Atypical Psychotic Symptoms Research Articles

DiGeorge Syndrome With Atypical Psychotic Symptoms: The Need for a Multidisciplinary Methodology

DiGeorge syndrome (DGS), known as 22q11.2 deletion syndrome or velocardiofacial syndrome, is one of the most common microdeletion syndromes in humans. Developmental delay, intellectual disability, congenital cardiac and gross vessel anomalies, hypocalcemia, and hearing loss may be seen and characterized by dysmorphic facial features. The syndrome has high risk for psychiatric disorders, specifically intellectual disability and psychotic disorders. Dysmorphic features may be overlooked and the diagnosis may be delayed for years. We explore a case of DGS with intellectual disability and atypical psychotic symptoms. A 19-year-old female patient had atypical psychotic symptoms, dysmorphic facial features, and unilateral hearing loss. Intellectual disability was detected in the IQ test evaluation. A detailed investigation and genetic evaluation resulted in a diagnosis of DGS. This case report highlights the variable clinical presentation of DGS in each patient and the need for a multidisciplinary methodology to diagnose and treat it. [ Psychiatr Ann . 2023;53(9):432–435.]

Distinguising Between Manic Psychosis and Auto-immune Encephalitis: Review of the Literature and Case Report

Introduction In a case series of 100 patients presenting to psychiatric services with psychotic symptoms, Dalmau and colleagues identified that often young women, with key features such as tiredness and short-term memory impairment, were found to be suffering from NMDA-receptor autoimmune encephalitis (AIE). However, distinguishing AIE from true psychotic illness can be challenging. As a consequence, there is a need to help clinicians identify potential patients suffering from AIE. Objectives To identify relevant clinical features of AIE and to propose a strategy that will help psychiatrists screen for AIE. Methods A review of the recent literature, and illustration with a clinical case. Results AIE should be considered especially in female patients presenting in the context of headache, fever, and viral illness-type prodromes, with atypical psychotic symptoms such as agitation, bizarre behaviour, disinhibition, and poorly formed and segmented delusions. Neurocognitive symptoms such as rapid language disintegration and short term memory loss should also prompt further investigation. Progression of AIE leads to motor dysfunction (seizures, dyskinesia), and secondarily autonomic instability and hypoventilation. A young female with a prolonged and severe episode of manic psychosis presented with some of these features, which is why we considered AIE as a differential diagnosis. Conclusions Clinicians should consider AIE when they are faced with a young female presenting with psychotic symptoms and a history of autoimmune illness, with a protracted and unusually severe illness. Investigating for AIE provides an exciting opportunity for psychiatrists to work with neurologists within a multidisciplinary team.

Adult Psychiatric Diagnosis of Niemann-pick Disease Type C (Case Study)

Niemann-Pick disease is a rare, inborn metabolic illness with autosomal recessive inheritance. Its essential characteristic is the disorder of the lysosomal storage of cholesterol, which results in an intracellular accumulation of cholesterol and glycosphingolipoids (the latter are formulated from the former) with consequent cellular lesion. Niemann-Pick disease has three types (A-C), out of which patients suffering from the clinically heterogeneous type C can reach adulthood, and have neuropsychiatric symptoms besides hepatosplenomegaly, so the diagnosis can be identified in the adult psychiatric practice. Among rare diseases, it belongs to those few for which a disease-specific therapy exists. A case with Niemann-Pick disorder Type C identified by us will be referred to. The patient concerned has another rare inborn disease; she has been suffering from Epidermolysis bullosa since infancy. There is no known genetic relationship between the two diseases. In this patient a juvenile form of the NP-C storage disorder has developed, and besides the innate visceral symptoms, neuropsychiatric alterations appeared in the form of learning disabilities. In the beginning, she was treated for attention disorder and specific learning difficulties, then from adolescence for the clinical syndrome of cyclothymia. The first neurological signs also manifested during puberty. The clinical diagnosis of NP-C was made in early adulthood after the recognition of atypical psychotic symptoms and dementia. Besides the symptomatic treatment, we have already been able to start the illness-specific therapy, and now we can show the results of the treatment’s first year.

Trouble psychotique secondaire à un syndrome de Fahr : à propos d’une observation

Fahr's syndrome is a rare disorder characterized by abnormal deposits of calcium in areas of the brain that control movement, including the basal ganglia and the cerebral cortex associated with many neurological and psychiatric abnormalities such as a rigid hypokinetic syndrome, mood disorders and cognitive impairment. Fahr's syndrome is secondary to some disorders, such as hypoparathyroidism. We report the case of a 56 year-old man, with a history of cataract, who was admitted to our psychiatric hospital for the first time in his life because of psychotic symptoms associated with irritability and aggressiveness. Since the age of 38 the patient had become nervous, 10 years later he developed tonic-clonic seizures. Two months ago, he began expressing delusions of persecution against his wife and sons and making fugues. According to his family during this period, he was agitated, aggressive, and suffered from insomnia and anorexia. The general and psychiatric examination showed an upright and bronzed patient with neglected hygiene. He was indifferent to his environment and expressed poor mimics and gestures. He was anxious, suspicious and not very talkative. He was conscious but his attention was slightly decreased. Moreover, he was not aware of his problems. The neurological examination showed extrapyramidal syndrome with postural tremor and cerebellar ataxia. A cranial computed tomography brain scan found bilateral, symmetric basal ganglia calcifications, in favour of Fahr's syndrome. Phosphocalcic investigations revealed low concentration of serum calcium at 1.01mmol/L (normal 2.15 to 2.57mmol/L) and hyperphosphoremia at 2.69mmol/L (normal 0.81 to 1.55mmol/L). He also had low concentrations of 25-OH vitamin as well as decreased urinary levels of phosphate and calcium. The blood level of parathyroid hormone was 0ng/L. The diagnosis of Fahr's syndrome, revealing a hypoparathyroidism was posed. He was supplemented with calcium and alpha cholecalciferol and treated with clozapine (100mg per day). After four weeks, psychotic symptoms responded well to this treatment without expressing any side effects, notably seizures. Psychotic symptoms seen in Fahr's disease include auditory and visual hallucinations, complex perceptual distortions, delusions, and fugue state. Some of them were manifest in this patient. It is likely that the psychosis in both Fahr's disease and schizophrenia share a similar pathology. Positive psychotic symptoms, hallucinations, and paranoia are not necessarily generated by the classical hypothesis of dopamine-mediated attachment of salience to internally generated stimuli. Still, there is some evidence that disruption of the cortex involved in the pathophysiology of schizophrenia is also seen in Fahr's disease, particularly in areas of the limbic system. Psychiatrists should consider Fahr's syndrome as a differential diagnosis in the evaluation of psychosis associated with seizures. This case, along with others in the literature, further emphasizes the importance of the role of neuro-imaging and the search for disrupted phosphocalcic metabolism in patients with atypical psychotic symptoms. Moreover, further research should focus on pharmacologic interventions. The efficacy and risks of neuropharmacologic and psychopharmacologic interventions in Fahr's syndrome, and correlates of good and poor outcome with these interventions remain to be defined.

The Significance of At-Risk Symptoms for Psychosis in Children and Adolescents

The early detection and treatment of people at risk for psychosis is currently regarded as a promising strategy in fighting the devastating consequences of psychotic disorders. Currently, the 2 most broadly used sets of at-risk criteria, that is, ultra-high risk (UHR) and basic symptom criteria, were developed mainly in adult samples. We review the data regarding the presence and relevance of at-risk symptoms for psychosis in children and adolescents. The few existing studies suggest that attenuated psychotic symptoms (APS) and brief limited intermittent psychotic symptoms (BLIPS) do have some clinical relevance in young adolescents from the general population. Nevertheless, their differentiation from atypical psychotic symptoms or an emerging schizotypal personality disorder, as well as their stability and predictive accuracy for psychosis, are still unclear. Further, standard interviews for UHR criteria do not define a minimum age for the assessment of APS and BLIPS or guidelines as to when and how to include information from parents. APS and basic symptoms may be predictive of conversion to psychosis in help-seeking young adolescents. Nevertheless, the rate and timing, and thus the required observation time, need further study. Moreover, no study has yet addressed the issue of how to treat children and adolescents presenting with at-risk symptoms and criteria. Further research is urgently needed to examine if current at-risk criteria and approaches have to be tailored to the special needs of children and adolescents. A preliminary rationale for how to deal with at-risk symptoms for psychosis in clinical practice is provided.

Major Depressive Disorder With Psychosis-Like Symptoms Among Latinos

The lifetime prevalence of psychosis-like symptoms among Latinos living in the United States is 9.5%, and up to 27% of Latinos with major depressive disorder also experience psychosis-like symptoms. Yet clinicians remain uncertain about the nature and clinical implications of these putative psychotic symptoms, and there is no consensus about treatment strategies. The authors conducted a review of the literature to examine the epidemiology, clinical features, and significance of psychosis-like symptoms among Latinos, particularly when such symptoms present with major depressive disorder, and the strategies to treat them. A search of the National Library of Medicine was conducted for all articles published through February 2011 by using the keywords "Hispanic" and "Latino" with "depression and psychotic," with "idiom of distress," and with "psychotic." A total of 37 articles were reviewed. In clinical settings, the prevalence of psychosis-like symptoms among cross-sections of Latino patients ranged from 22% to 46% and was even higher among Latino veterans. Psychosis-like symptoms were associated with higher medical and psychiatric comorbidity and greater suicidality, functional impairment, and utilization of services. The authors describe the types of psychosis-like symptoms experienced by Latinos and propose criteria for the differential diagnosis of such symptoms and typical psychotic features. Clinicians treating depressed Latinos are often confronted with the clinical dilemma of whether to augment antidepressants with an antipsychotic. The authors argue that atypical psychotic symptoms experienced by Latinos with major depressive disorder are nonpsychotic manifestations and that antipsychotic medication should be delayed unless treatment of depression fails to address the psychosis-like symptoms.

Psychosis and Dandy–Walker complex: report of four cases

Concurrence of psychosis and Dandy–Walker complex (DWC) has been reported in some medical literature. Here, we reported four patients with concurrent psychosis and DWC of all four subtypes. Some clinical features found were juvenile or young adult age onset, high frequency of family history of psychosis, atypical psychotic symptoms, and high prevalence of cognitive deficit and refractoriness to treatment, in line with the cases in previous reports. These findings might help further illuminate the role that the cerebellum plays in the etiology of schizophrenia or bipolar disorder.

Early-onset schizophrenia and obsessive–compulsive disorder in a young man with Dandy-Walker variant

Concurrence of psychosis and Dandy–Walker complex (DWC) has been reported in some medical literature. Here, we reported four patients with concurrent psychosis and DWC of all four subtypes. Some clinical features found were juvenile or young adult age onset, high frequency of family history of psychosis, atypical psychotic symptoms, and high prevalence of cognitive deficit and refractoriness to treatment, in line with the cases in previous reports. These findings might help further illuminate the role that the cerebellum plays in the etiology of schizophrenia or bipolar disorder.

Phenomenology and Diagnostic Stability of Youths with Atypical Psychotic Symptoms

This study aimed to better characterize the phenomenology and diagnostic stability of youths that report atypical psychotic symptoms. In a 2-year longitudinal follow-up study, youths reporting atypical psychotic symptoms (n = 20) were compared with youths with schizophrenia (n = 27) and youths with bipolar disorder with psychotic features (n = 22) on psychotic, dissociative, and general symptomatology, comorbid diagnoses, previous abuse, and overall functioning. Diagnoses were obtained using structured diagnostic interviews (i.e., the Structured Clinical Interview for DSM-IV and the Diagnostic Interview for Children and Adolescents). None of the subjects reporting atypical psychotic symptoms went on to develop a classic psychotic illness by the year 2 follow-up. These subjects had significantly higher rates of abuse and dissociative symptoms, and were significantly more likely to receive a diagnosis of posttraumatic stress disorder (PTSD) or a depressive disorder than youths with schizophrenia or bipolar disorder. Our findings suggest that youths with atypical, fleeting, or situationally specific hallucinations are more likely to have a mood or anxiety disorder (such as PTSD) than a current or prodromal psychotic illness.

Psychotic symptoms among male adolescent detainees in The Netherlands.

This study investigated the prevalence of psychotic symptoms among incarcerated boys as well as the relationship between these symptoms and violent offending and criminal recidivism. The presence of psychotic symptoms was assessed in a representative sample of 204 incarcerated boys aged 12-18 using the Diagnostic Interview Schedule for Children (DISC-2.3). Seventy-two percent of the study participants had committed a violent index offense and 30 percent were criminal recidivists. Thirty-four percent (95% confidence interval [CI]: 27-41%) were DISC-2.3 psychosis screen positive: 25% (95% CI: 19-31%) reported at least one pathognomonic of schizophrenia symptom and 9% (95% CI: 6-14%) reported at least three non-pathognomonic psychotic symptoms. In addition, 33 percent (95% CI: 26-40%) reported one or two isolated, atypical psychotic symptoms. The presence of psychotic symptoms was not associated with violent offending or criminal recidivism. The high prevalence rate of psychotic symptoms among incarcerated boys calls for increased attention to diagnosis and treatment of psychosis. To obtain conclusive answers regarding the relationship between psychosis and violent offending, additional studies are needed in general population samples.