Transient Fever Response After ECT in a Patient with Catatonic Schizophrenia: A Case Report. / Katatonik Sizofreni Hastasinda EKT Sonrasi Ortaya Çikan Geçici Ates Yaniti: Olgu Sunumu.

Electroconvulsive therapy (ECT) is an effective and safe treatment method for many psychiatric disorders. In general medical practice, ECT may cause side effects as most other treatment methods do. Headache, myalgia, nausea, vomiting, confusion, anterograde amnesia are common side effects of electroconvulsive therapy. Fever; in addition to general medical conditions such as infection, malignancy, connective tissue diseases, drug treatments, malignant hyperthermia, convulsions, it can also occur due to conditions such as neuroleptic malignant syndrome (NMS), serotonin syndrome, catatonia, malignant catatonia, which are frequently encountered in psychiatry clinics. In the literature, transient fever response due to electroconvulsive therapy application have been described, albeit rarely. Although there are many proposed mechanisms for the emergence of a fever response, regardless of its cause, it is still not understood why some fever responses occur. In this article, we present the differential diagnosis of the fever response, possible causes, and the mechanisms that may reveal the secondary fever response to electroconvulsive therapy in a case with a diagnosis of catatonic schizophrenia, who developed a fever response during electroconvulsive therapy sessions and no fever response was observed at times other than electroconvulsive therapy sessions. In this case, postictal benign fever response associated with electroconvulsive therapy was considered after excluding other medical conditions that may cause a fever response after electroconvulsive therapy. Keywords: ECT, Fever, Catatonia, NMS.

c.4168G>A(p.Ala 1390Thr) Variation in KMT2D Gene Detected in an Ultra-treatment-resistant Schizophrenia Patient: A Case Report and Literature Review.

Schizophrenia has a multifactorial etiology with a significant genetic component. Genome-wide association studies have identified common variants in candidate genes. However, the common variant can only account for a portion of the genetic variation underlying the disorder. Therefore, researchers suggest that rare variants may be one source of missing heritability in schizophrenia. We report the case of a 20-year-old male patient diagnosed with early-onset and ultra-treatment-resistant schizophrenia and mild intellectual disability and discuss certain rare genetic variants that may be involved in the etiology. He was hospitalized for the initiation of clozapine treatment and was referred to the department of genetics because he had macrocephaly, high arched palate, a prominent forehead, hearing impairment, and hyperpigmented skin lesions. The whole exome sequencing analysis revealed a heterozygous 4168G>A(p.Ala1390Thr) variant in exon 15 of KMT2D (Lysine N-Methyltransferase 2D) (NM_003482.4) gene, which is associated with Kabuki Syndrome. The variants in KMT2D have been reported to be associated with brain development and may play a role in schizophrenia. We discussed the relationship between schizophrenia and genetic variants detected in this case in light of the literature.

[The Relationship Between Lifetime Hypomanic Symptoms and Activation Syndrome in Major Depressive Disorder]. / Major Depresyon Hastalarinda Yasam Boyu Hipomanik Belirtiler ve Aktivasyon Sendromu Iliskisi.

OBJECTIVE: Activation syndrome (AS), as described by the U.S. Food and Drug Administration (FDA), comprises 10 bipolar associated symptoms which starts after antidepressant therapy. The aim of this study is to investigate whether there is a relationship between lifetime hypomanic symptoms and the development of AS in patients diagnosed with major depressive disorder (MDD).  METHOD: The study was conducted at Hacettepe University Faculty of Medicine Department of Psychiatry. A total of 60 consecutive outpatients diagnosed with MDD were assessed at three time points; before the initiation of antidepressant therapy (baseline), at 2nd week and at 4th week. At the initial interview the patients completed the Hypomania Checklist-32 (HCL-32) in order to assess the lifetime history of hypomanic symptoms. Barnes Akathisia Rating Scale (BARS), Hamilton Rating Scale for Depression (HAM-D), Hamilton Anxiety Rating Scale (HAM-A) and Young Mania Rating Scale (YMRS) were utilized to detect the symptoms of AS at each assessment.  RESULTS: AS was detected in 25 (41.7%) patients. The most prevalent symptoms of AS were insomnia (31.7%), anxiety (25%) and irritability (15%). A significant difference was found in the HCL-32 scores of patients with and without AS. A moderate correlation between the number of AS symptoms and HSL-32 test scores were also determined.  CONCLUSION: AS development was more common among the depressed patients with lifetime history of hypomanic symptoms. Given the frequency of misdiagnosis of BPD as MDD, it would be helpful to assess the hypomanic symptoms systematically with scales similar to HSL-32 in depressive patients before prescribing antidepressant medication.

Alteration of the affective modulation of the startle reflex during antidepressant treatment.

Whereas the amplitude of the startle reflex varies with stimulus valence in the normal population, a lack of this affective modulation has been reported in patients with major depressive disorder. The present study sought to clarify blunted startle modulation as a feature of depression by comparing 16 patients diagnosed with major depression prior to and after 2 weeks of SSRI treatment, and 16 healthy controls. The affect-modulated startle reflex paradigm and the Self-Assessment Manikin were used to probe affective reactivity. In addition, a preliminary analysis of change in affective reactivity pattern was performed with depressed patients who could be assessed in the eighth week of treatment (n = 13). The control group showed a linear trend in response across valence categories, which was stable over sessions. Blunted affective reactivity was observed only in the patients and persisted after 2 weeks of treatment. Nevertheless, a linear trend could be detected in the eighth week of treatment. These findings confirm that the affective reactivity is blunted in depression and provide initial evidence for the lack of change in the early phase of SSRI antidepressant treatment. Nevertheless, in a small group, the emergence of a linear trend in response was evident later with treatment. Large-scale studies are required to assess the relation between the treatment response and the change in affective modulation of the startle reflex, as a potential biomarker.

Neuropsychological, electrophysiological and neurological impairments in patients with obsessive compulsive disorder, their healthy siblings and healthy controls: Identifying potential endophenotype(s).

The etiology of obsessive-compulsive disorder (OCD) has not been clarified. This study aimed to investigate the cognitive, neurological, electrophysiological functions which are reflected in executive functions, memory, visuospatial integration; neurological examination and auditory event related potentials (AERP) (N100, N200, P200 and P300) in patients with OCD, their siblings, and control subjects and to determine potential endophenotypic markers. Thirty-three patients with OCD, 18 siblings and 21 controls; matched for age, gender and years of education were included. Yale Brown Obsessive Compulsive Symptoms Checklist Scale, Hamilton Depression-Rating Scale, an exhaustive neuropscyhological test battery and Neurological Evaluation Scale were administered. Their AERP recordings were obtained. Executive functions and visuospatial integration were highly impaired in patients and slightly in their siblings compared to controls. P200 amplitude was sorted as siblings>patients>controls. P300 amplitude was sorted as patients

Assessment of health-related quality of life, depression, and anxiety in slowly and rapidly progressive neuromuscular disorders.

OBJECTIVES: To compare health-related quality of life (HRQoL) and psychosocial features in rapidly progressive neuromuscular disorders (RPNMD) and slowly progressive neuromuscular disorders (SPNMD) in adult ambulatory patients, to determine individual needs in 2 separate progression groups. METHODS: Thirty-nine SPNMD patients and 46 RPNMD patients were recruited. The functional independence measurement (FIM) was employed to evaluate the functional status. For the assessment of depression, anxiety, and HRQoL, patients were requested to fill out a Beck Depression Inventory, State-Trait Anxiety Inventory, and the Nottingham Health Profile (NHP). This study was performed at the Department of Physical Therapy and Rehabilitation, Hacettepe University Faculty of Health Science, Ankara, Turkey between August and December 2009. RESULTS: The FIM total score did not differ between the 2 groups. Only energy was significantly high (worse) among the dimensions of NHP in RPNMD patients. None of the other sub-items differed between the 2 patient groups. The SPNMD patients were more depressed than the RPNMD patients. The mean state and trait anxiety scores were significantly higher in SPNMD patients as well. CONCLUSIONS: Significant depressive or anxious symptomatology is not associated with amyotrophic lateral sclerosis (ALS). The diagnosis of SPNMD should alert physicians in an equivalent promptness to ALS and possible depression or anxiety, and concerns of patients regarding the chronic, though slowly progressive course of the disease.

[Two stiff person cases misdiagnosed as conversion disorder]. / Kati insan sendromunda konversiyon bozuklugu yanlis tanisi: iki olgu.

Modern psychiatric diagnostic systems classify neurological symptoms that cannot be explained by a physical disease or another psychiatric disorder as conversion disorder (CD) or dissociative motor disorder. It is a well-known fact that the overall rate of misdiagnosis of conversion symptoms is high. The most common presenting symptoms of misdiagnosed patients are gait and movement disturbances. Stiff-person syndrome (SPS) is a rare progressive autoimmune neurological disorder. The identification of antibodies against glutamic acid decarboxylase (GAD) in association with SPS provided an important contribution to the understanding of the pathophysiology of this syndrome. Patients may present with severe muscle rigidity and sudden contractions. Simultaneous contraction of agonist and antagonist muscles produces gait disturbance. SPS can be exacerbated by emotional stressors, and sudden auditory, visual, and tactile stimuli. Herein we present 2 patients that were referred for psychiatric assessment, because their neurological symptoms initially could not be explained by a neurological disease, and subsequently diagnosed as SPS. The aim of this case report is to draw attention to the psychiatric presentations of SPS and to emphasize the importance of complete psychiatric and neurological examination, including brain imaging and electrophysiological studies, in the differential diagnosis of CD.

[Evoked potentials and regional cerebral blood flow changes in conversion disorder: a case report and review]. / Konversiyon bozuklugunda uyarilmis potansiyeller ve beyin kan akimi degisiklikleri: olgu sunumu ve gözden geçirme.

Conversion disorder is defined as the presence of functional impairment in motor, sensory or neurovegetative systems which cannot be explained by a general medical condition. Although the diagnostic systems emphasize the absence of an organic basis for the dysfunction in conversion disorder, there has been a growing interest in the specific functional brain correlates of conversion symptoms in recent years, particularly by examining neuroimaging and neurophysiological measures. In this case report, regional cerebral blood flow changes and evoked potentials of a patient with conversion symptoms are presented. Somatosensory evoked potentials (SEP) of this patient with conversion disorder who had signs of movement disorder revealed that the latency to N20, P 25 waves were in normal limits while the amplitudes of the P25 and N33 components were extremely high (giant SEP). Regional cerebral blood flow assessment revealed hypoperfusion in the left parietal and temporal lobes of the brain. Three months after the first assessment, the control scans showed that the left parietal hypoperfusion disappeared while the left temporal hypoperfusion was still present. The following SEP evaluations which were repeated twice in three months intervals after the initial recordings, showed the persistence of the abnormalities in somatosensorial measures. The neurophysiological and neuroimaging findings in conversion disorder were reviewed and the results of the evaluations of this case were discussed in this article.

Obsessive compulsive symptoms associated with quetiapine treatment in a schizophrenic patient: a case report.

PURPOSE: Atypical antipsychotics (AAPs) are used as adjunct therapy in the treatment of resistant obsessive-compulsive symptoms (OCSs). Paradoxically other reports suggest that AAPs, particularly clozapine, risperidone, and olanzapine can induce de novo emergence or exacerbation of OCSs in psychotic patients. The authors present here the first report suggesting an association between de novo appearance of OCSs and quetiapine treatment in a schizophrenic patient. CASE: The patient was a 33-year-old woman with the diagnosis of paranoid schizophrenia, who displayed OCSs for the first time during treatment with quetiapine. The symptoms reduced remarkably when fluoxetine was added to her treatment regimen while keeping the quetiapine dosage unchanged. CONCLUSION: AAP-induced OCSs merit consideration and early identification, as these drugs are now widely in use in clinical practice. This rare but disabling side effect should also be monitored in quetiapine treated schizophrenic patients.

[The utility of an endophenotype approach in overcoming the difficulties in bipolar and schizophrenia genetics]. / Bipolar Bozukluk ve Sizofreni Genetigindeki Sorunlarin Giderilmesinde Endofenotip Yaklasiminin Yeri.

Despite the progress in molecular genetics, the genes responsible for the development of bipolar disorder (BPD) and schizophrenia have not yet been identified. This failure can be attributed to an ambiguous phenotypic description and several variations in the genetic transmission of these diseases. There is a growing consensus that an endophenotype approach may be utilized to overcome the difficulties regarding the phenotypic description and facilitate the identification of the susceptibility or protective genes. The endophenotypes which can be defined as subclinical vulnerability markers may assist in the identification of the genetic underpinnings of psychiatric disorders regardless of the disease status. This approach may provide well-defined phenotypes having a stronger relationship with the pathophysiology and genetic etiology than with the diagnostic categories themselves. An endophenotype may be an inherited neurophysiological, neuropsychological, cognitive, neuroanatomical, biochemical or endocrinological trait. Nevertheless, it must be 1) associated with illness, 2) present in nonaffected family members at a higher rate than in the general population, 3) present within the normal population to a lesser extent and 4) state-independent. Besides increasing the power of genetic analysis in BPD and schizophrenia, an endophenotype approach may help in reshaping the classical nosological systems and diagnostic categories. Lastly, it may have additional use in psychiatry, including the development of suitable animal models for these disorders. In this article, the rationale for the use of endophenotypes in genetic studies of BPD and schizophrenia is discussed and the proposed candidate endophenotypes for both disorders are reviewed.

Is vitamin D hypothesis for schizophrenia valid? Independent segregation of psychosis in a family with vitamin-D-dependent rickets type IIA.

The vitamin D hypothesis of schizophrenia is a recent concept bringing together old observations on environmental risk factors and new findings on the neurodevelopmental effects of vitamin D. Candidate genes related to the vitamin D endocrine system have not yet been fully explored for this purpose. The coexistence of vitamin-D-dependent-rickets type II with alopecia (VDDR IIA) and different forms of psychosis in the same inbred family has provided us with an opportunity to investigate the presumed relationship between vitamin D deficiency and psychosis. Psychiatric examination and molecular genetic studies were performed in this family overloaded with psychotic disorders and VDDR IIA. Forty members were evaluated in order to describe their phenotypic features. The family was tested for a linkage to the chromosome 12q12-q14 region where the vitamin D receptor (VDR) gene is located. Psychosis was the common phenotype in the 18 psychiatrically affected members. Pedigree analysis did not show a cosegregation of psychosis and rickets. Lod scores were not significant to prove a linkage between psychosis and VDR locus. The authors concluded that (1) the neurodevelopmental consequences of vitamin D deficiency do not play a causative role in psychotic disorders, (2) these two syndromes are inherited independently, and (3) vitamin D deficiency does not act as a risk factor in subjects susceptible to psychosis.

The effects of post-surgical administration of goserelin plus anastrozole compared to goserelin alone in patients with severe endometriosis: a prospective randomized trial.

BACKGROUND: Among patients using GnRH analogues for endometriosis it has been postulated that peripheral and inflammation-induced in-situ aromatization of adrenal androgens are probably the main reasons for the high rates of failure during follow-up. We hypothesized that in cases with premenopausal severe endometriosis, use of a combination of anastrozole and goserelin to achieve almost maximal endocrine blockade of estrogen synthesis after conservative surgery may increase the pain-free interval and reduce the recurrence rates as compared to goserelin alone. METHODS: In a prospective randomized trial, we evaluated the efficacy of using either a combination of anastrozole and goserelin for 6 months or goserelin alone for 6 months after conservative surgery for severe endometriosis. The primary outcome measures were the symptom recurrence rates and the impact of treatment on endometriosis-related multidimensional score. The secondary outcome measures were the impact of allocated treatment regimens on menopausal quality of life and on lumbar spine bone mineral density (BMD). RESULTS: When we analyzed the Kaplan-Meier survival curves, we detected a statistically significant advantage of goserelin plus anastrozole as compared to goserelin only, in terms of the median time to detect symptom recurrence (>2.4 versus 1.7 months; log-rank test; P=0.0089). This statistically significant advantage occurred with a relative risk of 4.3 [95% confidence interval (CI) 1.3-9.8]. Three cases out of 40 recurred in the goserelin plus anastrozole arm (7.5%), whereas we detected recurrences in 14 cases out of 40 cases in the goserelin-only arm (35%) during the follow-up period of 24 months. Based on these data, the interpretation of Kaplan-Meier curves indicates that at the end of follow-up, 54.7 versus 10.4%, respectively, of the patients were free of recurrence. The mean of the differences in terms of Deltabaseline-24 months post-medical therapy multidimensional score were statistically significant in favour of goserelin and anastrozole (9.2 +/- 2.1 versus 6.7 +/- 2.8; paired t-test; P<0.0001; 95% CI 1.5-4.0). We observed a statistically significant difference in suppression of estradiol concentrations and a significantly greater BMD loss at the end of treatment in the goserelin and anastrozole arm as compared to goserelin-only arm. However, this did not elicit deterioration in menopausal quality of life and the observed bone loss was not significant in terms of DeltaBMD between the groups at 2 years of treatment withdrawal. CONCLUSIONS: Six months of treatment with anastrozole and goserelin as compared to goserelin alone increased the pain-free interval and decreased symptom recurrence rates in patients following surgery for severe endometriosis. Furthermore, menopausal quality of life and BMD at 2 years after medical therapy remained unaffected.

[Hunting the susceptibility gene for psychosis: a study of a family overloaded with schizophrenia and bipolar disorder]. / Sizofreni ve bipolar bozuklugun yüklülük gösterdigi genis bir ailede psikoza yatkinlik geninin arastirilmasi.

OBJECTIVE: It is a long-standing debate whether schizophrenia and bipolar disorder are separate clinical entities or different poles on a spectrum. In this paper we present a family overloaded with schizophrenia, and schizoaffective, bipolar and unipolar disorders. Common loci for bipolar affective disorder and schizophrenia were tested by linkage analysis. METHOD: The pedigree of an index family which had been followed by our department for nearly 20 years was extended. The index family members were diagnosed by two psychiatrists with two distinct structured interview schedules (SCID-I and SADS-L). A field visit was undertaken for the evaluation of the extended family (n= 40) and SADS-L was used for psychiatric assessment. Blood samples were collected for molecular studies. A linkage study has been performed for overlapping susceptibility regions for schizophrenia and affective disorders (10p13-p12, 13q32, 18p and 22q11-q13) and a locus (20p11.2-q13) to which a linkage had been shown in a bipolar family who lived in the same region. Both autosomal recessive and dominant mode of inheritance were assumed in the analysis. RESULTS: The pedigree consisted of 108 individuals of whom 23 are affected. All affected subjects presented psychotic features except for 5 unipolar patients. The pedigree was reconstructed with respect to psychosis phenotype. Further linkage and haplotype analysis excluded all five loci on chromosomes 10, 13, 18, 20 and 22 under both autosomal dominant and recessive modes of inheritance assumption. CONCLUSION: A potential linkage between the psychosis gene and reported susceptibility loci overlapping in bipolar affective disorder and schizophrenia was not demonstrated Genome-wide analysis should be performed.

Laparoscopic presacral neurolysis for endometriosis-related pelvic pain.

BACKGROUND: Some patients with endometriosis are candidates for sympathectomy of the superior hypogastric plexus. The objective of this paper is to describe our technique of laparoscopic presacral neurolysis for sympathectomy and to report 1 year results of the first 15 cases. METHODS: To achieve this objective in a prospective observational study of 1 year follow-up; we performed laparoscopic presacral chemical neurolysis with phenol in 15 patients with pelvic pain and minimal-moderate endometriosis. The main outcome measures were: the impact of treatment on pelvic symptom resolution, non-opioid analgesic consumption during menses, sexual performance and observed complications and side effects during 1 year follow-up. RESULTS: We noted a significant reduction in total pelvic symptom score as compared with baseline mean (SD) of 9.04 (1.2). The mean difference [95% confidence interval (CI)] of reduction was 5.7 (4.9-6.5), 5.8 (5.0-6.6) and 5.8 (4.9-6.6) from the baseline at the 3rd, 6th and 12th postoperative month (P < 0.001). We observed a significant improvement in Sabbatberg Sexual Rating Scale as compared with baseline mean (SD) of 30.9 (4.3). The mean difference (95% CI) of increase was 33.4 (30.3-36.4), 33.2 (30.1-36.2) and 33.2 (30.1-36.3) from the baseline at the 3rd, 6th and 12th postoperative month. We observed a significant reduction in analgesic consumption during menses in terms of total naproxen sodium tablets as compared with baseline mean (SD) of 8.9 (1.1). The mean difference (95% CI) of reduction in the total number of naproxen sodium 250 mg tablets was 6.5 (5.5-7.5), 6.7 (5.7-7.7) and 6.6 (5.6-7.6) from the baseline at the 3rd, 6th and 12th postoperative month. The most common side effect was constipation. CONCLUSION: Laparoscopic presacral neurolysis is feasible and simple. More data is needed to support its efficacy and safety.

A randomized controlled trial of levonorgestrel releasing IUD and thermal balloon ablation in the treatment of menorrhagia.

Our aim was to compare the treatment of menorrhagia either with a levonorgestrel-releasing intrauterine device or with endometrial thermal balloon ablation. The primary endpoints of evaluation were menstrual blood flow reduction and the increase in hemoglobin values, while the secondary end points were adverse side effects; health related quality of life. After randomization, 36 women underwent outpatient thermal balloon ablation under local anesthesia and an intrauterine device releasing 20 microgram/day of levonorgestrel, were inserted within the first 7 days of menses to 36 women. Both techniques were found to be significantly effective in reducing the menstrual blood loss but in comparison thermal balloon ablation was more effective in Deltamean +/- SD decrease of pictorial sores (388.2 +/- 21 vs 343 +/- 27; p < 0.001). We noted a significant but similar increases in Deltamean +/- SD hemoglobin values (3.9 +/- 1.7 vs 3.7 +/- 1.4; p:.21). Patients treated by thermal balloon ablation reported fewer side effects and perceived a higher health related quality of life in physical role functioning. At one year of follow-up, the medicated device was effective but not as effective as thermal balloon ablation in reducing the menstrual blood loss. However it was found to be as effective as thermal balloon ablation in increasing the hemoglobin values. The side effect profile of the medicated device may alter its acceptability by reducing the perceived health related quality of life in menorrhagic women with no desire for further childbearing.

Outcome measures of interepisode bipolar patients in a Turkish sample.

BACKGROUND: We aimed to study the correlations of several outcome measures in bipolar patients with the clinical features of interepisode period. METHODS: Bipolar patients who were diagnosed according to DSM-III-R or IV were contacted and asked for a further evaluation. Interepisode bipolar patients (n = 100) were interviewed with the Schedule for Affective Disorders and Schizophrenia (SADS). In addition the Brief Disability Questionnaire (BDQ), the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) and the Global Assessment Scale (GAS) were administered to assess outcome. They were also asked to check the List of Life Events (LLE) for the last six months. RESULTS: Our results can be summarised as follows: (1) quality of life was predicted by current subthreshold depressive symptoms; (2) the number of previous depressive episodes, current subthreshold depressive and manic symptoms predicted disability; (3) the number of previous depressive episodes and the duration of hospitalisation as well as current subthreshold depressive and manic symptoms predicted overall functioning; (4) the number and distress level of life events were correlated with suicidal symptoms. CONCLUSIONS: Our findings suggest that outcome measures were correlated with subsyndromal disorder, the number of previous depressive episodes and the duration of hospitalisation.