Cocaine Induced Postictal Psychosis: a Rare Cause of Antipsychotic Resistant Psychosis.

Voluntarism in Consultation Psychiatry: The Forgotten Capacity

Visual and Auditory Hallucinations During Normal Use of Paroxetine for Treatment of Major Depressive Disorder

Persistent Auditory Hallucinations That Are Unresponsive to Antipsychotic Drugs

Back to table of contents Previous article Next article LETTERFull AccessA Possible Case of Peduncular Hallucinosis in a Patient with Parkinson’s Disease Successfully Treated With QuetiapineDavid R. Spiegel M.D.Brandy Lybeck B.S.Victoria Angeles M.D.,David R. Spiegel M.D.Search for more papers by this authorBrandy Lybeck B.S.Search for more papers by this authorVictoria Angeles M.D.Search for more papers by this author,Published Online:1 Apr 2009https://doi.org/10.1176/jnp.2009.21.2.225aAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: Peduncular hallucinosis was first described by Lhermitt as odd visual hallucinations stemming from lesions affecting the midbrain, pons, and thalamus. 1 We report on an elderly female with Parkinson’s disease who possibly exhibits this rare form of perceptual disturbance. Case Report Our patient is a 76-year-old Caucasian woman with a 3-year history of Parkinson’s disease, presenting with acute dyspnea which resulted in her hospitalization. She reported visual hallucinations of “mechanical bugs walking around the hospital” and “two people fighting” in the corner of her room. The visual hallucinations began 1 year prior to her hospitalization and were nondistressing. She had insight into the visual hallucinations. Our patient was treated with carbidopa- l -dopa until 4 months prior to admission. The patient’s mental status exam was notable for bradyphasia, psychomotor retardation, and limited range of affect. She had signs of a pill rolling tremor on her left hand. She was otherwise alert and oriented times 3 with no fluctuations in consciousness. She reports visual hallucinations in the absence of bizarre delusions or auditory hallucinations. Cognitive examination was notable for deficits in short-term recall (which improved with cues) and attention span. An MRI scan of the brain revealed a hyper-intense focus adjacent to the right thalamus consistent with an old lacunar infarct. An EEG revealed no eliptiform discharges or significant slowing.Our patient was treated with quetiapine for the visual hallucinations, with a noted decrease in the number of hallucinations for the remainder of the hospital stay.Discussion Visual hallucinations often suggest a wide range of etiologies. Hallucinations and delusions occur in up to 40% of patients with Parkinson’s disease. Visual hallucinations are typically associated as a side effect of dopamine agonists, such as carbidopa- l -dopa, in about 20% of Parkinson’s disease patients; however, our patient’s visual hallucinations persisted despite discontinuation of carbidopa- l -dopa. 2 The differential diagnosis for visual hallucinations includes neurodegenerative dementias, such as Parkinson’s dementia, postictal states, intoxications/delirium tremens, migraine headache with aura, and narcolepsy. 3 Peduncular hallucinosis is a rare form of visual hallucination characterized by intense, vividly colored, nonstereotypical visual images of people, animals, and plants that are nonthreatening to the patient. The exact mechanism for peduncular hallucinosis is unknown. One theory is that when “normal” afferent input is decreased, for example by diminished visual acuity, spontaneous cerebral activity of the visual system is disinhibited, resulting in visual hallucinations. However, given the rarity of such cases, it may be that cerebral pathology may render some elderly patients vulnerable to this disinhibited phenomena associated with pontine lesions. 4 However, according to Cubo et al., 5 visual hallucinations are more likely to occur with more severe overall Parkinson’s symptoms and longer duration of Parkinson’s disease. Our patient only had Parkinson’s disease for 3 years and was only mildly impaired by the illness. Thus, based on clinical and radiographic findings, peduncular hallucinosis was considered in the differential diagnosis of our patient’s visual hallucinations. In closing, the emergence of new-onset visual hallucinations in the elderly warrants an MRI of the brain and, although rare, peduncular hallucinosis should be considered in the differential diagnosis, especially with brain stem or thalamic infarcts. Department of Psychiatry, Eastern Virginia Medical School, Norfolk, Virginia

Back to table of contents Previous article Next article LETTERFull AccessA Possible Case of Peduncular Hallucinosis in a Patient with Parkinson’s Disease Successfully Treated With QuetiapineDavid R. Spiegel M.D.Brandy Lybeck B.S.Victoria Angeles M.D.,David R. Spiegel M.D.Search for more papers by this authorBrandy Lybeck B.S.Search for more papers by this authorVictoria Angeles M.D.Search for more papers by this author,Published Online:1 Apr 2009https://doi.org/10.1176/jnp.2009.21.2.225aAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: Peduncular hallucinosis was first described by Lhermitt as odd visual hallucinations stemming from lesions affecting the midbrain, pons, and thalamus. 1 We report on an elderly female with Parkinson’s disease who possibly exhibits this rare form of perceptual disturbance. Case Report Our patient is a 76-year-old Caucasian woman with a 3-year history of Parkinson’s disease, presenting with acute dyspnea which resulted in her hospitalization. She reported visual hallucinations of “mechanical bugs walking around the hospital” and “two people fighting” in the corner of her room. The visual hallucinations began 1 year prior to her hospitalization and were nondistressing. She had insight into the visual hallucinations. Our patient was treated with carbidopa- l -dopa until 4 months prior to admission. The patient’s mental status exam was notable for bradyphasia, psychomotor retardation, and limited range of affect. She had signs of a pill rolling tremor on her left hand. She was otherwise alert and oriented times 3 with no fluctuations in consciousness. She reports visual hallucinations in the absence of bizarre delusions or auditory hallucinations. Cognitive examination was notable for deficits in short-term recall (which improved with cues) and attention span. An MRI scan of the brain revealed a hyper-intense focus adjacent to the right thalamus consistent with an old lacunar infarct. An EEG revealed no eliptiform discharges or significant slowing.Our patient was treated with quetiapine for the visual hallucinations, with a noted decrease in the number of hallucinations for the remainder of the hospital stay.Discussion Visual hallucinations often suggest a wide range of etiologies. Hallucinations and delusions occur in up to 40% of patients with Parkinson’s disease. Visual hallucinations are typically associated as a side effect of dopamine agonists, such as carbidopa- l -dopa, in about 20% of Parkinson’s disease patients; however, our patient’s visual hallucinations persisted despite discontinuation of carbidopa- l -dopa. 2 The differential diagnosis for visual hallucinations includes neurodegenerative dementias, such as Parkinson’s dementia, postictal states, intoxications/delirium tremens, migraine headache with aura, and narcolepsy. 3 Peduncular hallucinosis is a rare form of visual hallucination characterized by intense, vividly colored, nonstereotypical visual images of people, animals, and plants that are nonthreatening to the patient. The exact mechanism for peduncular hallucinosis is unknown. One theory is that when “normal” afferent input is decreased, for example by diminished visual acuity, spontaneous cerebral activity of the visual system is disinhibited, resulting in visual hallucinations. However, given the rarity of such cases, it may be that cerebral pathology may render some elderly patients vulnerable to this disinhibited phenomena associated with pontine lesions. 4 However, according to Cubo et al., 5 visual hallucinations are more likely to occur with more severe overall Parkinson’s symptoms and longer duration of Parkinson’s disease. Our patient only had Parkinson’s disease for 3 years and was only mildly impaired by the illness. Thus, based on clinical and radiographic findings, peduncular hallucinosis was considered in the differential diagnosis of our patient’s visual hallucinations. In closing, the emergence of new-onset visual hallucinations in the elderly warrants an MRI of the brain and, although rare, peduncular hallucinosis should be considered in the differential diagnosis, especially with brain stem or thalamic infarcts. Department of Psychiatry, Eastern Virginia Medical School, Norfolk, Virginia

A 46-year-old woman with bipolar affective disorder of 4 year’s duration was admitted for acute onset of agitation, delirium and confusion. She had been placed in 4-point restraints during transfer from another hospital. On admission, the patient was agitated and restless and was verbally abusive to the hospital staff. Her skin was warm and sweaty, clinically dehydrated. She was tachycardic with a heart rate ranging between 97 and 120/min. The rhythm was normal. She had mild bilateral pedal edema and was afebrile. She was oriented to place but not to time or person. She appeared to be experiencing visual and auditory hallucinations and had racing thoughts. Her speech was pressured but not dysarthric. She had a coarse tremor in her upper limbs and brisk tendon reflexes but no ataxia. The patient had been prescribed a number of medications to treat recurrent auditory (hears her dead fathers voice) and visual hallucinations (seeing angels) as well as paranoid delusions. These included ziprasidone and risperidone. Her most recent medication was lithium 600 mg a day. According to her family, the patient’s ability to perform self-care had worsened over the previous year and she no longer took pride in her care. There was no family history of any psychiatric or thyroid illness. Patient’s thyroid function was normal 2 months prior, checked by her psychiatrist. Her abnormal blood count (CBC) and liver panel admission results were: white blood …

Article AbstractBecause this piece does not have an abstract, we have provided for your benefit the first 3 sentences of the full text.To the Editor: Delusional infestation, also known as Ekbom syndrome and delusional parasitosis, is a clinical disorder in which affected individuals have the fixed, false belief that they are infected with parasites or other living organisms. It is classified as a delusional disorder, somatic type in the DSM-5. This condition is also encountered by dermatologists. We present a case of delusional infestation in an individual infected with the human immunodeficiency virus (HIV).

A patient manifesting an acute psychosis after receiving an injection of procaine penicillin is reported. The psychosis began immediately after drug administration and gradually abated over a forty-eight-hour period. The clinical presentation was dominated by paranoid delusions and a Capgras-like syndrome. Sixty-six previously reported cases were identified and reviewed. Patients manifested combinations of fear, auditory hallucinations, somatic hallucinations, visual hallucinations, and paranoid or religious delusions. The syndrome may occur with inadvertent intravenous injection of procaine and most likely reflects the action of procaine on limbic system structures.

IntroductionNeurocysticercosis (NCC) is the most common parasitic infection of the central nervous system (CNS)(1)(2). It is caused by larvae stages of Taenia Solium and is the major cause of acquired epilepsy worldwide(3). Seizure disorders are common neurological manifestation(4); however, neuropsychiatric manifestations have also been reported(5,6). Humans acquire infection through ingestion of eggs of Taenia Solium from contaminated food(7). The brain immunological response towards the cysts may be responsible for the pleomorphic manifestations(8), including psychiatric symptoms that may take years before the onset of seizures(6). As a result, diagnostic confusion is common, and this often affects management and outcome.Case reportWe report a case of 30-year-old black African male who presented with a history of auditory hallucinations and behavioral changes without focal neurologic signs or symptoms. The onset of generalized tonic-clonic seizures prompted him to seek medical attention although prodromal psychiatric symptoms started about a year before the onset of seizures. MRI of the brain revealed multiple cysts involving mainly the cerebral cortex.ConclusionThis case highlights the need to exclude organic cortical pathology should in rare forms of psychiatric manifestations such unilateral auditory hallucinations and acute behavioral disturbances. Correct diagnosis and prompt management will prevent complications and usually have a favorable prognosis.Key clinical messagePleomorphic manifestations of NCC pose a challenge in diagnosis. We present a case of a 30-year old male who presented with prodromal psychiatric symptoms before the onset of generalized tonic-clonic seizures. This case highlights challenges in diagnosis though prompt management promises a favorable outcome.

This study sought to elucidate the relation of clinical, neuropsychological, and seizure variables to chronic and postictal psychoses in patients with temporal lobe epilepsy. Forty-four patients with treatment-refractory temporal lobe epilepsy were given formal psychiatric evaluations; 29 patients had no psychiatric disorder or a nonpsychotic disorder, eight patients had postictal psychoses, and seven patients had chronic psychoses. Comparisons of clinical, neuropsychological, magnetic resonance imaging, and seizure variables were made between the nonpsychotic and the psychotic patients and, secondarily, between the patients with transient postictal psychoses and those with chronic psychoses. Bitemporal seizure foci, clustering of seizures, and absence of febrile convulsions were associated with both postictal psychoses and chronic psychoses. Younger age at onset of epilepsy and lower verbal and full-scale IQs differentiated the patients with chronic psychoses from those with postictal psychoses. Patients with temporal lobe epilepsy with chronic and postictal psychoses show similar profiles of clinical and seizure variables, suggesting shared etiologic factors. These factors may increase the propensity to develop psychotic symptoms, while other factors, such as time of onset of epilepsy and underlying neuropathology, may determine whether transient or chronic psychotic symptoms develop. Even among patients with treatment-refractory temporal lobe epilepsy, a specific subgroup of patients, characterized by bitemporal seizure foci, an absence of febrile convulsions, and a history of clustering of seizures, appears to be particularly prone to develop psychotic disorders. A process similar to secondary epileptogenesis may be involved in the development of the psychoses.

Any attempt to compare the definitions of symptoms listed for "primary psychoses" with those adopted in studies of psychoses in patients with epilepsy (PWE) will encounter problems of heterogeneity within both conditions. In this manuscript, five psychotic illnesses listed in Diagnostic and Statistical Manual of Mental Disorders-5th Edition (DSM-5), that is, brief psychotic illness, schizophreniform disorder, schizophrenia, delusional disorder, and schizoaffective disorder are compared with postictal (or periictal) and interictal psychotic disorders in PWE. After examining definitions of primary psychoses, definitions of psychoses adopted in the papers dealing with postictal and interictal psychoses are summarized. Further, diagnostic criteria of five types of psychotic disorders in PWE proposed in 2007 by Krishnamoorthy et al. are also discussed, which include postictal psychosis, comorbid schizophrenia, iatrogenic psychosis caused by antiepileptic drugs (AEDs) (AED-induced psychotic disorder: AIPD), and forced normalization. Evidently, a comparison between postictal psychosis and schizophrenia is pointless. Likewise, schizophrenia may not be an appropriate counterpart of forced normalization and AIPD, given their acute or subacute course.Based on these preliminary examinations, three questions are selected to compare primary psychoses and psychoses in PWE: Is postictal psychosis different from a brief psychotic disorder? Does epilepsy facilitate or prevent the development of psychosis or vice versa? Is interictal psychosis of epilepsy different from process schizophrenia? In conclusion, antagonism between psychosis and epileptic seizures in a later stage of active epilepsy seems not to be realized without reorganization of the nervous system promoted during an earlier stage. Both genetic predisposition and the summated effects of epileptic activity must be taken into consideration as part of a trial to explain interictal psychosis. Interictal psychosis is an aggregate of miscellaneous disorders, that is, co-morbid schizophrenia, AED-induced psychotic disorders, forced normalization, and "epileptic" interictal psychosis. Data are lacking to conclude whether differences exist between process schizophrenia and "epileptic" interictal psychosis in terms of negative symptoms, specific personal traits, and the "bizarre-ness" of delusory-hallucinatory contents. These discussions may shed light on the essence of process schizophrenia, thus allowing it stand out and receive increased focus.

Charles Bonnet syndrome (CBS) is by complex visual hallucinations and ocular pathology causing vision loss. It has been considered that CBS occurs frequently in elderly visually handicapped patients and the hallucinations are limited to the visual modality. Three hypotheses we examined were: (1) whether visual impairments are associated with visual hallucinations (2) whether visual impairments are associated with auditory hallucinations (3) whether the development of visual and auditory hallucinations in patients with visual impairments is associated with age. Data from the National Comorbidity Survey Replication (NCS-R) in the United States were used to examine whether associations between visual impairments and visual hallucinations can be found in the general population, and whether such influences of visual impairments are limited to the visual modality and to specific age groups. Prevalence of visual and auditory hallucinations in respondents with visual impairments were 12.8% (95% Confidence Interval (CI)=3.4-22.2%) and 7.1% (95%CI=2.6-11.6%) respectively. Although the point estimates were substantive, the odds ratios between visual impairments and existence of visual hallucinations or auditory hallucinations were not statistically significant (odds ratio (OR)=2.43, 95%CI=0.92-6.44, P=0.07 and OR=2.16, 95%CI=0.87-5.33, P=0.10, respectively) in the whole sample. Association between visual impairments and visual hallucination was significant (OR=3.09, 95%CI=1.06-8.99, P<0.05) only in the elderly (age group 60-), while significant association was found between visual impairments and auditory hallucinations in a younger age group (age group 18-39, OR=13.25, 95%CI=2.99-58.75, P<0.001). Visual impairments act as a trigger for both visual and auditory hallucinations. In patients with visual impairments, the presence of visual hallucinations was associated with an age over 60, while the existence of auditory hallucinations was associated with an age under 39.

“Mr. H” is a 52-year-old homeless divorced Caucasian man with a history of paranoid schizophrenia, alcohol, opiate, and cocaine use disorders, and hepatitis C virus (HCV) infection complicated by cirrhosis and hepatic encephalopathy. After a 2-month inpatient psychiatric admission for worsening psychosis and suicidal ideation, Mr. H was referred to our partial hospital program for ongoing psychiatric treatment. Mr. H’s psychiatric history first became notable for substance use and psychotic symptoms in his late teens, and his first psychiatric hospitalization occurred in his early 20s. In recent years, he exhibited a pattern of increasingly frequent psychiatric hospitalizations, of which he had 15 in the past 7 years. His hospitalizations were often precipitated by the emergence of command auditory hallucinations, paranoia, and thought broadcasting. His psychosis was sometimes accompanied by depressed mood, hopelessness, suicidal ideation, generalized anxiety, and active substance use involving alcohol, cocaine, or both. He had no history of suicide attempts or violence. He had been treated with a variety of antipsychotic and antidepressant medications, although he struggled to adhere to treatment. A remote clozapine trial was noted in his records, although no details were provided on the trial’s timing, dosage, duration, or efficacy, and Mr. H was unable to recall them. He had no documented treatment with long-acting antipsychotic injections. Mr. H’s substance use consisted of significant and chronic alcohol use, and he hadmademultiple attempts to achieve sobriety with the assistance of detoxification and 12-step programs. He first used alcohol at age 13, and his use became regular and problematic in his late teens. He reported his drinking over the past 5 years as daily on average, with approximately 5–6 drinks per day, and more on some occasions. He often required detoxification with benzodiazepines on admission to psychiatric facilities. He was periodically treated with acamprosate, usually after inpatient admissions, but his adherence to the medication was inconsistent, and he did not report significant reductions in alcohol use. Mr. H also had a history of cocaine and opiate use (occasionally by intravenous injection, in his 20s and 30s). Coincident with his marriage in his mid-20s, he accrued 30 consecutive months of sobriety from drugs and alcohol, his longest substance-free period. His last use of alcohol and cocaine occurred just before his latest hospitalization. He had few social supports, and his substance use and repeated hospitalizations had contributed to his divorce after a few years of marriage and multiple episodes of homelessness lasting several months, including the loss of his apartment 3 months before his current partial hospital admission. Mr. H’s medical history was notable for hypertension and untreated chronic HCV genotype 1 infection of unknown duration, diagnosed 5 years ago when elevated liver enzyme levels were noted during a psychiatric admission. Cirrhosis was identified 2 years after his HCV diagnosis, again during a psychiatric admission, in the setting of symptoms of hepatic encephalopathy. Mr. H had experienced persisting pancytopenia related to hypersplenism and liver disease over the past 5 years, with white blood cell counts ranging from 2.5 to 4.0310/L. Historically, his medical care was sporadic and suffered from fragmentation, limited coordination, and poor adherence to followup recommendations. On admission to the partial hospital program, Mr. H reported no psychotic or mood symptoms. He identified urges to use alcohol but was motivated to remain sober. He was fully oriented, with grossly intact attention and memory. His medications included aripiprazole, 30 mg daily, and risperidone, 1 mg twice daily. To reduce the risk of recurrent hepatic encephalopathy, he was being treated with lactulose. He received diphenhydramine, 50 mg, and zolpidem, 5 mg, each night for insomnia. Because of a recent positive tuberculin skin test, he was being treated for latent tuberculosis with daily isoniazid and vitamin B6. Mr. H engaged in the partial hospital program’s cognitivebehavioral therapy-based group therapy program and met individually with members of a multidisciplinary treatment team. Over the next 8 weeks, his mental status was notable for fluctuations in mood, anxiety, and psychosis. He intermittently reported alcohol and cocaine use. Despite antipsychotic medication, Mr. H had ongoing persecutory delusions, auditory hallucinations that varied in frequency and perceived loudness, and occasional delusional misidentification (Capgras syndrome) and visual hallucinations. The Repeatable Battery for the Assessment of Neuropsychological Status, administered to Mr. H on two occasions when he did not have confusion or prominent mood or psychotic symptoms, demonstrated impairment in immediate memory, visuospatial construction, and attention. To minimize potential hepatic stress from polypharmacy, antipsychotic monotherapy was pursued by discontinuing risperidone, which had not improved his psychotic symptoms appreciably after it was added to aripiprazole. Mr. H tolerated this change well, and aripiprazole was then

Aims: To investigate the relationship between psychotic symptoms and cognitive impairment in Alzheimer's disease (AD). Methods: A total of 108 subjects affected by AD were subdivided into subjects without delusions (ND), subjects with paranoid delusions (PD), subjects with delusional misidentifications (DM), subjects with both DM and PD (DM+PD), subjects with visual hallucinations (v-HALL), and subjects without visual hallucinations (N-HALL). Results: PD and ND subjects performed similarly on neuropsychological tests, while DM patients performed significantly worse than PD and ND patients. v-HALL patients performed worse than N-HALL patients on memory, visuospatial, and executive functions. As for behavioral features, DM and v-HALL subjects reported higher scores on the abnormal motor behavior subscale of the neuropsychiatric inventory (NPI); PD subjects reported higher scores on the disinhibition subscale of the NPI. The severity of PD was predicted by the severity of disinhibition (B = 0.514; p = 0.016) but not by neuropsychological performances. The severity of DM was predicted by age (B = 0.099; p = 0.048) and MMSE (B = -0.233; p = 0.001). The severity of v-HALL was predicted by age (B = 0.052; p = 0.037) and scores on an immediate visual memory task (B = -0.135; p = 0.007). Conclusions: The occurrence of PD may require the relative sparing of cognitive functions and be favored by frontal lobe dysfunction, while DM is associated with the overall level of cognitive impairment. Finally, v-HALL are associated with the impairment of visuospatial abilities.

Panayiotopoulos syndrome