Integration of Clozapine-associated Harm Obsessions into Cognitive Behavioral Conceptualization and Treatment Planning for Thought Broadcasting: A Case Study.

BACKGROUND AND OBJECTIVES: As many as 30% of individuals with a schizophrenia spectrum disorder experience obsessive-compulsive symptoms (OCS). Clozapine has demonstrated superior efficacy for the treatment of medication-resistant schizophrenia but it is also associated with an increased risk for OCS. Because pharmacologic management of clozapine-related OCS can be particularly challenging, cognitive behavioral therapy (CBT) should be considered. Nevertheless, there are few detailed accounts of CBT for OCS and schizophrenia. METHODS: The authors describe the interdisciplinary outpatient care of a client who had a 25-year history of schizoaffective disorder, bipolar type, and OCS. The case formulation was used to guide interventions to target core schemas of being dangerous and defective. The case study describes the cognitive behavioral formulation, treatment targets, treatment course, and functional and symptom response. RESULTS: The client received 21 sessions of a formulation-based CBT for psychosis protocol, which included a 6-session course of exposure with response prevention, consisting of imaginal and in vivo exposure to multiple salient harm stimuli. Reduced ratings of distress and a 50% reduction in OCS suggest that habituation and inhibitory learning occurred. The treatment of OCS resulted in the complete resolution of thought broadcasting. Subsequently, the client was more successful in his efforts to adhere to an action schedule. LIMITATIONS: The use of both the treatment approach described in this clinical case report and contemporaneous medication management preclude comment on the mechanism(s) of the therapeutic change observed in this case. CONCLUSIONS: This report presents a means of conceptualizing the interplay between thought broadcasting and harm obsessions and discusses considerations in identifying and treating individuals with similar comorbid conditions, particularly in the context of clozapine treatment for medication-resistant psychosis.

Endocrinopathies and renal outcomes in lithium therapy: impact of lithium toxicity.

BACKGROUND: Lithium is the mainstay of treatment for bipolar disorder, mania and an augmentation therapy in patients with treatment resistant depression. It has a narrow therapeutic index, with recognized adverse multi-system and endocrine side effects. AIM: To assess the impact of lithium therapy, in particular lithium toxicity, on the development of endocrine and renal disorders in a cohort of patients in a single tertiary referral centre in Ireland. STUDY DESIGN: A retrospective analysis was performed of the prevalence of lithium toxicity and renal, thyroid and parathyroid dysfunction in our study population. METHODS: We collected laboratory data from the Clinical Chemistry department of the Adelaide and Meath Hospital incorporating the National Children's Hospital (AMNCH), Dublin, Ireland. Our study population included all patients who had at least one serum lithium measurement from January 1st 2000 to December 31st 2014 inclusive. RESULTS: A total of 580 patients were included in the study. Among our study group, 70 patients (12.1%) had 1 toxic lithium measurement (lithium level >1.2 mmol/l). 27.8% (n > 161) of patients developed stage 3 Chronic kidney Disease (CKD) or higher, which was commoner in those patients who developed toxic lithium levels (P < 0.0001) and in those who developed hypernatraemia (P > 0.0001). 16.2% of patients (n > 94) had one serum sodium >145 mmol/l during follow up. 60 patients(10.3%) had a TSH >10 mU/l, while complete suppression of TSH (<0.05 mU/l) was observed in 22 patients (3.8%) during follow-up. 4% (n > 37) of the study population had ≥1 serum corrected calcium level > 2.55 mmol/l, and 4 patients had biochemical confirmation of primary hyperparathyroidism but PTH levels were only performed in 2.8% (n > 16) of the studypopulation. CONCLUSION: Stage 3 CKD is common in patients receiving lithium therapy. Lithium toxicity is associated with CKD and hypernatraemia. Thyroid dysfunction and hypercalcaemia are common in patients receiving lithium therapy. Patients receiving lithium therapy require surveillance of renal, thyroid and bone biochemistry.

Recurrent unipolar mania: A comparative, cross-sectional study.

INTRODUCTION: A significant number of patients experience recurrent episodes of mania without depressive episodes. Evidence from the available literature suggests that these patients differ from typical "bipolar" or "manic-depressive" patients, but results have been inconsistent. The current study aims to add to this literature by comparing the demographic, clinical and risk factor profiles of patients with recurrent mania with and without depression. METHODS: 66 patients with a diagnosis of bipolar I disorder were divided into "unipolar mania" (recurrent mania alone, MA) and "bipolar" (both mania and depression, MD) sub-groups. Comorbid diagnoses were assessed using the Mini International Neuropsychiatric Interview (MINI), and genetic and environmental risk factors were explored using the Diagnostic Interview for Genetic Studies (DIGS), Childhood Trauma Questionnaire (CTQ), and an additional questionnaire designed for the purpose of the study. Differences between the MA and MD groups in terms of demographic variables, clinical profile, comorbidities and antecedent risk factors were explored. RESULTS: Patients with both mania and depression had higher frequencies of lifetime suicide attempts, antidepressant treatment, and catatonic symptoms. There was some evidence of an association between overcrowding in childhood and the presence of depressive episodes. No other differences in demographic, clinical or risk factor variables could be found between the two groups. DISCUSSION: Our results are consistent with the view that unipolar mania is not a distinctive disorder, or even a distinctive subtype of bipolar disorder. However, this conclusion is provisional as it is based only on clinical and demographic data.