Clinical Characterization, Course, and Treatment of Othello Syndrome: A Case Series and Systematic Review of the Literature.

BACKGROUND: Othello syndrome (OS) is a condition characterized by a delusion of jealousy that one's spouse is having extramarital affairs. As in the eponymous Shakespearean tragedy, there is an unfortunate risk of violence. For patients with these symptoms, consultation-liaison psychiatrists may be asked to assist with evaluating the differential diagnosis, assessing safety, and developing treatment options. OBJECTIVE: This study's objective was to solidify current knowledge of the clinical presentations and management of OS through a systematic review of the literature and description of 2 new cases. METHODS: We conducted a literature search from the start of relevant databases through August 2023 to identify English language case reports of adults (≥18 years) with OS that described clinical evaluations, biological treatments, and outcomes. We extracted demographics, proposed etiologies, treatment choices and responses, duration of delusions, comorbid psychiatric symptoms, neuro-radiographic findings, and presence of physical violence. We reported clinical findings for 2 new cases. RESULTS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we screened 705 abstracts and conducted full-text reviews of 118 articles to identify 73 cases published from 1983 to 2023 meeting inclusion criteria. The mean age was 58.2 years with male predominance (M:F = 1.88). Etiologies included primary psychiatric disorders (16, 22%), other medical conditions (38, 52%), and medications or other substances (19, 26%). Delusional disorder, cerebrovascular accident, and dopaminergic agonists were the most common etiologies, respectively, in these groups. Antipsychotics were the most common treatment (57, 78%). Symptom remission was reported in 51 (70%) cases. The average duration of OS was 39.5 months. Of 32 cases reporting brain imaging insults, 12 of 20 (60%) showed right-sided lesions, and 8 of 20 (40%) showed left-sided lesions, with 9 of 32 (28%) located in the frontal lobes. The most commonly co-existing psychiatric symptom was depression (14, 19%). Violence was reported in 25 cases (34%). Our 2 new cases were consistent with these findings. CONCLUSIONS: OS may be a manifestation of several neuropsychiatric conditions, primarily delusional disorder, cerebrovascular accident, Alzheimer's dementia, and the use of dopaminergic agonists. One-third of cases include violent behaviors. It appears to respond to antipsychotic medications, but treatment is delayed more than 3 years on average. Available data have not localized OS to a specific brain region.

Functional and clinical outcomes of delusional disorder and schizophrenia patients after first episode psychosis: a 4-year follow-up study.

BACKGROUND: Literature has typically associated delusional disorder with a poorer prognosis relative to schizophrenia, without considering the confounding effect of age despite the differential age of onset. This study therefore aims to investigate the diagnostic stability, clinical, functional, and neurocognitive differences of Chinese first-episode psychosis age-matched patients with delusional disorder and schizophrenia at four years. METHODS: 71 delusional disorder and 71 age-matched schizophrenia patients were followed up for four years after their initial episode. Their symptoms, insight in psychosis, side effects of medication, medication compliance, functioning, and neurocognitive performance were assessed at four years. RESULTS: At four years, 65% of DD patients maintained the same diagnosis, while the rest shifted to SZ. Only those without a diagnostic shift were included in the analysis. Delusional disorder patients (n = 46) experienced greater general psychopathology and poorer insight, but better attitude towards medication than schizophrenia patients (n = 71). Social and occupational functioning, quality of life, and cognitive functioning, however, were similar in delusional disorder and schizophrenia patients. CONCLUSIONS: Results indicate that delusional disorder is less diagnostically stable than schizophrenia. Their outcomes in a Chinese population were largely similar at four years after removing the confounding age factor, implying that delusional disorder and schizophrenia may not be as distinct as previously thought.

[Features of cognitive impairment in individuals with paranoid schizophrenia combined with alcohol dependence syndrome]. / Osobennosti kognitivnykh narushenii u lits s paranoidnoi shizofreniei v sochetanii s sindromom zavisimosti ot alkogolya.

OBJECTIVE: To compare the cognitive functioning of patients with paranoid schizophrenia with alcohol dependence syndrome and patients with this disease without comorbid alcohol pathology. MATERIAL AND METHODS: The study included 34 patients with a diagnosis of schizophrenia, paranoid form, aged 24 to 39 years (22 men and 12 women). The experimental group included 17 patients with paranoid schizophrenia combined with alcohol dependence syndrome with diagnosed symptomatic alcoholism. The comparison group included 17 patients with a similar diagnosis without a comorbid disorder. The duration of the disease in both groups was 5-10 years. The main research tool was a neuropsychological examination, which included the Benton test, the pathway test, the Mini-Mental State Examination (MMSE), and the constructive praxis test. RESULTS: Moderate cognitive impairments were found in patients with schizophrenia in combination with comorbid pathology, combined with disorders of intellectual flexibility and cognitive control. Also, in the experimental group, marked disorders of constructive praxis and visual memory were noted, which indicates a lesion of the occipital-parietal parts of the brain. Thus, in the course of the study, cognitive disorders were identified in patients with schizophrenia in combination with alcohol addiction: disturbances of perceptual organization, cognitive flexibility and attention switching, visual memory. CONCLUSION: Concomitant alcohol dependence is a significant factor for changing cognitive functions in patients with schizophrenia: control functions suffer, visual memory is disturbed and constructive apraxia is noted.

[Differences in the cognitive status of patients with schizophrenia depending on the genesis of concomitant encephalopathy]. / Razlichiya kognitivnogo statusa bol'nykh shizofreniei v zavisimosti ot geneza soputstvuyushchei entsefalopatii.

OBJECTIVE: To analyze the cognitive status of patients with schizophrenia and organic cerebral pathology of various genesis. MATERIAL AND METHODS: The study included 75 patients diagnosed with paranoid schizophrenia (F20.0). Depending on the type of organic brain lesion, all patients were divided into four groups: patients with paranoid schizophrenia without organic brain pathology (n=41), patients with dyscirculatory encephalopathy (n=15), patients with post-traumatic encephalopathy (n=12), patients with toxic encephalopathy (n=7).The Brief Assessment of Cognition in Schizophrenia (BACS) and the Rey-Osterrieth Complex Figure (ROCF) followed by the evaluation of the results with the Boston Qualitative Scoring System (BQSS)were used to assess the cognitive status. RESULTS AND CONCLUSION: Patients with schizophrenia without concomitant cerebral pathology had a better state of the cognitive sphere compared to patients whose underlying disease was aggravated by encephalopathy of various genesis. In particular, it applied to such cognitive functions as verbal memory, speech fluency, problem-solving behavior, long-term visual-motor memory, organization and constructive ability. According to the results of this study, patients with posttraumatic encephalopathy had the least pronounced cognitive deficit among patients with an organic brain lesion. In turn, patients with toxic encephalopathy had the worst indicators of the state of the cognitive sphere.

Factors related to memory absence and delusional memories in patients in intensive care units managed with light sedation.

OBJECTIVES: Currently, light sedation is typically given to patients in intensive care units and studies have not extensively examined the factors related to absences or abnormalities of their memories. We, therefore, analysed the factors related to the absence/abnormalities of patients' memories in intensive care units. RESEARCH METHODOLOGY: A secondary analysis of previously collected survey data examining patients' experiences in an intensive care unit was undertaken (n = 405; women = 38%; median age = 70 years). To observe absent or distorted memories, patients were interviewed after leaving the intensive care unit. We analysed key factors through content analysis of the interviews and field notes. SETTING: The intensive care unit of a university hospital. MAIN OUTCOME MEASURE: Patients' absent or distorted memories after leaving the intensive care unit. RESULTS: Half the patients reported an absence of memories. This was associated with old age and with longer duration of mechanical ventilation. Absent or fragmentary memories were not distressing. Fragmentary and fearful intensive care unit memories were associated with being older. Delusional memories, some of which reflected actual events, were present in 3% of patients. CONCLUSION: Absence of memories were not distressing, delusional memories occurred less and these memories could comprise of an event in ICU that is difficult for patients to understand.

Iatrogenic cerebral abscess leading to resolution of severe delusional disorder.

A cerebral abscess (focal infection of brain parenchyma) carries a high mortality and morbidity. Iatrogenic cerebral abscesses are less common and make up 10% of all cases. The presence of a cerebral abscess can rarely improve a patient's prognosis and quality of life, however this case illustrates an abscess and its treatment following a prolonged course of antibiotics leading to resolution of a severe psychotic disorder. This is a case report of a 32-year-old female inpatient at a psychiatric hospital with a long-standing history of congenital hydrocephalus, cerebral palsy and organic delusional disorder who developed an iatrogenic cerebral abscess after insertion of an implantable intracranial pressure monitoring device. After receiving treatment of 6 weeks of intravenous meropenem the patient's mental condition rapidly improved, she became stable and euthymic and was discharged home. The patient has since had no delusions or hallucinations and is living independently at home.

Hypercalcaemia in a patient with paranoid schizophrenia - a case report.

Hypercalcaemia is associated with a number of symptoms that appear in of various parts of body systems. Renal dysfunction or cardiovascular abnormalities present only a part of the multidirectional action of the disturbed calcium balance. It is important for every diagnosis to know the cause of this condition and the mechanism that is responsible in a given situation for the distribution of calcium ions. A CASE REPORT: Diagnosis presents the case of a 51-year-old woman with hypercalcaemia and thyrotoxicosis. The patient had been taking lithium preparations for 20 years, until she was hospitalized in the Department of Nephrology due to symptoms and poisoning confirmed biochemically with this substance. Dyselectrolytemia (hypernatremia, hypercalcaemia) and polydipsia, polyuria and a weight loss were found. According to the laboratory tests performed in the Department of Endocrinology, high levels of PTH in the blood, hypercalcaemia, normophosphataemia, normocalciuria, hypophosphaturia and normal renal function were found. In differential diagnosis, lithium poisoning or primary hyperparathyroidism (PHP) was considered to be the most likely pathomechanism of PTH-dependent hypercalcaemia, not to mention the possible effects of thyrotoxicosis. The patient underwent USG and MRI of the neck, followed by BACC selected by previous imaging of changes in the vicinity of the lower pole of the left thyroid lobe and focal lesions in the right thyroid lobe. After endocrinological diagnosis, the patient was provided with antithyroid drugs and directed to the Department of Nuclear Medicine with the aim of extend the diagnosis with scintigraphy of the parathyroid glands. CONCLUSIONS: As demonstrated by this case, differential diagnosis of hypercalcaemia and thyrotoxicosis is important. From a practical point of view, the causes of hypercalcaemia can be divided into primary hyperparathyroidism (PHP) and "all others", and among the causes of thyrotoxicosis, those less frequent should remembered. The variety of symptoms, potential causes and overlapping disease indicate the validity of individual approach to each patient.

Cognitive Behavioural Therapy for Nightmares for Patients with Persecutory Delusions (Nites): An Assessor-Blind, Pilot Randomized Controlled Trial.

OBJECTIVE: Nightmares are relatively common in patients experiencing psychosis but rarely assessed or treated. Nightmares may maintain persecutory delusions by portraying fears in sensory-rich detail. We tested the potential benefits of imagery-focused cognitive behavioural therapy (CBT) for nightmares on nightmare severity and persecutory delusions. METHOD: This assessor-blind parallel-group pilot trial randomized 24 participants with nightmares and persecutory delusions to receive CBT for nightmares delivered over 4 weeks in addition to treatment as usual (TAU) or TAU alone. Assessments were at 0, 4 (end of treatment), and 8 weeks (follow-up). Feasibility outcomes assessed therapy uptake, techniques used, satisfaction, and attrition. The primary efficacy outcome assessed nightmare severity at week 4. Analyses were intention to treat, estimating treatment effect with 95% confidence intervals (CIs). RESULTS: All participants offered CBT completed therapy (mean [SD], 4.8 [0.6] sessions) with high satisfaction, and 20 (83%) participants completed all assessments. Compared with TAU, CBT led to large improvements in nightmares (adjusted mean difference = -7.0; 95% CI, -12.6 to -1.3; d = -1.1) and insomnia (6.3; 95% CI, 2.6 to 10.0; d = 1.4) at week 4. Gains were maintained at follow-up. Suicidal ideation was not exacerbated by CBT but remained stable to follow-up, compared with TAU, which reduced at follow-up (6.8; 95% CI, 0.3 to 3.3; d = 0.7). CBT led to reductions in paranoia (-20.8; 95% CI, -43.2 to 1.7; d = -0.6), although CIs were wide. Three serious adverse events were deemed unrelated to participation (CBT = 2, TAU = 1). CONCLUSIONS: CBT for nightmares is feasible and may be efficacious for treating nightmares and comorbid insomnia for patients with persecutory delusions. It shows promise on paranoia but potentially not on suicidal ideation.

Precuneus and psychiatric manifestations: Novel neurobiological formulations through lesion based connectivity mapping of psychopathology.

Lesion-based investigations of psychopathology have preceded contemporary network-neuroscience initiatives. However, brain-lesions detected in routine psychiatric practice are often considered incidental and therefore ignored. Here, we illustrate a strategy to combine individual subject-level lesion information with open-source normative functional-connectomics data to make putative, neuroscience-informed symptom interpretation. Specifically, we report a patient with left precuneus granulomatous lesion and seizures followed by two distinct symptoms - kinetopsia and delusions of nihilism and guilt - which had a differential treatment response. The lesion-based brain-mapping approach could identify correlated (default-mode) and anti-correlated (temporo-parieto-occipital) networks, which enabled a neurobiological formulation of these diverse clinical manifestations.

[Treatment of refractory aggressiveness by amygdalotomy and posteromedial hypothalamotomy by radiofrequency]. / Tratamiento de la agresividad refractaria mediante amigdalotomia e hipotalamotomia posteromedial por radiofrecuencia.

INTRODUCTION: Since, under certain circumstances, defensive or attacking behaviours display a pattern of motor dominance, as observed in subjects who participate in contact or fighting sports, aggressive behaviour was considered to have a dominant motor pattern. With the aim of preventing the functional problems reported with bilateral lesion procedures involving both the central nucleus of the amygdala and the posteromedial hypothalamus, the decision was made to combine them; thus, an amygdalotomy of the central nucleus of the amygdala and a posteromedial hypothalamotomy were to be performed simultaneously and unilaterally, on the basis of the motor dominance of the patient determined by means of the Edinburgh test. PATIENTS AND METHODS: This study describes the surgical experience in a series of nine patients diagnosed with refractory neuroaggressive syndrome. As part of the study protocol, a magnetic resonance brain scan was performed to rule out the presence of neoplasms, vascular diseases, infections and degenerative disorders. The degree of aggressiveness was quantified using Yudofsky's Overt Aggression Scale. Additionally, manual dominance was determined by means of the Edinburgh test. RESULTS AND CONCLUSIONS: Good control of aggressiveness was seen immediately. In some cases it was necessary to reduce the antipsychotic or benzodiazepine medication, as it was seen to increase aggressiveness. Only one case required a second surgical intervention. Follow-up was achieved in 100% of the cases at 24 months and 78% at 36 months.

TITLE: Tratamiento de la agresividad refractaria mediante amigdalotomia e hipotalamotomia posteromedial por radiofrecuencia.Introduccion. Dado que, en algunas circunstancias, las conductas defensivas o de ataque muestran un patron de dominancia motora, tal como se observa en los sujetos dedicados a los deportes de contacto o de lucha, se considero que la conducta agresiva tiene un patron motor dominante. Con el fin de evitar los problemas funcionales descritos con los procedimientos de lesion bilateral tanto del nucleo central de la amigdala como del hipotalamo posteromedial, se decidio combinarlos; es decir, realizar amigdalotomia del nucleo central de la amigdala e hipotalamotomia posteromedial de manera unilateral y simultanea, basandose en la dominancia motora del paciente mediante la prueba de Edimburgo. Pacientes y metodos. Este estudio muestra la experiencia quirurgica en una serie de nueve pacientes con el diagnostico de sindrome neuroagresivo resistente al tratamiento farmacologico. Dentro del protocolo de estudio, se les realizo resonancia magnetica cerebral para descartar la presencia de neoplasias, enfermedades vasculares, infecciones y trastornos degenerativos. El grado de agresividad se cuantifico mediante la escala global de agresividad de Yudofsky. Adicionalmente, se determino la dominancia manual a traves de la prueba de Edimburgo. Resultados y conclusiones. El buen control de la agresividad se observo de modo inmediato. En algunos casos fue necesario reducir la medicacion de antipsicoticos o benzodiacepinas, ya que aumentaban la agresividad. Solo un caso requirio una segunda cirugia. Se logro seguimiento del 100% de los casos en 24 meses y del 78% en 36 meses.

Improvement in renal prognosis with prompt hemodialysis in hyperosmolar hyperglycemic state-related rhabdomyolysis: A case report.

RATIONALE: Acute kidney injury is common and correctable in patients with a hyperosmolar hyperglycemic state (HHS). Nevertheless, hyperglycemic crisis may also contribute to the development of rhabdomyolysis, which can worsen renal function and lead to high mortality in such patients. PATIENT CONCERNS: Herein, we report a case of hyperosmolar hyperglycemic state-related rhabdomyolysis and acute renal failure with an excellent outcome. DIAGNOSIS: A 26-year-old Asian female with underlying paranoid schizophrenia presented with newly diagnosed type 2 diabetes mellitus complicated with HHS. Her renal function deteriorated rapidly in spite of standard management for hyperglycemic crisis. Rhabdomyolysis was subsequently diagnosed according to the high levels of serum creatine kinase (CK) (37,710 U/L, normal range: 20-180 U/L) and myoglobin (5167.7 ng/mL, normal range: 14.3-65.8 ng/mL). INTERVENTIONS: After treatment failure of intravenous hydration plus loop diuretic agent for rhabdomyolysis related acute renal failure, temporary hemodialysis was performed 3 times to relieve oligouria and pulmonary edema. OUTCOMES: Her renal function recovered well after temporary renal replacement therapy. LESSONS: Rhabdomyolysis is a complication of HHS. Delayed detection can be fatal, and timely renal replacement therapy can result in an excellent prognosis. Therefore, it is crucial for clinicians to detect and treat such patients as early as possible to avoid impairing their renal function.

Rituximab-Treated Pemphigus Foliaceus in a Schizophrenic Patient: A Challenging Exercise in Diagnosis, Management, and Follow-Up.

Dermatology was consulted in the care of a 58-year-old man with a history of paranoid schizophrenia, neuroleptic malignant syndrome, a positive purified protein derivative test, and a lack of bathing for approximately 4 years who had been admitted to the hospital because of thick, crusted lesions over an increasing portion of his body. Admitted involuntarily, he was disinterested in the history, physical examination, and diagnostic testing. Comorbid schizophrenia presented a unique challenge because he was unable to participate in his care effectively. His story was told through caregivers. Although mostly compliant, the patient was reserved and indifferent, and had little to add even with direct questions.

Could the screening for correct oral health reduce the impact of death due to bolus asphyxia in adult patients? A forensic case report.

INTRODUCTION: "Bolus death" or "Café Coronary syndrome" refers to death due to asphyxia caused by an occlusion of the upper airways due to food. In this kind of asphyxia, the food bolus obstructs the larynx or the bronchial branches. This kind of event often affects subjects with acute intoxication due to alcohol or drugs, or with edentulism and with neurological or psychiatric diseases. CASE REPORT: An elderly woman, suffering from schizophrenia, was found dead in her house due to food bolus asphyxia. The post-mortem toxicological analysis on the deceased's biological fluids revealed the presence of tricyclic antidepressants, antipsychotics and neuroleptics. Study of the oral cavity showed the presence of partial edentulism and periodontal disease. HYPOTHESIS: We hypothesize that this kind of asphyxia in adults can be prevented. We believe that there are two major preventable factors: edentulism and salivation disorders in elderly and neuropsychiatric patients. The primary prevention of these pathologies would deal with the basic physician, similarly to other screenings already effectively in place. CONCLUSIONS: It is possible to prevent fatal asphyxia in subjects who suffer from this kind of diseases through appropriate screening. This prevention strategy would greatly reduce the amount of choking deaths in adults.