Transcranial magnetic stimulation-associated mania with psychosis: A case report.

Transcranial magnetic stimulation (TMS) is a noninvasive procedure used in the treatment of depression. We observed TMS-associated mania with psychotic symptoms in a 55-year-old male diagnosed with MDD and generalized anxiety disorder without history of psychosis or mania. Owing to poor pharmacotherapeutic response and worsening symptomatology, TMS was introduced while continuing phenelzine; this was initially successful in demonstrating positive effects on mood. However, the patient began to develop symptoms consistent with mania with psychosis and was hospitalized. Both TMS and phenelzine were discontinued, leading to significant improvement of the symptoms of mania and psychosis. Phenelzine was later reintroduced for maintenance treatment of depression and anxiety, with no recurrence of mania or psychosis. This case report implicates TMS as a possible cause of mania and psychosis symptoms.

Bypassing shame and conversion disorder.

We report a case of conversion disorder (partial aphonia) that was successfully treated with speech therapy. During the one year duration of this illness, the patient regained transiently (minutes) her normal speech on a few occasions, independently of concomitant pharmacological interventions. One year after recovery she developed aphonia for the second time, which responded again to speech therapy, although the response rate was slower. Several mechanisms of conversion disorder are reviewed as specifically applied to this case. The possible role of pertinent shame mechanisms in the conversion pathology is discussed.

Interactions between antidepressants, sleep aids and selected breast cancer therapy.

Depression and insomnia are very significant pathologies in cancer patients as they contribute to the patient's overall cure and quality of life. Moreover, untreated depression and ongoing insomnia are associated with decreased immune responses and lower survival rates. With all disease states and especially with cancer, close attention to drug-drug interactions and the potential impact on the efficacy of therapy is paramount. One area of particular interest due to the lack of well-done clinical trials is drug-drug interaction(s) between antidepressants and cancer treatment. Pharmacokinetics of a certain drug allows for prediction of certain drug interactions based on chemical properties of the agents involved. If the agents depend on their metabolites for activity, active drug level will be decreased through this enzyme inhibition. In this paper, we looked at the cytochrome-P450 drug interactions between antidepressants and sleep aids with Selective Estrogen Receptor Modulators (SERM). Newer SERM metabolisms are less influenced by interactions with medications used to treat depression. However, tamoxifen metabolism could be severely altered by several antidepressants. This has direct consequences as patients on tamoxifen and antidepressant can have double the risk of relapse to cancer in two years. We discussed those interactions and made recommendations for clinical use.

Toward a better identification and treatment of schizophrenia prodrome.

The prodromal period leading to schizophrenia has been the focus of significant interest in recent years. This is due not only to the possibility of identification of preschizophrenic states but also to the potential for improving prognosis as a result of early intervention. There are many approaches to the identification of the schizophrenia prodrome. Interventions in the prodromal period have met with various degrees of success. In this article, the authors present an overview of the literature reflecting the development of the prodromal concept and its implications for early identification. They also discuss various interventions proposed for this period and some ethical considerations related to these interventions. Despite the growing body of knowledge in this field, there is a need for more research data to support the establishment of treatment guidelines. Future directions of research are also discussed.

Emergency Department Wait Times for Geriatric Psychiatric Patients.

OBJECTIVE: Older adults with complicated illnesses such as Alzheimer's disease often require specialized treatment in geriatric facilities when inpatient psychiatric hospitalization is needed. However, there is a shortage of these inpatient facilities. Thus, patients could wait in the emergency department (ED) for days pending availability of a bed at an appropriate facility. The objective of this study was to quantify that wait time. METHODS: Records for patients aged 60-89 years who were seen in the ED and had a psychiatric consultation over a 2-year period (July 2014 to June 2016) were reviewed. Total mean time spent in the ED was calculated on the basis of check-in time and time discharged from the ED. We also attempted to calculate the mean wait time for psychiatric consultation and wait time to disposition; however, for many visits, there was no record of when the consultation request was placed and when the recommendations were relayed back to the ED physician. RESULTS: Mean age at time of visit was 66.67 years. Diagnosis of dementia or a neurocognitive disorder most commonly led to referral to geriatric psychiatry rather than other psychiatric services. Of the visits, the most common disposition recommendation was for discharge with outpatient follow-up, and the least common recommendation was admission to the medical unit. The mean time in the ED was over a day for patients with a recommendation for admission and only 13 hours for patients with a recommendation for discharge. CONCLUSIONS: Overall, the findings of this study reiterate the need for more intensive research and improvements in the assessment and care of older adults with psychiatric needs in the ED setting.

Deep brain stimulation for obsessive compulsive disorder: A review of results by anatomical target.

Studies suggest deep brain stimulation (DBS) as a treatment modality for the refractory obsessive-compulsive disorder (OCD). It is unclear where to place the DBS. Various sites are proposed for placement with the ventral capsule/ventral striatum (VC/VS) among the most studied. Herein, we aim to summarize both quantitative Yale-Brown Obsessive-Compulsive Scale (YBOCS) data and qualitative descriptions of the participants' symptoms when given. A literature search conducted via PubMed yielded 32 articles. We sought to apply a standard based on the utilization of YBOCS. This yielded 153 distinct patients. The outcome measure we focused on in this review is the latest YBOCS score reported for each patient/cohort in comparison to the location of the DBS. A total of 32 articles were found in the search results. In total, 153 distinct patients' results were reported in these studies. Across this collection of papers, a total of 9 anatomic structures were targeted. The majority of studies showed a better response at the last time point as compared to the first time point. Most patients had DBS at nucleus accumbens followed by VC/VS and the least patients had DBS at the bilateral superolateral branch of the median forebrain bundle and the bilateral basolateral amygdala. The average YBOCS improvement did not seem to directly correlate with the percentile of patients responding to the intervention. Well-controlled, randomized studies with larger sample sizes with close follow up are needed to provide a more accurate determination for placement of DBS for OCD.

Weight gain changes in patients with aripiprazole monotherapy compared with aripiprazole-antidepressant polypharmacy in an outpatient sample.

OBJECTIVE: This study seeks to evaluate the weight gain effect within a community-based population of patients with diagnoses of depression, mood disorder, and schizophrenia receiving aripiprazole over a period of at least 6 months. METHOD: The four million members of Kaiser Permanente of Southern California (KPSC) were queried for a four-year period between January 1, 2010 and December 31, 2013. The initial cohort comprised 25,682 KPSC members who received at least one dispense of aripiprazole. This initial cohort was split into those who received aripiprazole as a monotherapy ("Alone" group) and those who were given aripiprazole as part of a combination therapy. The group of patients that received aripiprazole and antidepressant with high serotonin reuptake inhibition we called "High" group while the group receiving aripiprazole and bupropion combination we called "Low" serotonin group. We compared the primary endpoint of mean percent weight change from baseline after 180 days of continuous treatment between the three groups. Three pairwise comparisons were made: High versus Alone, Low versus Alone, and Low versus High, using adjusted and unadjusted linear regression models. RESULTS: Within this population, patients on aripiprazole monotherapy showed statistically significant weight gain in all three groups. However, there was no statistically significant difference in weight gain between the aripiprazole monotherapy, the high serotonergic combination group, and the low serotonergic combination group. This finding applied even within the subset of patients who were considered obese (body mass index > 30). CONCLUSIONS: The results suggest that weight gain is unchanged by combination treatments, but further research is required.

The role of oxidative stress in anxiety disorder: cause or consequence?

Anxiety disorders are the most common mental illness in the USA affecting 18% of the population. The cause(s) of anxiety disorders is/are not completely clear, and research in the neurobiology of anxiety at the molecular level is still rather limited. Although mounting clinical and preclinical evidence now indicates that oxidative stress may be a major component of anxiety pathology, whether oxidative stress is the cause or consequence remains elusive. Studies conducted over the past few years suggest that anxiety disorders may be characterised by lowered antioxidant defences and increased oxidative damage to proteins, lipids, and nucleic acids. In particular, oxidative modifications to proteins have actually been proposed as a potential factor in the onset and progression of several psychiatric disorders, including anxiety and depressive disorders. Oxidised proteins are normally degraded by the proteasome proteolytic complex in the cell cytoplasm, nucleus, and endoplasmic reticulum. The Lon protease performs a similar protective function inside mitochondria. Impairment of the proteasome and/or the Lon protease results in the accumulation of toxic oxidised proteins in the brain, which can cause severe neuronal trauma. Recent evidence points to possible proteolytic dysfunction and accumulation of damaged, oxidised proteins as factors that may determine the appearance and severity of psychotic symptoms in mood disorders. Thus, critical interactions between oxidative stress, proteasome, and the Lon protease may provide keys to the molecular mechanisms involved in emotional regulation, and may also be of great help in designing and screening novel anxiolytics and antidepressants.

Empathy as a method of identification of the debut of the prodrome of schizophrenia.

Early identification of the prodrome of schizophrenia is difficult due to the nonspecificity of the symptoms and the limitations of the available tools. In this article, the authors discuss the usefulness of phenomenological and morphoanalytic methods for identification of the prodrome of schizophrenia, and they propose the use of empathy as an additional tool to by-pass same of the difficulties encountered by the previous approaches.

A Case of Attempted Bilateral Self-Enucleation in a Patient with Bipolar Disorder.

Attempted and completed self-enucleation, or removal of one's own eyes, is a rare but devastating form of self-mutilation behavior. It is often associated with psychiatric disorders, particularly schizophrenia, substance induced psychosis, and bipolar disorder. We report a case of a patient with a history of bipolar disorder who gouged his eyes bilaterally as an attempt to self-enucleate himself. On presentation, the patient was manic with both psychotic features of hyperreligous delusions and command auditory hallucinations of God telling him to take his eyes out. On presentation, the patient had no light perception vision in both eyes and his exam displayed severe proptosis, extensive conjunctival lacerations, and visibly avulsed extraocular muscles on the right side. An emergency computed tomography scan of the orbits revealed small and irregular globes, air within the orbits, and intraocular hemorrhage. He was taken to the operating room for surgical repair of his injuries. Attempted and completed self-enucleation is most commonly associated with schizophrenia and substance induced psychosis, but can also present in patients with bipolar disorder. Other less commonly associated disorders include obsessive-compulsive disorder, depression, mental retardation, neurosyphilis, Lesch-Nyhan syndrome, and structural brain lesions.

The dynamics of insight in the prodrome of schizophrenia.

INTRODUCTION: Schizophrenia is characterized by diminished insight, which fluctuates with disease progression. Insight deterioration in the prodrome of schizophrenia is poorly understood. Despite pharmacologic treatment, including early interventions, there is a high risk of relapse and need of acute care in schizophrenia patients. OBJECTIVE: To study if insight deterioration occurs during the prodrome and if insight preservation early in the illness might predict a better prognosis. METHODS: Data was collected retrospectively from the records of 24 patients initially diagnosed with schizophrenia during a 2-year period. Patients' progress was then tracked over a 3-year period. Insight was determined by a physician's subjective evaluation, patient interest and participation in treatment planning, and patient accuracy in reporting behaviors and symptoms when compared with reports from collaterals. RESULTS: Ten patients were determined to have insight regarding the developing illness at different presentations at the hospital. Insight preservation correlated with less need for emergency visits and fewer hospitalization days (P<.005). It was also associated with more depressive and anxious mood (P<.000). Patients and family members described early, ego-dystonic perceptual disturbances followed by diminished insight. Awareness into the illness, symptoms, and attribution of symptoms to the illness fluctuated at different presentations in the insight group. In the other group, insight was nil at each presentation after the psychotic debut. CONCLUSION: Most patients maintain insight during the perceptual disturbance phase. Insight diminishes as the early delusional phase sets in. Higher levels of preserved insight seem to correlate with less need for acute treatment. Further research in this area is warranted for determining if early insight oriented interventions in the prodromal phase can improve the prognosis of schizophrenia.

Mindfulness-Based Cognitive Therapy for Patients With Depression Decreases the Need for Outpatient Visits.

OBJECTIVE: To determine if the use of mindfulness-based cognitive therapy (MBCT) in patients with a history of 2 or more episodes of major depressive disorder and other mood disorders will decrease the need for medication management and other interventions and will also decrease the need for outpatient services and the overall cost of treatment. METHODS: The study patients completed MBCT group sessions between January 1, 2010, and December 31, 2013. Patients who had 2 or more episodes of major depressive disorder (recurrent MDD) were categorized into a group. The remaining patients with other mood disorders were placed in a comparison group. The mean differences in drug treatments and hospital utilizations between the recurrent MDD and nonrecurrent MDD group were compared. Wald P values and 95% CIs were obtained for both adjusted and unadjusted estimated mean differences. Covariates were adjusted for age at start of MBCT, gender, and race/ethnicity. RESULTS: The final sample consisted of 142 patients (93 recurrent MDD and 49 others). There was no significant difference in the effect of MBCT on medication changes between recurrent MDD patients and nonrecurrent MDD patients. Recurrent MDD patients who participated in MBCT experienced reduction in all calls and visits (P = .0068) and less psychiatric visits (P = .0026) in the year after MBCT when compared with the visits before the intervention. CONCLUSIONS: This study evaluated the effectiveness of MBCT in reducing the need for additional psychiatric services. The study evaluated patients who received MBCT over 3 years and demonstrated that MBCT decreased the need for care regardless of medication changes. The results raise the question of whether MBCT allows patients to respond to situations more skillfully or if MBCT itself decreases depressive symptoms. The limitations of this study include a small sample size, patient selection, and its design as a retrospective study. However, this study may have implications as a treatment strategy that may be generalizable to other clinics and patient populations.

Five Supplements and Multiple Psychotic Symptoms: A Case Report.

Dietary supplements, including vitamins, minerals, herbs, amino acids, and enzymes, have become increasingly more common and are used by approximately half of the US population. About three-fourths of supplements are obtained with no prescription from a physician, which raises medical concerns regarding safety as these products do not require US Food and Drug Administration approval. Common reasons for taking dietary supplements include improved mood, improved mental function, depression relief, anxiety reduction, and treatment of simple and migraine headaches. The use of herbs for medicinal purposes has a long-standing history among many cultures. We present the case of a 43-year-old man, who was taking dietary supplements, with a 6-month history of psychotic symptoms that increasingly caused impairment in functioning and eventually led to involuntary hospitalization. The published data with regard to supplements causing psychosis, herb-to-herb interaction, and reliability of herbal supplement manufacturers are discussed.

Brain metabolic changes during cigarette craving.

BACKGROUND: In functional brain imaging studies, exposure to cues related to cocaine, opiates, and alcohol in dependent individuals is associated with activation of the anterior cingulate gyrus, amygdala, orbitofrontal cortex, and dorsolateral prefrontal cortex. Craving for these substances positively correlates with activity in the orbitofrontal cortex, dorsolateral prefrontal cortex, and anterior insula. The objective of this study was to determine changes in regional cerebral glucose metabolism and correlations between craving and regional metabolism in heavy cigarette smokers exposed to cigarette-related cues. METHODS: Twenty heavy smokers (who smoked > or =20 cigarettes per day) and 20 nonsmoking control subjects underwent 2 fluorine 18-fluorodeoxyglucose positron emission tomography scans 10 days apart in randomized order: one while watching a videotape that presented cigarette-related cues and handling a cigarette, and the other while watching an educational (nature) videotape and handling a neutral object (pen). RESULTS: From the neutral to the cigarette cue scan, heavy smokers had greater increases than nonsmoking controls in relative glucose metabolism in the perigenual anterior cingulate gyrus spanning the midline. Significant positive correlations were found between intensity of craving and metabolism in the orbitofrontal cortex, dorsolateral prefrontal cortex, and anterior insula bilaterally. An unexpected positive association was found between craving and metabolism in the right sensorimotor cortex. CONCLUSIONS: Brain regions associated with arousal, compulsive repetitive behaviors, sensory integration, and episodic memory are activated during exposure to cigarette-related cues and cigarette craving. These regional brain activations and associations with craving are similar to findings with other addictive substances.

Factors associated with the prodromal progression of schizophrenia that influence the course of the illness.

OBJECTIVE: This study examined factors influencing the prognosis of patients with different prodromal manifestations of schizophrenia and the association of diagnosis and antipsychotic treatment with the frequency of future acute inpatient care. METHODS: Data was collected from the medical records of 24 patients initially diagnosed with schizophrenia. RESULTS: Seventy-six percent of the patients (N=18) had at least one psychiatric assessment before the debut of schizophrenia. Patients who were assessed prior to the initial diagnosis of schizophrenia presented in two distinct time frames. Patients in the first wave received a different Axis I diagnosis, depending on the phase of prodrome upon time of initial evaluation. Receiving any Axis I diagnosis during the prodromal stage in wave one correlated with an increased need for acute inpatient treatment (P>.0001) in the following 3 years. Among the patients in wave two, those who received antipsychotic treatment required less acute inpatient care than those who did not (P=.004). CONCLUSION: Obtaining a psychiatric history of assessments and interventions during the prodromal period of schizophrenia can be useful for prognosis.

Identification of the schizophrenia prodrome in a hospital-based patient population.

The identification of the schizophrenia prodrome remains a clinical challenge. We analyzed the clinical course of the prodromal symptoms of 24 patients with first-time diagnosis of schizophrenia over a two year period. Their progress was tracked over three years. Patients in the study group reported to mental health care providers years before the schizophrenia diagnosis with subtle, but consistent, alterations in perception and behavior. Furthermore, they received an axis I diagnosis and were prescribed medications, which suggest that they constitute a distinct clinical population.

Implications of Sensorineural Hearing Loss With Hydrocodone/Acetaminophen Abuse.

Sensorineural hearing loss is an infrequently recognized side effect of pain medication abuse. Chronic pain patients treated with opiates develop different degrees of tolerance to pain medications. In many cases, the tolerance becomes the gateway to a variety of cycles of overuse and unmasking of significant psychiatric morbidity and mortality. An individualized approach utilizing combined treatment modalities (including nonopiate pharmaceuticals) is expected to become the norm. Patients can now be provided with multidisciplinary care that addresses an individual's psychiatric, social, and medical needs, which requires close cooperation between physicians of varying specialties. This report describes a patient who experienced hearing loss from hydrocodone/acetaminophen abuse.

Differences between smokers and nonsmokers in regional gray matter volumes and densities.

BACKGROUND: Magnetic resonance imaging (MRI) studies have demonstrated large-scale brain abnormalities in cigarette smokers, such as ventricular enlargement and atrophy. Converging lines of evidence point to functional differences between smokers and nonsmokers in specific brain regions, namely the lateral prefrontal cortex (PFC), anterior cingulate cortex (ACC), ventral striatum, and thalamus. Using MRI, we examined these regions for differences in gray matter between smokers and nonsmokers. METHODS: Thirty-six otherwise healthy adults (19 smokers and 17 nonsmoking control subjects) underwent three-dimensional Fourier-transform spoiled-gradient-recalled acquisition MRI of the brain. Both hand-drawn regions of interest and the computer program voxel-based morphometry were used to assess group differences in regional gray matter volumes and densities, respectively. RESULTS: Smokers had smaller gray matter volumes and lower gray matter densities than nonsmokers in the PFC bilaterally, along with smaller volumes in the left dorsal ACC and lower gray matter densities in the right cerebellum. Smokers also had negative associations between pack-year smoking history and PFC gray matter densities. CONCLUSIONS: Smokers and nonsmokers differed in regional gray matter in brain areas previously linked with nicotine dependence. These findings might reflect effects of chronic smoking, predisposing traits that lead to smoking, or some combination of these factors.

Transprocessing: a proposed neurobiological mechanism of psychotherapeutic processing.

How does the human brain absorb information and turn it into skills of its own in psychotherapy? In an attempt to answer this question, the authors will review the intricacies of processing channels in psychotherapy and propose the term transprocessing (as in transduction and processing combined) for the underlying mechanisms. Through transprocessing the brain processes multimodal memories and creates reparative solutions in the course of psychotherapy. Transprocessing is proposed as a stage-sequenced mechanism of deconstruction of engrained patterns of response. Through psychotherapy, emotional-cognitive reintegration and its consolidation is accomplished. This process is mediated by cellular and neural plasticity changes.