Atypical antipsychotic-induced mania: A systematic review and meta-analysis.

BACKGROUND: The possibility of atypical antipsychotics (AA) to induce manic symptoms has been raised by several articles. The objective of this study was to describe whether exposure to AA may induce mania in mood disorders. METHODS: We performed a systematic review following the preferred reporting items for systematic reviews and meta-analysis guidelines. The systematic search encompassed all relevant studies published until April 4th, 2022. A meta-analysis testing whether treatment emergent mania (TEM) is more frequent with the use of AA compared with placebo was performed. RESULTS: A total of 52 studies were included in the systematic review. We found 24 case reports or case series describing 40 manic/hypomanic episodes allegedly induced by AA. Twenty-one placebo-controlled trials were included in a meta-analysis including 4823 individuals treated with AA and 3252 individuals receiving placebo. Our meta-analysis showed that the use of AA protects against the development of TEM (OR: 0.68 [95 % CI: 0.52-0.89], p = 0.005). LIMITATIONS: AA-induced mania/hypomania was not the primary outcome in any of the observational or interventional studies. TEM was not homogeneously defined across studies. In most case reports it was not possible to establish causality between the use of AA and the development of manic symptoms. CONCLUSIONS: TEM is more frequent with placebo than with AA, which suggests that AA exposure does not represent a relevant risk for TEM. Mania/hypomania induced by an AA seems to be rare events, since anecdotal evidence from case reports and case series were not observed in observational prospective and interventional studies.

Triggers for acute mood episodes in bipolar disorder: A systematic review.

OBJECTIVES: To identify triggers of acute mood episodes in bipolar disorder (BD). METHODS: We performed a systematic review in the following databases: Pubmed, Embase, and PsycInfo following the preferred reporting items for systematic reviews and meta-analysis guidelines. The systematic search encompassed all relevant studies published until May 23rd, 2022. RESULTS: A total of 108 studies (case reports/case series, interventional, prospective and retrospective studies) were included in the systematic review. While several decompensation triggers were identified, pharmacotherapy was the one with the largest body of evidence, particularly the use of antidepressants as triggers of manic/hypomanic episodes. Other identified triggers for mania were brain stimulation, energy drinks, acetyl-l-carnitine, St. John's wort, seasonal changes, hormonal changes and viral infections. There is a relative paucity of evidence concerning triggers for depressive relapses in BD, with possible triggers including fasting, decreased sleep and stressful life events. CONCLUSIONS: This is the first systematic review about triggers/precipitants of relapse in BD. Despite the importance of identification and management of potential triggers for BD decompensation, there is a lack of large observational studies addressing this topic, with most of the included studies being case reports/case series. Notwithstanding these limitations, antidepressant use is the trigger with the strongest evidence for manic relapse. More studies are needed to identify and manage triggers for relapse in BD.

The plague: a case of delusional infestation with folie à deux / A praga: um caso de delírio de infestação com folie à deux

Folie à deux or Shared psychotic disorder (SPD) is a rare condition characterized by shared psychotic symptoms between two or more individuals. Delusional parasitosis (DP) is an uncommon psychiatric illness in that patients believe they are infested by insects, without evidence to support this belief. DP occurs in 5­15% of SPD. We report a case of cutaneous DP with SPD between an elderly mother and a daughter that lived together and withdrew from other social contacts for the last three years. We aim to highlight the relationship between SPD and DP, its prognosis, and clinical implications.

Folie à deux ou Perturbação Psicótica Compartilhada (PPC) é uma condição rara caracterizada por sintomas psicóticos compartilhados entre dois ou mais indivíduos. O delírio parasitário (DP) é uma doença psiquiátrica incomum em que os pacientes acreditam estar infestados por insetos, sem evidências que sustentem essa crença. O DP ocorre em 5 a 15% das PPC. Relatamos um caso de um DP cutâneo com PPC entre uma mãe idosa e uma filha que viviam juntas e afastadas de outros contatos sociais nos últimos três anos. O nosso objetivo é destacar a relação entre PPC e o DP, o seu prognóstico e implicações clínicas

Schizoaffective Disorder: How long does it take to diagnose? A case report / Transtorno Esquizoafetivo: Quanto tempo leva para diagnosticar?: "relato de caso"

Introduction: It is reported a case of a 57-year-old woman with multiple psychiatric hospitalizations, during which different diagnostic hypotheses and therapeutic procedures were proposed. Case report: After analyzing the patient's clinical records, the medical team proposed a diagnosis of Schizoaffective Disorder. This disorder presents a high risk of recurrent hospitalizations and high costs associated with therapeutic and follow-up withdrawal, yet there is limited data to assess the post-discharge critical periods. Final considerations: Further research in this area is required to adopt effective therapeutic strategies, reduce the probability of hospital admissions, improve prognosis, and lessen associated financial costs.

Introdução: é relatado o caso de uma mulher de 57 anos com múltiplas hospitalizações psiquiátricas, durante as quais diferentes hipóteses diagnósticas e terapêuticas associadas foram propostas. Relato do caso: Após análise dos registos clínicos, a equipa médica propôs o diagnóstico de Perturbação Esquizoafetiva. Esta Perturbação apresenta um elevado risco de re-internamento, para além do custo associado ao abandono do seguimento clínico e terapêutico. Porém, não existem dados suficientes que avaliem os períodos pós-alta. Consideracoes finais: Portanto, tornam-se necessárias pesquisas mais amplas na área para adotar estratégias terapêuticas eficazes, reduzir a probabilidade de re-internamento, melhorar o prognóstico e minimizar os custos financeiros associados.

Pseudo Bartter Syndrome in anorexia nervosa.

INTRODUCTION: Anorexia nervosa is a psychiatric disorder with various non-psychiatric manifestations that arise from the self-imposed malnourishment and possible purging behaviors. These medical manifestations or complications may mimic non psychiatric disorders and difficult the diagnosis of an eating disorder. CASE REPORT: We report the case of a patient with a binge-eating/purging subtype of anorexia nervosa, whose purges consisted in diuretic abuse. She kept her purges secret and during more than 1 year she was admitted several times in the emergency room for, sometimes life-threatening, hypokalemia. Furthermore, she consulted practitioners from different specialties and was hospitalized in a nephrology service to investigate chronic hypokalemia and other metabolic and hydroelectrolytic disturbances. A Bartter Syndrome was suspected, and she underwent genetic testing. Eventually she started psychiatric follow up and was admitted as an inpatient under the care of a specialized eating disorders unit. CONCLUSION: This patient presented a series of metabolic disturbances secondary to the diuretic abuse, that mimicked the manifestations of hereditary tubulopathies like Bartter Syndrome. Coincidentally it was found that the patient had a mutation in a gene linked to Bartter Syndrome, that wasn't enough to justify this diagnosis. So, a Pseudo Bartter Syndrome secondary to the diuretic abuse was evident. The focus on medical manifestations delayed the recognition of the anorexia nervosa and the associated diuretic abuse as the main cause of the electrolyte and metabolic disturbances. This case emphasizes the importance of being familiarized with the non-psychiatric manifestations of eating disorders, so they may be rapidly recognized and managed. LEVEL OF EVIDENCE: Level V, Case Report.

Poststroke Bipolar Disorder.

ABSTRACT: Various diseases that impact different systems and organs in the body may trigger manic episodes. Strokes are often associated with psychiatric symptoms, particularly depressive and, more rarely, manic. We herein report a case of bipolar disorder secondary to cerebrovascular disease in a 67-year-old man with no personal or family history of psychiatric illness who, at the age of 64, had a bilateral ischemic stroke in the middle cerebral artery territory. About 20 days after this stroke, he experienced a manic episode. Three years later, he experienced a second manic episode, with another hospitalization in a psychiatric ward. With this case, we intend to emphasize that, although rare, the diagnosis of mania after stroke should not be forgotten, and most important, one should be aware of the recurrence of affective episodes just as in non-medical-caused bipolar disorder.

Nonalcoholic Wernicke-Korsakoff Syndrome Resulting From Psychosis.

ABSTRACT: Wernicke encephalopathy (WE) results from thiamine deficiency. If undiagnosed or inadequately treated, WE evolves into Korsakoff syndrome (KS). We herein report a case of nonalcoholic Wernicke-Korsakoff syndrome (WKS) that resulted from malnutrition due to psychosis in a 42-years-old male patient. Thiamine deficiency was secondary to severe malnourishment due to poisoning delusions and daily life disorganization in a patient with previously unrecognized schizophrenia. Besides the presence of WE's classic triad of signs, brain magnetic resonance imaging showed also typical thalamic lesions. Furthermore, the patient also presented anterograde and retrograde amnesia, executive dysfunction, and confabulations, compatible with KS being already present. Intravenous treatment with thiamine was given for 37 days. Improvement in cognitive functions and brain imaging alterations was evident. Nevertheless, persistent WKS deficits were present. This case highlights the multiplicity of etiologies of WKS, namely, psychiatric, and its debilitating consequences if not promptly recognized and treated.

Cariprazine Use in Early Psychosis: Three Case Reports.

Objective: Cariprazine is a new atypical antipsychotic approved for the acute and maintenance treatment of schizophrenia (1, 2) and for the treatment of manic or mixed episodes associated with bipolar I disorder (1). Recently, cariprazine also got extended FDA-approval for the treatment of depressive episodes in adults with bipolar I disorder (3). The use of low doses of atypical antipsychotics is an essential component of early intervention in psychosis. For its particular performance and tolerability, cariprazine is becoming an important option for the treatment of first-episode psychosis. Method: Three patients experiencing first-episode psychosis (FEP) were successfully treated with cariprazine. Two patients were in their first months of the disease, and the third patient was in his third year after the FEP. Results: The three patients had a diagnosis of non-affective FEP, which includes schizophrenia, delusional disorder, and schizoaffective disorder. One of them was in their third year after the FEP with a predominance of negative symptoms at this stage of the disorder. All the patients were treated with cariprazine with a target dose of 3-4.5 mg/day. The three patients showed improvements in their psychosis, including a decrease in negative symptoms. No significant side effects were reported. Conclusion: Our three case reports indicate that cariprazine is an atypical antipsychotic beneficial in the treatment of early psychosis. Treatment with low doses of cariprazine could be effective and tolerable in this phase of the disorder. Future studies with longer follow-up of FEP patients are recommended to confirm these positive results of cariprazine in the early phases of psychosis.

Psychosis in Huntington´s Disease. a rare and Under-Investigated Psychiatric Manifestation / Psychosis in Huntington's Disease: uma manifestação psiquiátrica rara e pouco investigada

Introduction: Psychotic symptoms are among the least prevalent and under-investigated psychiatric manifestations (PM) of Huntington's disease (HD). Case report: We herein report a case of a 31-year-old male patient who presented PM with a predominance of negative symptoms, without any significant abnormal movement. HD was diagnosed based on positive DNA analysis and family history. HD imposes longitudinal follow-up through a multidisciplinary approach in order to improve the quality of life and prognosis. Conclusion: This case report highlights the importance of comprehending the PM in the initial presentation of HD so that the diagnosis is not delayed until the onset of motor symptoms.

Introdução: Os sintomas psicóticos estão entre as manifestações psiquiátricas (MP) menos prevalentes e pouco investigadas da doença de Huntington (DH). Relado de caso: Relatamos o caso de um paciente do sexo masculino, 31 anos, que apresentou MP com predomínio de sintomas negativos, sem qualquer movimento anormal significativo. A DH foi diagnosticada com base em uma análise de DNA positiva e na história familiar. A DH impõe um acompanhamento longitudinal por meio de uma abordagem multidisciplinar, a fim de melhorar a qualidade de vida e o prognóstico. Conclusão: Este relato de caso destaca a importância da compreensão das MPs na apresentação inicial da DH, para que o diagnóstico não seja atrasado até ao aparecimento dos sintomas motores

Pobreza, instituições e segurança: perspectivas de familiares de adolescentes assassinados no Ceará / Poverty, institutions and security: perspectives of adolescents' families murdered in Ceará / Pobreza, instituciones y seguridad: perspectivas de familiares de adolescentes asesinados en el Ceará

Objetivou-se, por meio de levantamento, analisar as implicações da pobreza na segurança e no acesso institucional de familiares de jovens assassinados no Ceará. Participaram do estudo 263 familiares, os jovens eram homens (97,7%) e negros (70,3%) com idades entre 11 e 19 anos (M = 16,6; DP = 1,34). As análises desenvolvidas foram descritivas e comparativas (qui-quadrado e ANOVA). Os participantes apresentaram baixa confiança institucional, mas o grupo mais pobre apresentou significativamente menos confiança na polícia (χ 2= 30,36; p < 0,001). O grupo mais pobre indicou significativamente mais as batidas policiais representando perigo no bairro (χ2 = 5,5; p < 0,01) e mais a percepção da presença policial como intimidadora (F = 34,487; p < 0,001). Não houve diferenças significativas em relação aos motivos da violência no bairro. Observa-se a existência de uma gestão da morte vinculada a uma estrutura de Estado e de sociedade que criminaliza a pobreza.

This study aims was to analyze the implications of the poverty condition on security and access to institutions in the perceptions of adolescents' families members and young people murdered in Ceará. 263 families of adolescent victims of homicide participated in the study aged between 11 and 19 (M = 16.6, SD = 1.34), blacks (70.3%), males (97.7%) and family income of one to two minimum wages (64.1%). A survey was conducted, the questions related to territorial security, institutional relations and multidimensional poverty. The analyzes were descriptive and comparative (chi-square and ANOVA). The results show that families in situations of greater poverty have less access to institutions, assess their territories as more dangerous and suffer more violence. It is observed the existence of a death management linked to a structure of State and society that criminalizes poverty

Se objetivó analizar las implicaciones de la condición de pobreza en la seguridad y el acceso a las instituciones para miembros de familias de adolescentes y jóvenes asesinados en Ceará. En el estudio participaron 263 familias de adolescentes víctimas de homicidio, con edades entre 11 y 19 años (M = 16,6, SD = 1,34), negros (70,3%), hombres (97,7%) e ingresos familiares de uno a dos salarios mínimos (64,1%). Se realizó una encuesta, las cuestiones aplicadas se refirieron a la seguridad territorial, las relaciones institucionales y la pobreza multidimensional. Los análisis fueron descriptivos y comparativos (chi-cuadrado y ANOVA). Los resultados apuntan que las familias en situaciones de pobreza más intensa tienen menos acceso a las instituciones, evalúan sus territorios como más peligrosos y sufren más violencia. Se observa la existencia de una gestión de la muerte vinculada a una estructura de Estado y sociedad que criminaliza la pobreza.

First-Episode Psychosis and Hypokalemia: A Case Report and Review of the Literature.

Hypokalemia is the most frequent electrolyte abnormality seen in clinical practice. Hypokalemia is defined as serum potassium below 3.5 mEq/L and is usually asymptomatic and only identified in routine laboratory analysis. However, in some cases, symptoms include hypertension, palpitations, muscle weakness, easy fatigability, cramping and myalgias, memory impairment, disorientation and confusion, depressed or anxious mood, and irritability. Although rare, hypokalemia has been associated with psychosis. In particular, hypokalemia has been associated with psychotic exacerbations in patients with chronic psychotic disorder. We present a case report of a young female who developed a first presentation of acute psychosis and in which complementary investigations revealed hypokalemia. The psychosis resolved in few hours after replacement therapy with potassium chloride. The patient returned her usual functioning after discharge and there were no signs of psychosis at six-month follow-up.