Psychotropic Management in Cotard Syndrome: Case Reports Supporting Dual Medication Management.

Cotard syndrome is a rare presentation where patients present with nihilistic thoughts of dying or already being dead. These delusions manifest from either a medical or psychiatric etiology and can be difficult to treat. Recently Couto and Gonçalves purposed that treatment should include an atypical antipsychotic alone or in combination with either a mood stabilizer or antidepressant. Here the authors advocate for a more specific but well-known psychotropic regimen, namely the combination of olanzapine and fluoxetine. We conducted a literature review and of 246 papers identified, only three reported using a combination of fluoxetine and olanzapine with many of them having limited or confounding information that make it difficult for us to comment on the historically efficacy of this medication combination. Therefore, the authors provide two case examples of patients being treated successfully with olanzapine and fluoxetine. One, a 66-year-old male veteran and another 76-year-old male veteran. Both of these cases hold significance as the patient's psychotic depression was so severe as to warrant ECT as a possible treatment. In both cases, this medication combination was able to avoid the procedure. Overall, with the addition of our cases and the sparse information available in the literature, we propose the combination of fluoxetine and olanzapine as an effective Cotard syndrome treatment.

Nortriptyline-Induced Room Tilt Illusion.

Room tilt illusion (RTI) is a rare and transient perceptual disturbance in which an individual perceives their surroundings as having been rotated or tilted, usually at 90 or 180 degrees. Primarily linked with vestibular disorders and neurological lesions, this report details the only reported occurrence of the RTI phenomena in nortriptyline use for treatment-refractory depression. The patient developed RTI six days after starting the medication and the disturbance resolved after medication cessation. Although the mechanism behind such a phenomenon with medication use has not been elucidated, its etiology may rest on the effect of tricyclic antidepressants on the vestibulo-thalamo-cortical system and visual-vestibular integration. Clinicians should be aware of the potential for such a medication-induced perceptual disturbance, especially in the workup for more serious etiologies in elderly patients with co-morbidities.

A Case of Neuroleptic Malignant Syndrome in the Context of Lithium Toxicity and Aripiprazole Use.

OBJECTIVE: Neuroleptic malignant syndrome (NMS) is a rare life-threatening condition that providers should be cognizant of when prescribing dopamine-receptor antagonists. Atypical antipsychotic agents were initially considered to have a lower risk of inducing the development of NMS compared with conventional antipsychotic. Considerable evidence, however, has suggested that atypical antipsychotics are associated with NMS, including the partial dopamine agonist, aripiprazole. There is growing evidence that other psychotropics, including lithium, cause this condition. Here, the authors present a case of a patient who developed NMS from lithium and aripiprazole and provide a literature review of reported NMS cases with either psychotropic. METHOD AND RESULTS: The authors report the case of 60-year-old male patient who developed NMS over a hospital course during which both aripiprazole and lithium were prescribed. In addition, a literature review was performed and a summary of cases of NMS induced by either lithium and/or aripiprazole is provided. CONCLUSIONS: This case adds to the growing body of literature of aripiprazole and lithium-induced NMS. Only 2 other cases are reported where concomitant aripiprazole and lithium use lead to NMS. Interestingly, our patient did develop lithium toxicity during hospitalization, but the NMS diagnosis occurred after lithium toxicity resolved. This varies from the other 2 cases where NMS developed despite lithium levels always being therapeutic. Unfortunately, there are more questions than answers surrounding this rare complication involving these 2 psychotropics and clinical vigilance is warranted when using these psychotropics especially in cases where aripiprazole and lithium are used in combination.

Pimavanserin Use in Lewy Body Dementia: A Case Report Demonstrating the Medication's Efficacy.

Pimavanserin is an antipsychotic that is approved for use in Parkinson's disease psychosis. Working as a serotonin 2A inverse agonist, pimavanserin allows patients to improve their psychotic symptoms without worsening the motor symptoms of Parkinson's. This mechanism is mediated via serotonin receptors and may allow for pimavanserin to be considered for use in other disease processes that present with psychosis. Here, the authors describe the case of a 75-year-old man with Lewy Body Dementia (LBD) who was started on pimavanserin. The response of the patient to the medication was measured over a six-week time course using the Scales for the Assessment of Positive Symptoms of Schizophrenia (SAPS). Overall, pimavanserin was shown to be effective in this patient with LBD. The authors also provide a review of the sparse literature attesting to other off-label uses for this unique antipsychotic.

Clozapine and COVID-19: A Case Report and Clinical Considerations.

BACKGROUND: The emergence of coronavirus SARS-CoV-2, and the subsequent global epidemic of COVID-19, brought with it innumerable new clinical experiences across all medical specialties, and psychiatry is no exception. Individuals with serious mental illness, in particular schizophrenia and related disorders, may be especially susceptible to coronavirus infection given the overlapping risk factors of vulnerable sociodemographic status, increased challenges with quarantining requirements, and limited compliance with "respiratory etiquette." The case presented here describes a patient with schizophrenia who was being managed on clozapine and who developed symptomatic COVID-19 infection. Special care was taken to ensure that potential interactions between clozapine and the associated COVID-19 treatments were safe for the patient's mental and physical wellbeing. CASE PRESENTATION: A 71-year-old schizophrenic Caucasian male is being managed with clozapine. While hospitalized, the patient was screened positive for COVID-19 and was admitted to the ICU due to his declining respiratory status. He was treated with both remdesivir and prednisone. He was able to fully recover from his COVID-19 infection. CONCLUSION: The authors review the clinical characteristics of the case, highlighting both the overlapping synergistic effects and antagonistic influences of clozapine therapy in combination with COVID-19 and its associated treatments. A review of the literature offers an opportunity to examine various frameworks for individualized clinical decision-making while making the case for greater epidemiologic research into the optimal management of individuals with a psychotic disorder who are diagnosed with COVID-19 infection.

Couvade syndrome: more than a toothache.

BACKGROUND: Couvade Syndrome is best characterized as a somatic symptom disorder where the partner experiences somatic symptoms during their partner's pregnancy most often during the first and third trimesters. Several psychoanalytical theories have been proposed for this disorder. There are well studied mood changes that correspond to hormonal shifts that occur in response to anticipated parenthood which serve as a physiologic mechanism for this pathology. CASE: The following is a case of Couvade syndrome in the setting of a high risk pregnancy complicated by pre-eclampsia with severe features necessitating a preterm delivery. CONCLUSION: Expectant fathers should be screened for symptoms of Couvade Syndrome throughout the pregnancy in order to better support the familial unit.

Psychotic pregnancy denial: a review of the literature and its clinical considerations.

BACKGROUND: Pregnancy denial can be broken into two major types, non-psychotic and psychotic deniers, and further classified into pervasive, affective and persistent sub-types. It can lead to increased morbidity and mortality of the mother and neonate. Psychotic pregnancy denial is rare and the medical literature existing on the subject is limited to a small number of case reports and case series. No formal recommendation exists on the clinical management of psychotic pregnancy denial in the antenatal or postpartum period. The authors provide a comprehensive review of the literature regarding psychotic pregnancy denial, present an example of an unpublished case and provide suggestions for clinical management. CASE: A 33-year-old primigravida at 37 6/7 weeks gestation presented with new-onset psychotic pregnancy denial with no prior history of psychosis. She had a negative medical work-up for organic causes of psychosis. Using a multidisciplinary approach, the decision was made to deliver the fetus at 38 1/7 weeks via cesarean section due to concerns for patient and fetal safety. Following delivery, she was admitted to an inpatient psychiatric facility and underwent 16 bilateral electroconvulsive therapy (ECT) treatments to which she showed complete response. CONCLUSION: Psychotic pregnancy denial is rare and potentially dangerous. Delivery prior to 39 weeks gestation is reasonable for worsening psychiatric disease but careful consideration of the risk-benefit analysis and ethical framework must be deliberated.Teaching points: In cases of worsening psychiatric disease in pregnancy, a multidisciplinary approach is necessary for comprehensive care. Psychotic denial of pregnancy leads to increased maternal and neonatal morbidity and mortality. Delivery prior to 39 weeks gestational age is reasonable to expedite psychiatric treatment.PrecisUsing a multidisciplinary approach, the decision to deliver before 39 weeks gestation is reasonable for worsening psychiatric disease.

Delirium Secondary to Lamotrigine Toxicity.

BACKGROUND: Lamotrigine is a phenyltriazine medication that has been approved by the United States Food and Drug Administration as monotherapy and as an adjunctive agent for the treatment of seizure disorder. It was later approved by the FDA for the treatment of bipolar disorder. Lamotrigine is generally well tolerated by patients, but some serious symptoms can occur during treatment. These severe side effects include rashes and multi-organ failure. Lamotrigine has also been associated with the development of mental status changes, frequently when used concurrently with other medications that may impact the metabolism of lamotrigine. OBJECTIVE: To present the case of a 65-year-old man being treated with lamotrigine and valproic acid who developed mental status changes after the addition of sertraline to his medication regimen, and to compare this case to existing cases reported in the literature. DISCUSSION: Our case adds to the existing literature by demonstrating that patients may experience adverse medication effects despite lamotrigine levels that are normally considered to be in the therapeutic range, highlighting the importance of clinical correlation when obtaining medication levels. CONCLUSION: Clinicians should use caution interpreting lamotrigine levels when working up delirium, as normal levels may not rule out the development of lamotrigine toxicity.