines outside of mental health such as physical, occupational, and speech therapy. This article examines these issues and suggests strategies to better address mental healthcare needs for PD patients in the future.

One month of nitrous oxide abuse causing acute vitamin B 12 deficiency with severe neuropsychiatric symptoms.

A 21-year-old university student studying abroad in the USA presented to the emergency department with double vision, lower extremity weakness with difficulty ambulating and other neuropsychiatric symptoms. MRI of the brain and spinal cord were normal. Vitamin B12 was 78 pg/mL (58 pmol/L, reference 211-911 pg/mL). The patient had been using nitrous oxide capsules used for whipped cream recharging, which she obtained from other students, a few times daily for a month for the purpose of anxiety relief. The patient was not a vegan or vegetarian. The patient was treated with intramuscular vitamin B12 repletion with partial resolution of neurologic symptoms and discharged on vitamin B12 supplementation.

Pesticides as the drivers of neuropsychotic diseases, cancers, and teratogenicity among agro-workers as well as general public.

The need to maximize agricultural productivity has made pesticides an indispensable part of current times. Farmers are unaware of the lurking consequences of the pesticide exposure, which endanger their health. It also puts the unsuspecting consumers in peril. The pesticides (from organophosphates, organochlorine, and carbamate class) disrupt the immune and hormonal signaling, causing recurrent inflammation, which leads to a wide array pathologies, including teratogenicity. Numerous farmers have fallen victim to neural disorders-driven suicides and lungs, prostate/breast cancer-caused untimely deaths. Green revolution which significantly escalated agricultural productivity is backfiring now. It is high time that environmental and agricultural authorities act to restrain the excessive usage of the detrimental chemicals and educate farmers regarding the crisis. This review discusses the biological mechanisms of pesticide-driven pathogenesis (such as the activation or inhibition of caspase, serine protease, acetylcholinesterase) and presents the pesticide-exposure-caused health deterioration in USA, India, and Africa. This holistic and critical review should be an eye-opener for general public, and a guide for researchers.

Management of behavioral and psychological symptoms in people with Alzheimer's disease: an international Delphi consensus.

ABSTRACTObjectives:Behavioral and psychological symptoms of dementia (BPSD) are nearly universal in dementia, a condition occurring in more than 40 million people worldwide. BPSD present a considerable treatment challenge for prescribers and healthcare professionals. Our purpose was to prioritize existing and emerging treatments for BPSD in Alzheimer's disease (AD) overall, as well as specifically for agitation and psychosis. DESIGN: International Delphi consensus process. Two rounds of feedback were conducted, followed by an in-person meeting to ratify the outcome of the electronic process. SETTINGS: 2015 International Psychogeriatric Association meeting. PARTICIPANTS: Expert panel comprised of 11 international members with clinical and research expertise in BPSD management. RESULTS: Consensus outcomes showed a clear preference for an escalating approach to the management of BPSD in AD commencing with the identification of underlying causes. For BPSD overall and for agitation, caregiver training, environmental adaptations, person-centered care, and tailored activities were identified as first-line approaches prior to any pharmacologic approaches. If pharmacologic strategies were needed, citalopram and analgesia were prioritized ahead of antipsychotics. In contrast, for psychosis, pharmacologic options, and in particular, risperidone, were prioritized following the assessment of underlying causes. Two tailored non-drug approaches (DICE and music therapy) were agreed upon as the most promising non-pharmacologic treatment approaches for BPSD overall and agitation, with dextromethorphan/quinidine as a promising potential pharmacologic candidate for agitation. Regarding future treatments for psychosis, the greatest priority was placed on pimavanserin. CONCLUSIONS: This international consensus panel provided clear suggestions for potential refinement of current treatment criteria and prioritization of emerging therapies.

Possible Garcinia cambogia-Induced Mania With Psychosis: A Case Report.

Garcinia cambogia is a Southeast Asian fruit becoming increasingly popular as a weight management supplement. Hydroxycitric acid (HCA) is the primary active ingredient which demonstrates serotonergic- and muscarinic-enhancing properties via inhibition of selective serotonin reuptake and acetylcholinesterase. We report a young adult female with no history of bipolar disorder who developed mania and psychosis approximately 1 week following initiation of G cambogia and the Cleanse and Detox™ dietary supplement manufactured by Apex Vitality Health. She presented with a predominantly expansive mood, psychomotor agitation, disorganized and pressured speech, flight of ideas, grandiosity, delusions, and auditory hallucinations. Following discontinuation of G cambogia and the initiation of lithium and quetiapine, the patient experienced rapid and progressive mood stabilization and was discharged after 8 days. Seven previous case reports associating (hypo)mania and/or psychosis with G cambogia consumption have been published. The chronology of mania and/or psychosis onset may appear between 1 and 8 weeks following initiation of G cambogia. Psychiatric symptoms have resolved with G cambogia discontinuation in some instances and may not require chronic pharmacotherapy. Our report should encourage further research and case reports regarding this adverse event and the reconciliation of complete herbal supplement use at clinic visits and hospital admissions.

Sauna Bathing and Risk of Psychotic Disorders: A Prospective Cohort Study.

OBJECTIVE: Sauna bathing has been suggested to promote mental well-being and relaxation, but the evidence is uncertain with respect to mental disorders. We aimed to assess the association of frequency of sauna bathing with risk of psychosis in the Kuopio Ischemic Heart Disease prospective population-based study. SUBJECTS AND METHODS: Baseline sauna bathing habits were assessed in 2,138 men aged 42-61 years who had no history of psychotic disorders. Participants were classified into three groups based on the frequency of sauna bathing (once, 2-3, and 4-7 times per week). RESULTS: During a median follow-up of 24.9 years, 203 psychotic disorders were recorded. A total of 537, 1,417, and 184 participants reported having a sauna bath once a week, 2-3 times, and 4-7 times per week, respectively. In Cox regression analysis adjusted for age, compared to men who had 1 sauna session per week, the hazard ratio (95% confidence intervals) of psychosis for 4-7 sauna sessions per week was 0.23 (0.09-0.58). In a multivariable model adjusted for several risk factors and other potential confounders, the corresponding hazard ratio was 0.21 (0.08-0.52). The association was similar after further adjustment for total energy intake, socioeconomic status, physical activity, and C-reactive protein (0.22 [0.09-0.54]) and was unchanged on additional adjustment for duration of a sauna session and temperature of the sauna bath (0.23 [0.09-0.57]). CONCLUSION: Our study suggests a strong inverse and independent association between frequent sauna bathing and the future risk of psychotic disorders in a general male population.

Marijuana and Psychosis: Policy Implications for Treatment Providers.

In 2017, the annual prevalence of marijuana use rose to 24% among 8th to 12th graders, despite decreases in rates of other illicit substance use.1 This is of concern, as increasing use is coupled with declining perception of harm among adolescents,1 increasing potency of cannabis,2 ease of adolescents' access to marijuana,1 and progressive medicalization and legalization of marijuana. Exposure to high levels of Δ-9-tetrahydrocannabinol through cannabis use triggers repeated activation of the endogenous mesolimbic dopaminergic system, desensitization, and progressive enhancement of acquired susceptibility to psychosis.3.