Brainstem reflexes are hyperactive in patients with drug-induced akathisia.

Akathisia is a sensori-motor phenomenon which is generally encountered as an adverse effect of antidopaminergic medications suggesting involvement of dopaminergic pathways. We recently showed nociceptive flexor reflex was altered in akathisia as compared to restless legs syndrome and therefore, these findings may indicate co-involvement of pathways other than dopaminergic ones. To examine functional status of different pathways, we investigated auditory startle reflex (ASR), startle response to somatosensory input (SSS), and trigemino-cervical reflex (TCR) in a group of patients with akathisia. Consecutive seven patients with drug-induced akathisia and age- and gender-matched healthy subjects were prospectively included in the study. The diagnosis was made by appropriate clinical criteria. Brainstem reflexes, ASR, SSS, and TCR were examined in all participants. The probability, onset latency, amplitude, and duration were measured and compared between groups. The probability and amplitudes of ASRs were significantly increased and durations of ASRs and TCRs were prolonged in the patient group. Latencies of all responses as well as patterns of startle responses were similar between groups. The results reveal hyperactivity of the ASR and TCR in drug-induced akathisia. Hyperactive ASRs and TCRs also confirm suprasegmental hypodopaminergic state in akathisia. Although we keep in mind the confounding effects due to concurrent antidopaminergic treatments and the small sample group, we speculate that hyperactive ASRs and TCRs might be related to deficient control by forebrain and limbic-mainly amygdala-network in patients with drug-induced akathisia.

Orienting reaction may help recognition of patients with psychogenic nonepileptic seizures.

OBJECTIVE: Psychogenic nonepileptic seizures (PNES) are abrupt, paroxysmal changes in behavior or consciousness that may phenomenologically resemble epileptic seizures. Given the known association between anxiety and PNES, we hypothesized that in these subjects there may be evidence that the nervous system is hypersensitive to external stimuli. We aimed to test our hypothesis by means of the auditory startle reaction (ASR). By investigating ASR, we also had the opportunity to test presence of orienting reaction, which is generally defined as the second phase of response after the auditory stimulus, with longer latency. METHODS: We included 22 patients diagnosed as PNES and 25 age- and gender-matched healthy subjects. Clinical assessments and ASR recordings were performed. Electrophysiological findings were compared between patients with PNES and healthy subjects, including the presence of an orienting reaction. Orienting reaction was defined as a late response with latency between 100-1000ms. RESULTS: The mean ages of patients with PNES and healthy subjects were 34.9±12.3 years and 33.3±10.9 years, respectively (P=0.709). All patients were diagnosed as having conversion disorder. Additionally, 19 patients had depressive disorder and four had anxiety. The recruitment pattern of muscles and probability were similar between patients with PNES and healthy subjects. Orienting reaction was solely observed in patients with PNES (n=13, 59.1% of the patients vs. no healthy subject). The sequence and contribution of muscles in the orienting reaction changed almost in all patients. The duration of these responses was long, sometimes more than 200ms. CONCLUSION: PNES is associated with orienting reaction. This provides a possible electrophysiological marker of altered nervous system function in patients with PNES and may also reflect the distorted emotional processing in these patients.

Psychiatric Features in Neurotic Excoriation Patients: The Role of Childhood Trauma.

INTRODUCTION: Neurotic excoriation is a psychodermatological disease of primary psychological/psychiatric genesis, responsible for self-induced dermatological disorders. Childhood traumatic events are closely related with self-injurious behaviors. The aim of this study is to evaluate the psychiatric features of neurotic excoriation and to investigate the effect of childhood traumatic events on the disease. METHODS: Thirty-eight neurotic excoriation patients who did not receive any psychiatric treatment within the past year and 40 healthy individuals having similar sociodemographic features were included in the study. For clinical evaluation, the Structured Clinical Interview for DSM-IV Axis I Disorders, Beck Depression Inventory, Beck Anxiety Inventory, and Childhood Trauma Questionnaire-Short Form were applied to all the individuals. RESULTS: In this study, we observed that 78.9% of neurotic excoriation patients were diagnosed with at least one Axis I psychiatric disorder, the most frequent diagnoses of which were major depressive disorders and anxiety disorders. The anxiety and depression levels were significantly higher in the patient group than in the healthy individuals. Regarding the Childhood Trauma Questionnaire, emotional neglect, emotional abuse, and physical abuse subscales and weighted average total scores were found to be significantly higher in the patient group (p<.05). CONCLUSION: Our study has shown a close relationship between neurotic excoriation and childhood traumatic events as well as the accompanying psychiatric problems. We suppose that early interventions by both dermatologists and psychiatrists and especially a detailed investigation of childhood traumatic events by establishing a therapeutic collaboration are highly important and that using psychotherapeutic interventions can result in better treatment outcomes in many patients.

Dissociative depression among women with fibromyalgia or rheumatoid arthritis.

The aim of this study was to inquire about the possible relations of childhood trauma, anger, and dissociation to depression among women with fibromyalgia or rheumatoid arthritis. Fifty female patients diagnosed as having fibromyalgia (n = 30) or rheumatoid arthritis (n = 20) participated in the study. The Childhood Trauma Questionnaire, Somatoform Dissociation Questionnaire (SDQ), Dissociation Questionnaire (DIS-Q), Beck Depression Inventory (BDI), Spielberger State-Trait Anger Expression Inventory, and Dissociative Disorders Interview Schedule were administered to all participants. Women with a lifetime diagnosis of depressive disorder had higher scores for somatoform and psychoform dissociation than the nondepressive patients. However, childhood trauma scores did not differ between the 2 groups. In regression analysis, current severity of depression (BDI) was predicted by psychoform dissociation (DIS-Q) and lower education, and lifetime diagnosis of major depression was predicted by somatoform dissociation (SDQ). Whereas childhood emotional neglect predicted somatoform dissociation, psychoform dissociation was predicted by childhood sexual abuse. Mental processing of anger seems to be 1 of the dimensions of psychodynamics in trauma-related depressive conditions. In the context of the perceived threat of loss of control due to expressed anger and mental disintegration, somatoform dissociation seems to contribute to overmodulation of emotions in dissociative depression. Among patients suffering from physical illness with possible psychosomatic dimensions, assessment of somatoform dissociation in addition to psychoform dissociation may be helpful to understand diverse psychopathological trajectories emerging in the aftermath of childhood adversities. The recently proposed category of "dissociative depression" (Sar, 2011) seems to be a promising concept for future research on psychosomatic aspects of traumatic stress.

Ictal kissing behavior: neurological and psychodynamic overview.

This study is based on the psychodynamic and neurological analysis of three Turkish patients who displayed ictal kissing automatism during their seizures. To unveil the probable underlying causes of their kissing behaviors, all patients underwent psychiatric interviews after being evaluated by ictal video-EEG recordings. The group consisted of two females (ages 35 and 29) and one male (age 26). In addition to prominent oral automatisms, each patient also displayed behaviors of kissing or blowing kisses to individuals at close proximity. Seizures were related to the right temporal lobe in two patients and the left temporal lobe in one patient. Magnetic resonance imaging showed mesial temporal sclerosis in two of the patients (one left, one right) and was normal in one. According to the DSM-IV-TR criteria, each of the three patients also suffered from major depression, while the psychodynamic interviews revealed traumatic childhood histories and intense unfulfilled affective needs.

Treatment with group psychotherapy for chronic psychogenic nonepileptic seizures.

Although there have been a number of psychotherapy trials for chronic psychogenic nonepileptic seizures, evidence-based treatment options are limited. We developed an eclectic group psychotherapy which combines psychoeducation and behavioral and psychoanalytic techniques. Nine patients completed 12 weeks of psychotherapy. Patients were interviewed with SCID-I. They also filled in the following measures at the beginning and end of the therapy: Beck Depression Inventory, Dissociative Experiences Scale, Spielberger State-Trait Anxiety Scale, SF-36 Life Quality Scale, and Toronto Alexithymia Scale. Seizure frequency was assessed before and after the therapy and on follow-up visits at the fourth, sixth, ninth, and twelfth months. After one year of follow-up, the decrease in seizure frequency was highly significant (p<0.001). In addition, we observed significant improvements in the mental health subscale of the SF-36 (p=0.03) and the state (p=0.006) and trait (p=0.02) subscales of the Spielberger State-Trait Anxiety Scale at the end of the therapy. These results suggest that group psychotherapy might be a treatment option for chronic psychogenic nonepileptic seizures.

Childhood trauma and dissociation in schizophrenia.

BACKGROUND: This study is concerned with relationships between childhood trauma history, dissociative experiences, and the clinical phenomenology of chronic schizophrenia. SAMPLING AND METHODS: Seventy patients with a schizophrenic disorder were evaluated using the Structured Clinical Interview for DSM-IV, Dissociative Experiences Scale, Dissociative Disorders Interview Schedule, Positive and Negative Symptoms Scales, and Childhood Trauma Questionnaire. RESULTS: Childhood trauma scores were correlated with dissociation scale scores and dissociative symptom clusters, but not with core symptoms of the schizophrenic disorder. Cluster analysis identified a subgroup of patients with high dissociation and childhood trauma history. The dissociative subgroup was characterized by higher numbers of general psychiatric comorbidities, secondary features of dissociative identity disorder, Schneiderian symptoms, somatic complaints, and extrasensory perceptions. A significant majority of the dissociative subgroup fit the diagnostic criteria of DSM-IV borderline personality disorder concurrently. Among childhood trauma types, only physical abuse and physical neglect predicted dissociation. CONCLUSIONS: A trauma-related dissociative subtype of schizophrenia is supported. Childhood trauma is related to concurrent dissociation among patients with schizophrenic disorder. A duality model based on the interaction of 2 qualitatively distinct psychopathologies and a dimensional approach are proposed as possible explanations for the complex relationship between these 2 psychopathologies and childhood trauma.

Electroconvulsive therapy for bipolar depressive and mixed episode with high suicide risk after epilepsy surgery.

Mood disturbance is a common comorbid condition of temporal lobe epilepsy before and after surgery. Suicide is more frequent in patients with epilepsy than in the general population. As suicide is a major issue in both epileptic and depressive patients, it is critical to treat aggressively any psychiatric illness with suicidal ideation. We describe two patients who, after temporal lobe surgery, developed a serious bipolar disorder that necessitated electroconvulsive therapy (ECT), despite better seizure control. Unfortunately they were not able to commit to a regular treatment plan with their psychiatrists to prevent a suicide. These patients underwent a course of ECT treatments. After the ECT regimen, acute suicidal intent remitted and was replaced by chronic suicidal ideation without active intent or plan. The patients were then able to commit to a treatment plan regarding their medications and control visits. These cases represent the safe utilization of ECT as a rapid and effective treatment option for bipolar disorder with suicide ideation following epilepsy surgery. Patients and parents should be advised about possible psychiatric disturbances and suicide risk after epilepsy surgery, especially in the presence of a temporal lobe epilepsy, even when seizure control is achieved postoperatively.

[The effect of permanent ostomy on body image, self-esteem, marital adjustment, and sexual functioning]. / Kalici Ostomi Ameliyatinin Beden Algisi, Benlik Saygisi, Es Uyumu ve Cinsel Islevler Uzerine Etkisi.

OBJECTIVE: The aim of this study was to investigate the effects of permanent ostomy on body image, sexual functioning, self-esteem, and marital adjustment. METHOD: SCID-I outpatient forms were administered to 52 subsequent patients that underwent permanent colostomy or ileostomy operations, and 40 of them that did not fit any of the diagnostic criteria for psychiatric disorders were then administered a sociodemographic data questionnaire, and the Body Image Scale, Rosenberg Self-Esteem Scale, Dyadic Adjustment Scale, and Golombok Rust Sexual Functions scale. The control group consisted of 20 age- and gender-matched healthy volunteers. RESULTS: Body Image, Rosenberg Self-Esteem, and Dyadic Adjustment Scale scores were higher in permanent ostomy patients compared to controls, indicating more ostomy-related disturbance. Sexual functions were found to be impaired as well, except impotence and rapid ejaculation parameters. Complaints of anorgasmia were more frequent among female colostomy patients. Body image, and the touch, communication, and frequency parameters of sexual functioning were less disturbed in male patients than in females. Female patients with a psychiatric history experienced vaginismus problems more frequently. Patients with a history early childhood separation from parents had lower self-esteem scores and more frequently avoided sexual activity. Following ostomy surgery, the frequency of male impotence decreased over time. CONCLUSION: Permanent ostomy causes impairment in perceived body image, dyadic adjustment, and sexual functioning.

[Charles-Bonnet Syndrome: a report of two cases]. / Charles Bonnet sendromu: iki olgu sunumu.

Charles-Bonnet syndrome (CBS) occurs after the loss of vision or a decrease in visual ability and is characterized by visual hallucinations with insight and preserved cognitive status. In this paper, 2 cases in which vision was lost (in one patient due to hypophyseal macroadenoma and in the other due to diabetic retinopathy) are presented. The first case is a 35-year-old male referred to the psychiatry department for depressive complaints. He lost his vision due to optic atrophy following multiple surgeries for hypophyseal macroadenoma and visual hallucinations developed afterwards. Ziprasidone 80 mg/day was started and the hallucinations disappeared on the fifth day, but the medication had to be withdrawn because of severe vascular type headaches. Olanzapine 5 mg/day was subsequently used without benefit. He refused further medication and the visions gradually changed into sparkling lights and simple figures at the 7-month follow-up. The second case was a 54-year-old woman with a 20-year history of type-II diabetes mellitus. Visual hallucinations developed after bilateral visual loss due to diabetic retinopathy 4 years earlier. She responded well to treatment with quetiapine 100 mg/day and paroxetine 20 mg/day. Neither of the cases had reported their visual symptoms to their physicians; the second case was diagnosed after 4 years by active screening. Both of the cases had neuroanatomic lesions. CBS symptoms should be screened actively in patients with visual loss and physicians should be educated about diagnosing CBS. Novel antipsychotics, such as ziprasidone and quetiapine, seem to be effective alternatives for the treatment of CBS.

[Transference and countertransference in medically ill patients]. / Tibbi Hastalik Tanisi Konmus Hastalarda Aktarim ve Karsiaktarim.

Transference and countertransference feelings/reactions are a valuable source of information about a patient's inner world. A consultation liaison psychiatrist has to help the entire treatment team to understand the patient as well as treat the patient. Studies about transference and countertransference in medical settings are insufficient. An idealized transference often develops, usually at the beginning of the treatment, whereas negative transference occurs rarely. At other times a displaced transference, with anger, directed toward the medical team or one of its members may develop. Acute intense transference and countertransference feelings/reactions may be indicators of serious character pathology, such as Cluster B personality disorders. Patients with terminal illness are in need of perceiving the physician as an ideal and omnipotent figure; therefore, encouragement of a regressive relationship is recommended. There is always a risk of either avoidance or over involvement with the patient, especially in cases of catastrophic illness or injury. Not infrequently, interaction with the patient may evoke a traumatic experience in the therapist that has not been worked through sufficiently, and may hinder the therapist's ability to relate to his patient. Therapist countertransference feelings may be informative about the entire medical treatment process of the patient. Collaborative meetings with the medical team may help a therapists to understand their patients' inner worlds and to correct his/her dysfunctional attitudes, which in turn might positively affect treatment compliance and improve prognosis. Herein, the literature regarding transference and countertransference in medical patients is reviewed with case examples.

Quetiapine vs. risperidone in treating psychosis in neurosyphilis: a case report.

OBJECTIVE: A 44-year-old male patient presented with agitation, auditory hallucinations, and delusions of persecution was diagnosed as having neurosyphilis. METHODS: He was treated with penicillin G 24 million units/day, risperidone 6 mg/day, and memantine 20 mg/day with partial response to psychotic symptoms and significant extrapyramidal symptoms. RESULTS: On his follow-up, after 5 months, his cognitive status and serological tests remained the same, and his cell count was increased. A second therapy of penicillin was administered without any clinical improvement. On his second hospitalization for severe psychotic agitation after approximately 1 year, quetiapine 1200 mg/day was introduced and the psychiatric state improved immediately without significant side effect. CONCLUSIONS: Quetiapine, which has a low potential for producing extrapyramidal side effects, should be considered in the treatment of psychotic symptoms of neurosyphilis.

Dissociative identity disorder presenting as dermatitis artefacta.

Dermatitis artefacta is a rare psychiatric condition characterized by rubbing of skin blisters and denial of self-infliction. Dissociation may be comorbid with self-injurious behavior. A background of emotional disturbances during formative years and in later life often results in feelings of isolation and insecurity, which can lead to dissociation as a primary defense mechanism used to overcome traumatic events. In this case report, we describe a female patient with dermatitis artefacta associated with dissociative identity disorder. The patient was a 14-year-old girl. Multiple large, deep ulcerations with unnatural shapes were seen on her left forearm. The ulcerations were thought to be self-inflicted. Psychiatric examination revealed that she had a different identity, and inflicted the lesions when this was assumed. This case leads us to suggest that patients with dermatitis artefacta might have comorbid dissociative experiences, which cannot be identified easily.

Severe liver enzyme elevations after three years of olanzapine treatment: a case report and review of olanzapine associated hepatotoxicity.

Atypical antipsychotics commonly cause isolated asymptomatic increase in the aminotransferase levels. Among these atypical antipsychotics, mostly transient, asymptomatic increase in hepatic enzymes has been reported with olanzapine, however olanzapine rarely may induce a clinical and/or biological hepatic toxicity. The pathogenesis of olanzapine-associated hepatotoxicity is not well known and is mostly a transient phenomenon. However, substantial and lasting changes may occur and result in symptomatic hepatitis. In the following case report, we report on a 44-year-old female patient diagnosed as Bipolar Disorder Type I, whose liver enzyme levels increased ten fold of normal ranges during the third year of the olanzapine treatment and returned to the normal levels within three weeks after olanzapine discontinuation. Although significant liver enzyme elevations are uncommon during olanzapine treatment, based on reports of serious hepatotoxicity, controlled and longitudinal research are needed to learn side effects of this drug on liver. Clinicians should be aware of possible hepatotoxic effects of atypical antipsychotics and should monitor the liver enzyme levels whenever they feel necessary.

Orgasm-induced seizures: a study of six patients.

PURPOSE: Reflex seizures are known as the epileptic seizures triggered by some specific stimuli in sensitive patients. They are often classified according to the stimuli that trigger them rather than by the type of the seizure. Epileptic seizures induced by sexual orgasm are very rare in the literature. METHODS: We report six patients with different epileptic syndromes who experienced seizures after sexual intercourse and orgasm. RESULTS: All patients are women whose epileptogenic focus was in the right temporal in four and left frontal in one patient. One patient had pure generalized reflex epilepsy. CONCLUSIONS: Seizures induced by orgasm are very rare, with female and right hemisphere dominance requiring complex mechanisms to occur.

Excessive masturbation after epilepsy surgery.

Sexual behavior changes as well as depression, anxiety, and organic mood/personality disorders have been reported in temporal lobe epilepsy (TLE) patients before and after epilepsy surgery. The authors describe a 14-year-old girl with symptoms of excessive masturbation in inappropriate places, social withdrawal, irritability, aggressive behavior, and crying spells after selective amygdalohippocampectomy for medically intractable TLE with hippocampal sclerosis. Since the family members felt extremely embarrassed, they were upset and angry with the patient which, in turn, increased her depressive symptoms. Both her excessive masturbation behavior and depressive symptoms remitted within 2 months of psychoeducative intervention and treatment with citalopram 20mg/day. Excessive masturbation is proposed to be related to the psychosocial changes due to seizure-free status after surgery as well as other possible mechanisms such as Kluver-Bucy syndrome features and neurophysiologic changes associated with the cessation of epileptic discharges. This case demonstrates that psychiatric problems and sexual changes encountered after epilepsy surgery are possibly multifactorial and in adolescence hypersexuality may be manifested as excessive masturbation behavior.