Cases Of Psychosis Research Articles

Psychosis associated with cannabis withdrawal: systematic review and case series.

Abrupt cessation of heavy cannabis use can cause a withdrawal syndrome characterised by irritability, anxiety, insomnia, reduced appetite and restlessness. Recent reports have also described people in whom cannabis withdrawal immediately preceded the acute onset of psychosis. To identify cases of psychosis associated with cannabis withdrawal. We completed a systematic review of the literature, which comprised case reports, case series and other studies. We also searched a large electronic database of psychiatric healthcare records. The systematic review identified 44 individuals from 21 studies in whom cannabis withdrawal preceded the development of acute psychosis. In the health record study, we identified another 68 people, of whom 47 involved a first episode of psychosis and 21 represented further episodes of an existing psychotic disorder. Almost all people were daily cannabis users who had stopped using cannabis abruptly. Individuals who continued to use cannabis after the acute psychotic episode had a much higher risk of subsequent relapse than those who abstained (odds ratio 13.9 [95% CI: 4.1 to 56.9]; χ2 = 20.1, P < 0.00001). Abrupt cannabis withdrawal may act as a trigger for the first episode of psychosis and a relapse of an existing psychosis. Acute psychotic symptoms can emerge after the cessation, as well as following the use, of cannabis.

The effect of polygenic risk score and childhood adversity on transdiagnostic symptom dimensions at first-episode psychosis: evidence for an affective pathway to psychosis

Childhood adversity is associated with various clinical dimensions in psychosis; however, how genetic vulnerability shapes the adversity-associated psychopathological signature is yet to be studied. We studied data of 583 First Episode Psychosis (FEP) cases from the EU-GEI FEP case-control study, including Polygenic risk scores for major depressive disorder (MDD-PRS), bipolar disorder (BD-PRS) and schizophrenia (SZ-PRS); childhood adversity measured with the total score of the Childhood Trauma Questionnaire (CTQ); and positive, negative, depressive and manic psychopathological domains from a factor model of transdiagnostic dimensions. Genes and environment interactions were explored as a departure from a multiplicative effect of PRSs and total CTQ on each dimension. Analyses were adjusted for age, sex, 10 PCA, site of recruitment and for medication. A childhood adversity and PRS multiplicative interaction was observed between A) the CTQ and MDD-PRS on the predominance of positive (β = 0.42, 95% CI = [0.155, 0.682], p = 0.004); and depressive (β = 0.33, 95% CI = [0.071, 0.591], p = 0.013) dimensions; B) between the CTQ and BD-PRS on the positive dimension (β = 0.45, 95% CI = [0.106, 0.798], p = 0.010), and C) with the CTQ and SZ-PRS on the positive dimension (β = −0.34, 95% CI = [−0.660, −0.015], p = 0.040). Bonferroni corrected p-value of significance was set at 0.0125. In conclusion, despite being underpowered, this study suggests that genetic liability for MDD and BD may have a moderating effect on the sensibility of childhood adversity on depressive and positive psychotic dimensions. This supports the hypothesis of an affective pathway to psychosis in those exposed to childhood adversity.

Acute onset psychiatric diseases after SARS-CoV-2 virus infection among pediatric patients.

Psychiatric symptoms directly associated with SARS-CoV-2 virus infection have been reported sporadically in children. More cases of new-onset psychosis without severe cardinal symptoms, altered consciousness level, and psychogenic drug usage would offer compelling grounds for the association between the virus infection and psychosis. We collected the clinical data of pediatric patients with new onset psychiatric symptoms after the SARS-CoV-2 virus infection from December 2022 to Feb 2023 and followed up with them for 1 year. These children did not have severe respiratory, cardiovascular, or systemic symptoms. They were not given psychogenic drugs. We also searched Pubmed to identify previously reported acute onset psychiatric cases related to SARS-CoV-2 virus infection in children. We summarized these patients' clinical symptoms, laboratory examination, treatment, and prognosis. We reported 11 new cases of psychiatric disease directly related to SARS-CoV-2 virus infection and reviewed 12 previously reported cases among children and adolescents. They had various psychiatric symptoms within 3 weeks after the virus infection. Brain MRI and EEG recording did not reveal remarkable abnormalities. The cerebrospinal fluid analysis (CSF) could find increased protein, immunoglobulin, and IL-8 levels, disrupted blood-brain barrier, and positive oligoclonal band in a minority of the patients. Most of the patients had good outcomes. New-onset psychiatric symptoms directly related to SARS-CoV-2 virus infection are not rare phenomena among pediatric patients. CSF tests support the presence of central immune responses in some patients. Although these patients received different treatments, most of them had good prognoses.

7173 Cabergoline Induced Psychosis in a Patient with no Previous History of Psychiatric Disorder

Abstract Disclosure: B. Aryal: None. K. Kim: None. A. Shafi: None. M. Ganesh: None. Introduction: Cabergoline is a dopamine agonist (DA) used to treat prolactinomas. It is well established that DAs may cause psychotic symptoms. However, very few cases report cabergoline-associated psychosis in patients without personal or family history of psychiatric disorders. We report a rare case of cabergoline-induced psychosis in a patient with a prolactinoma without any underlying psychiatric disorder, which was managed with the addition of olanzapine. Case: A 41 year old male with no history of psychiatric disorder was started on cabergoline 0.5mg twice a week for a newly diagnosed prolactinoma. 4 weeks later, he presented to the emergency room for aggressive behavior and confusion for the past 2 weeks. He endorsed visual and auditory hallucinations. Cabergoline was discontinued. During hospitalization, he attempted suicide and required 1:1 observation. He was started on olanzapine per the inpatient psychiatry team. Surgical resection of the prolactinoma was considered given his acute psychosis associated with cabergoline. However, complete resection of the tumor was deemed impossible given encasement of the internal carotid arteries. After discussion with the patient, he underwent re-challenge with cabergoline 0.25mg weekly while on olanzapine under 1:1 observation in the ICU. He was monitored for 2 weeks and eventually discharged home on cabergoline 0.25mg twice a week and olanzapine with improvement in prolactin levels to 4973.7 ng/mL after 4 weeks. He continued to remain free of psychotic symptoms upon follow up as an outpatient. Discussion: Psychosis is a rare side effect of DA mediated via D2/D3 receptors in the mesocortical and mesolimbic pathways. Several cases report psychosis associated with cabergoline in patients with a history of psychiatric disorders. However only one case reports de novo psychosis. Our patient developed severe psychosis while on low-dose cabergoline for 4 weeks. This rare case of de novo cabergoline-associated psychosis re-emphasizes that psychosis may occur regardless of previous history of psychiatric disorder and independent of the dose or duration of cabergoline. Treatment of a prolactinoma in the setting of cabergoline-associated psychosis requires a multidisciplinary approach. Alternative treatment of surgical resection was considered for our patient. However surgical resection was not plausible given difficult surgical anatomy. Therefore he was monitored closely to re-initiate cabergoline while on olanzapine. Several cases report successful use of clozapine, aripiprazole, and quetiapine for patients with psychiatric symptoms while on cabergoline. Patients who are on cabergoline should be closely monitored for any psychotic symptoms. Further studies are warranted to identify patients at risk of developing psychosis while on cabergoline to tailor an individualized approach to therapy and monitoring. Presentation: 6/2/2024

Sensitivity of the familial high-risk approach for the prediction of future psychosis: a total population study.

Children who have a parent with a psychotic disorder present an increased risk of developing psychosis. It is unclear to date, however, what proportion of all psychosis cases in the population are captured by a familial high-risk for psychosis (FHR-P) approach. This is essential information for prevention research and health service planning, as it tells us the total proportion of psychosis cases that this high-risk approach would prevent if an effective intervention were developed. Through a prospective cohort study including all individuals born in Finland between January 1, 1987 and December 31, 1992, we examined the absolute risk and total proportion of psychosis cases captured by FHR-P and by a transdiagnostic familial risk approach (TDFR-P) based on parental inpatient hospitalization for any mental disorder. Outcomes of non-affective psychosis (ICD-10: F20-F29) and schizophrenia (ICD-10: F20) were identified in the index children up to December 31, 2016. Of the index children (N=368,937), 1.5% (N=5,544) met FHR-P criteria and 10.3% (N=38,040) met TDFR-P criteria. By the study endpoint, 1.9% (N=6,966) of the index children had been diagnosed with non-affective psychosis and 0.5% (N=1,846) with schizophrenia. In terms of sensitivity, of all non-affective psychosis cases in the index children, 5.2% (N=355) were captured by FHR-P and 20.6% (N=1,413) by TDFR-P approaches. The absolute risk of non-affective psychosis was 6.4% in those with FHR-P, and 3.7% in those with TDFR-P. There was notable variation in the sensitivity and total proportion of FHR-P and TDFR-P cases captured based on the age at which FHR-P/TDFR-P were determined. The absolute risk for psychosis, however, was relatively time invariant. These metrics are essential to inform intervention strategies for psychosis risk requiring pragmatic decision-making.

Lupus on the Mind: A Case of Psychosis in Uncontrolled Systemic Lupus Erythematosus.

Lupus on the Mind: A Case of Psychosis in Uncontrolled Systemic Lupus Erythematosus.

P32: Poststroke psychosis following pontine lesions in geriatric patients: a case series

Objectives: To analyze psychotic symptoms following pontine stroke to better understand the neuroanatomy underlying the symptoms.Methods: A case series including three cases of poststroke psychosis following pontine lesions and a literature review will be presented.Results: Case 1: 67-year-old female with hypertension, hyperlipidemia, hypothyroidism, chronic kidney disease, and stroke. She presented with daily tactile hallucinations on her left face and neck that felt like a snake wrapped around her, occasional visual and tactile hallucinations of a cat, and occasional sensations that her body was on fire. Initial MRI showed diffuse atrophy, small vessel ischemic changes, and chronic hemosiderin staining of the pons and left superior basal ganglia. Repeat MRI identified bilateral thalamic lacunar infarcts, an old left caudate/corona radiata intracranial hemorrhage, and prior left occipital intracranial hemorrhage. Symptoms were managed with quetiapine 12.5mg daily.Case 2: 74-year-old female with anemia, hypothyroidism, orthostasis, depression, mild cognitive impairment, temporal lobe epilepsy, and two strokes. She presented with near-daily distressing tactile hallucinations of worms, rubber bands, insects, snakes, and toy car wheels in her mouth. MRI showed chronic ischemic changes and central pontine and periventricular white matter lesions bilaterally with mild/moderate atrophy. Multiple medication trials and ECT treatment were aborted due to confusion and paranoia. Symptoms were managed with risperidone 2mg daily.Case 3: 80-year-old female with hypertension, hyperlipidemia, coronary artery disease, atrial fibrillation, gastrointestinal bleed, and depression. She presented with distressing delusions that she was infested with pinworms throughout her gastrointestinal tract, along with visual hallucinations of the worms. MRI showed nonspecific white matter changes and a small T2 hyperintensity in the left pons of either a lacunar infarct or ischemic microangiopathic changes. After a partial hospitalization program enrollment and a subsequent hospitalization, symptoms were managed with risperidone 1.5mg daily.Conclusions: Few case reports exist that describe peduncular hallucinosis, auditory hallucinations, or persistent tactile hallucinations following ischemic or hemorrhagic pontine lesions. The above cases demonstrate additional evidence of tactile and visual hallucinations following pontine stroke in geriatric patients, with imaging data localizing the lesions. Further research is needed to better understand the differing presentations, functional circuits, and neurochemical imbalances of psychosis following pontine lesion to improve diagnosis and treatments.

Polygenic Risk Scores and Twin Concordance for Schizophrenia and Bipolar Disorder

Schizophrenia and bipolar disorder are highly heritable psychiatric disorders with strong genetic and phenotypic overlap. Twin and molecular methods can be leveraged to predict the shared genetic liability to these disorders. To investigate whether twin concordance for psychosis depends on the level of polygenic risk score (PRS) for psychosis and zygosity and compare PRS from cases and controls from several large samples and estimate the twin heritability of psychosis. In this case-control study, psychosis PRS were generated from a genome-wide association study (GWAS) combining schizophrenia and bipolar disorder into a single psychosis phenotype and compared between cases and controls from the Schizophrenia and Bipolar Twin Study in Sweden (STAR) project. Further tests were conducted to ascertain if twin concordance for psychosis depended on the mean PRS for psychosis. Structural equation modeling was used to estimate heritability. This study constituted an analysis of existing clinical and population datasets with genotype and/or twin data. Included were twins from the STAR cohort and from the Swedish Twin Registry. Data were collected during the 2006 to 2013 period and analyzed from March 2023 to June 2024. PRS for psychosis based on the most recent GWAS of combined schizophrenia/bipolar disorder. Psychosis case status was assessed by clinical interviews and/or Swedish National Register data. The final cohort comprised 87 pairs of twins with 1 or both affected and 59 unaffected pairs from the STAR project (for a total of 292 twins) as well as 443 pairs with 1 or both affected and 20 913 unaffected pairs from the Swedish Twin Registry. Among the 292 twins (mean [SD] birth year, 1960 [10.8] years; 158 female [54.1%]; 134 male [45.9%]), 134 were monozygotic twins, and 158 were dyzygotic twins. PRS for psychosis was higher in cases than in controls and associated with twin concordance for psychosis (1-SD increase in PRS, odds ratio [OR], 2.12; 95% CI, 1.23-3.87 on case status in monozygotic twins and OR, 2.74; 95% CI, 1.56-5.30 in dizygotic twins). The association between PRS for psychosis and concordance was not modified by zygosity. The twin heritability was estimated at 0.73 (95% CI, 0.30-1.00), which overlapped with the estimate in the full Swedish Twin Registry (0.69; 95% CI, 0.43-0.85). In this case-control study, using the natural experiment of twins, results suggest that twins with greater inherited liability for psychosis were more likely to have an affected co-twin. Results from twin and molecular designs largely aligned. Even as illness vulnerability is not solely genetic, PRS carried predictive power for psychosis even in a modest sample size.

Evaluation of Schneiderian First-rank Symptoms in Patients of Psychosis Attending a Tertiary Care Center from North India

Abstract Background: The Schneiderian first-rank symptoms (SFRS) have played an extremely important role in the diagnostic systems in psychiatry. However, all studies do not seem to support Schneider’s claim that FRS confer a clear indication of schizophrenia when no organic syndrome is present. Objectives: The objectives of this study were as follows: (1) to examine the presence of SFRS in untreated cases of psychosis, (2) to see the degree of improvement in SFRS with treatment over 12 weeks of short-term follow-up, (3) to see correlation of SFRS with sociodemographic and clinical parameters in our patients, and (4) to see the correlation of SFRS among diagnostic subgroups in our patients. Materials and Methods: Setting: Psychiatry department of a multi specialty tertiary care center in North India. Study Design: This was a short-term prospective study. After taking ethical clearance from the institutional ethics committee and written informed consent from all the patients, data sets were prepared for 60 patients of untreated psychosis. Data analysis was done using the SPSS version 20.0. Results: Voices discussing (83.33%) and voices commenting (80%) were the most commonly noted SFRS, and the mean number of SFRS in our sample was 3.34. Somatic passivity (f = 10.80, P = 0.0001) and thought insertion (f = 6.75 and P = 0.004) could significantly differentiate between schizophrenia and other diagnostic subgroups of untreated psychosis in our study. Conclusions: Only somatic passivity, delusional perception, and thought insertion were extremely specific in distinguishing the patients of schizophrenia from nonschizophrenic patients.

Pilot study to test the feasibility and clinical efficacy of a psychosocial care programme for patients with psychosis in low-resource settings

BackgroundHome-based psychosocial care has the potential to improving outcomes in patients with schizophrenia and related disorders (SCZ). There is lack of India data for such care in early psychosis. We developed the “Saksham” programme, a bespoke self-managed home-based psychosocial care model, available in two formats: manual-based and mobile-application based. With the anticipated success of recruitment of early psychosis cases in our setting, we plan to test the such intervention in this population in future trials. AimTo assess the feasibility of the Saksham programme intervention in people with SCZ and its clinical efficacy as an adjunct to treatment as usual. MethodsSeventy-five patient-caregiver pairs (total n=150) were recruited. Patients received either: treatment-as-usual (TAU) (n=25), manual-based Saksham intervention+TAU (n=25), or app-based Saksham intervention+TAU (n=25). Feasibility (i.e. acceptability, practicality, demand, implementation and integration) was assessed at three-months. Participants were assessed for psychopathology, illness-severity, cognition, functioning, disability, and caregiver-coping at baseline, one-month, and three-month. The percentage changes over time were compared across three groups. ResultsMore found the mobile application-based intervention acceptable and easy-to-use than the manual-based intervention (92 % vs 68 %, and 76 % vs 68 %, respectively). Psychopathology and caregiver-burden improved significantly in all three groups (p<0.05). Cognition, disability, functioning, and caregiver burden improved significantly in the two Saksham intervention groups, with greater improvement in the Saksham app group (p<0.05). ConclusionHome-based intervention is feasible and acceptable in a low-resource setting, with preliminary evidence for effectiveness. These findings need corroboration with randomised controlled trials in early psychosis to ameliorate course of illness.

The inflamed brain.

Autoimmune conditions underlie some cases of psychosis. Scientists are expanding their search for patients, who often benefit from treatment.

Ethnic density and first episode psychosis in the British Pakistani population: findings from the East Lancashire Early Intervention Service.

Elevated risk of psychosis for ethnic minority groups has generally been shown to be mitigated by high ethnic density. However, past survey studies examining UK Pakistani populations have shown an absence of protective ethnic density effects, which is not observed in other South Asian groups. To assess the ethnic density effect at a local neighbourhood level, in the UK Pakistani population in East Lancashire. Data was collected by the East Lancashire Early Intervention Service, identifying all cases of first episode psychosis (FEP) within their catchment area between 2012 and 2020. Multilevel Poisson regression analyses were used to compare incidence rates between Pakistani and White majority groups, while controlling for age, gender and area-level deprivation. The ethnic density effect was also examined by comparing incidence rates across high and low density areas. A total of 455 cases of FEP (364 White, 91 Pakistani) were identified. The Pakistani group had a higher incidence of FEP compared to the White majority population. A clear effect of ethnic density on rates of FEP was shown, with those in low density areas having higher incidence rates compared to the White majority, whereas incidence rates in high density areas did not significantly differ. Within the Pakistani group, a dose-response effect was also observed, with risk of FEP increasing incrementally as ethnic density decreased. Higher ethnic density related to lower risk of FEP within the Pakistani population in East Lancashire, highlighting the impact of local social context on psychosis incidence.

Thyroid psychosis: when your hormones take over your mind: a case report

IntroductionHyperthyroidism, characterized by excessive production of thyroid hormones, is a common endocrine disorder that affects various body systems. While most commonly recognized for its classic symptoms such as weight loss, tremors, and palpitations, it is important to acknowledge that hyperthyroidism can also lead to a rare but significant complication: psychosis. Psychosis in the context of hyperthyroidism refers to the presence of delusions, hallucinations, and disordered thinking, which can significantly impact an individual’s mental health and overall well-being.ObjectivesThis case report aims to describe a rare case of hyperthyroidism-related psychosis in a patient including the clinical presentation, diagnosis, and management. Additionally, we aim to increase awareness of and promote further research into this condition.MethodsWe present a comprehensive case report detailing the clinical course of a 29-year-old male patient with no previous medical or psychiatric history, who sought urgent psychiatric evaluation at the Razi Hospital La Manouba’s emergency department due to escalating symptoms of agitation and paranoia persisting for three days. The patient, identified as Mr. S.O., a Tunisian male, presented with severe agitation and paranoia necessitating the use of restraints upon admission to the psychiatric emergency department. The initial physical examination revealed no notable abnormalities, except for the presence of tachycardia, which was subsequently confirmed on an electrocardiogram, arousing suspicion of a primary psychiatric illness.ResultsWhile the standard blood workup yielded unremarkable findings, the endocrine workup revealed decreased levels of thyroid-stimulating hormone (TSH) and elevated free thyroxine (FT4). Further laboratory investigations demonstrated elevated anti-thyroid-stimulating hormone receptor antibodies, leading to the diagnosis of Graves’ disease. Collaborative consultation with an endocrinologist resulted in the initiation of a treatment regimen consisting of methimazole, propranolol, and risperidone. Notably, within three days of the initiated therapy, the patient exhibited significant improvement in terms of reduced agitation, coherent speech, and the development of self-reflection regarding the episode, ultimately leading to his discharge on the seventh day of hospitalization. This case report serves to highlight the complexity of psychiatric presentations associated with underlying endocrine disorders and underscores the importance of interdisciplinary collaboration in achieving optimal patient outcomes.ConclusionsWhile mental health factors play a significant role in the development of psychosis, it is essential to recognize that underlying medical conditions may also contribute to its onset or exacerbation.Disclosure of InterestNone Declared

Menstrual Psychosis with Premenstrual Onset: A case presentation

IntroductionMenstrual psychosis has an acute onset and is characterised by confusion, stupor and mutism, delusions, hallucinations, or a manic syndrome lasting for a brief duration, with full recovery. These symptoms maintain periodicity in rhythm with the menstrual cycle. The symptoms may appear in the premenstrual phase or may begin with the onset of menstrual flow (catamenial psychoses). Usually, menstrual psychosis has a polymorphism of both psychotic and affective symptoms (Brockington I. Menstrual psychosis. World Psychiatry. 2005;4(1):9-17.). In this article we present a case of menstrual psychosis with premenstrual onset.ObjectivesA 26 years old, nulliparous single female with one mentally ill relative on her mother’s side (her grandmother) presented with an episodic illness characterized by mood swings, irrelevant speech, irritability, suspiciousness and thought disorder related to her menstrual cycles. She had earlier suffered prolonged attacks of mania, developed a recurrent episodic illness which returned every month for five years. Her menses began at 15. She presented with the history of a few episodes of manic illness starting five days before and ending suddenly with the onset of the menses.MethodsOn mental status evaluation during the index episode, the patient was agitated, had labile affect, grandiose and referential delusions and erotomania. A detailed physical examination, routine biochemistry, and gonadal hormonal assay were unremarkable.ResultsShe was started on olanzapine 10 mg/day, lithium 1200 mg/day and low-dose clonazepam. Although the severity of the psychotic and affective symptoms gradually reduced during the future menstrual cycles, they did not completely resolve.ConclusionsThe pathophysiology of menstrual psychosis is not exactly understood, but it has been postulated that fluctuation of the sex hormones occurring during the menstrual cycle is responsible. Previous studies have reported the association of psychosis with estrogen withdrawal (Mahé V, Dumaine A. Oestrogen withdrawal associated psychoses. Acta Psychiatr Scand. 2001;104(5):323-331.). Treatment strategies for menstrual psychosis include the use of oral contraceptive pills for the regulation of hormones during the menstrual cycle, in our case patient did not want to use oral contraceptive pills.Disclosure of InterestNone Declared

Atypical psychosis in a patient with intracranial hypertension: clinical case and review

IntroductionSeveral neurologic conditions can produce or mimic psychotic symptoms. It is important to make an exhaustive differential diagnosis between a psychiatric manifestation of an underlying neurological condition and a primary psychiatric one. We explore through the present clinical case of a young woman admitted to neurology the relationship between intracranial hypertension and a case of atypical psychosis that resolved itself with the treatment of the intracranial hypertension, without the need for antipsychotic medication.ObjectivesTo explore through the presented clinical case and the concerning literature the concept and management of psychotic-like symptoms in patients with intracranial hypertension.MethodsWe present a clinical case and a review of the existing literature concerning atypical psychosis or psychosis-like symptoms in cases of intracranial hypertension.ResultsWe report the case of a 24 year old woman with no relevant medical history hospitalised in the neurology unit due to suspected encephalitis. Native to New Zealand, she is brought from the airport due to behavioural alterations. During the last few days before admission she had presented with incoherent speech, derailment, religious and persecutory delusions, and erotomania towards her cousin. She described feelings of strangeness with her surroundings and of time moving at a different speed than usual, either faster or slower. She also had a headache and visual alterations, as well as memory errors concerning recent events, clouding of consciousness and inattention.No fever or other relevant physical symptoms. A lumbar puncture is done, which shows an opening pressure of 37mmHg but no other anomalies. Body CT scan shows no relevant findings. Empirical treatment with dexamethasone is initiated for suspected encephalitis, progressively reducing the dosage until suspension in the following days. During her stay at the hospital she is assessed by ophthalmology, which finds no abnormalities in the eye fundus examination, and psychiatry. A second evacuating lumbar punture is done to reduce intracraneal hypertension. No antipsychotic treatment is initiated: the symptomatology remitted with the lowering of intracranial pressure. At time of discharge, the patient remained asymptomatic without treatment and was able to return home to continue outpatient neurologic study of the etiology of the intracranial hypertension.Finally, we conduct a review ot the existing literature concerning psychotic and psychosis-like symptoms in patients with intracranial hypertension, to explore the diagnostic and management options of this rare finding.ConclusionsOur findings point to the existing relationship between intracranial hypertension and psychosis-like symptoms. Further studies on pathogenic mechanisms and therapeutic management are required.Disclosure of InterestNone Declared

A systematic review of the prevalence of psychosis in people with tuberculosis

IntroductionTuberculosis is a bacterial infectious disease caused by Mycobacterium tuberculosis. This disease predominately affects the lungs but also affects other parts of the body, including the central nervous system. According to the the World Health Organization (2023), tuberculosis has an incidence of 6.4 million people in 2022, with 1.5 million deaths attributed to this disease. Psychosis describes a group of disorders that affects a person’s thought process and perception. It is a serious disorder that can have a profound impact on a person’s mental and physical health. As a result, psychosis symptoms and its treatment can complicate the management of tuberculosis.Objectives The aim of this systematic review is to explore the association between tuberculosis and psychosis. It has been shown that up to 70% of patients with tuberculosis also have comorbid mental illness, this is likely to include psychosis. There are also shared risk factors between tuberculosis and psychosis, including poverty and homelessness, substance abuse, HIV positive serology and isolation. Tuberculosis medication, including isoniazid and rifampicin have been shown to have adverse psychiatric effects and we will examine if this includes psychosis.MethodsA systematic review was pre-registered with PROSPRO and performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. MEDLINE, OVID and PsychINFO databases were searched from beginning of records to September 2023. This included hand-search of relevant reference lists. Observational and epidemiological studies were included along with population based registries.ResultsOver one thousand (1,154) articles were identified and screened. There was significant heterogenity in results and over half of studies were from Asia and Africa. Many studies reported cases of drug-induced psychosis from anti-tubercular agents. Studies also discussed the increased risk of TB incidence among patients with psychosis and other psychiatric disorders.ConclusionsThis study identifies the importance of training healthcare workers in rapid detection of co-morbid psychosis in patients with tuberculosis, along with neuropsychiatric side effects of antitubercular agents. Integration of psychiatric and medical care of these patients would be of benefit to improve outcomes in this patient population. More research is needed on co-morbidity of tuberculosis and psychosis.Disclosure of InterestNone Declared

The Challenge of Lorazepam Failure: Malignant Catatonia Treated Successfully with Valproate

IntroductionDespite the unclear nature of catatonia, the treatment response of catatonia to benzodiazepines is widely known for its typical, dramatic recovery. The neurobiological correlates of this phenomenon regarding specific receptors and neurotransmitters are unclear, as are the potential treatment options. This is important to consider when the most commonly recommended treatments of catatonia with Lorazepam or Electroconvulsive Therapy (ECT) are unavailable or unsuccessful. In this report, we describe a case of severe, malignant catatonia and psychosis mostly unresponsive to Lorazepam during two different hospitalizations, but with eventual return to baseline after successful treatment with Valproate.Objectives-To describe a unique case of malignant catatonia that was unresponsive to Lorazepam-To illustrate the potential utility of Valproate as an alternative treatment strategy for catatonia MethodsThis is a case report.ResultsA 19-year-old Hispanic male presented to our hospital initially with family reports of severe and sudden depression with bizarre behavior. Prior to this admission, the patient had been discharged recently from another tertiary hospital following a 2-week admission for severe catatonia. Chart review from that admission scored the patient’s Bush-Francis Catatonia Rating Scale (BFCRS) at 16, which remained mostly unchanged after numerous additional intramuscular doses and standing oral doses of Lorazepam, with a reduction of BFCRS the next day of only 2. During the patient’s admission at our hospital, the patient endorsed bizarre, guilt-related delusions, and his catatonia was more severe and malignant with a BFCRS of 19, with tachycardia and diaphoresis. The patient was initially given a total of seven doses of a mix of intramuscular and oral Lorazepam (total 18mg), with a minimal 2-point reduction in BFCRS. As ECT was unavailable, Lorazepam was discontinued in favor of a trial of oral Valproate 500mg twice daily, and after his catatonia subsided (with a serum level of 60.8), he was started on oral Risperidone 0.5mg once at night, titrated up to 3mg twice daily, and eventually returned to baseline as confirmed by his family members.ConclusionsThe treatment of catatonia with Lorazepam is usually reliable and has been found to be up to 80% effective, but when the recommended use of benzodiazepines and ECT fail or are unavailable, there are few studies exploring the viability of alternative treatment options. With the use of Valproate, previous studies have shown it can treat even severe catatonia (KrÜger, J Neuropsychiatry 2001; 13:303-304), or can actually be its cause (Lauterbach, Neuropsychiatry, Neuropsychology, and Behavioral Neurology. 1998 Jul;11(3):157-163). As such, this case report highlights the importance of exploring alternative treatments for catatonia, including Valproate, in order to better tailor the management of this unique syndrome.Disclosure of InterestNone Declared

Cariprazine efficacy in a 40-year untreated case of a woman with predominantly negative symptoms of psychosis: A case report

IntroductionSeveral studies have demonstrated the unfavorable and neurotoxic effects of untreated psychosis (UP) on the brain. An estimated 10 to 12 cc of brain tissue could be potentially damaged due to neuroinflammation and oxidative stress when a first episode of psychosis goes untreated. Other studies have found a correlation between the duration of untreated psychosis (DUP) and treatment resistance or nonresponse. Evidence-based schizophrenia treatment mainly relies upon the use of first and second-generation antipsychotics, without solid evidence that the former is superior to the latter regarding the treatment of negative symptoms. Both groups, however, can come with a risk of side effects. Cariprazine, a third-generation antipsychotic, represents a safe and effective treatment, targeting both the positive and negative symptoms of schizophrenia.ObjectivesTo report a clinical case of a woman with an extreme DUP with predominantly negative symptoms of schizophrenia and highlight the favorable outcome cariprazine monotherapy had on her global functioning.Methods We report a clinical case of a 58-year-old woman with a history of a 40-year UP successfully treated with 4,5mg of cariprazine. The woman was brought involuntarily for psychiatric assessment at the emergency department with a clinical image of catatonic stupor and predominantly negative symptoms of psychosis. Her total PANSS score at admission was 129. The negative subscale score was 49. She was initially treated with 3mg cariprazine and 10mg olanzapine and was gradually left on 4,5mg cariprazine monotherapy with an adjunctive 30mg mirtazapine.ResultsThe patient was dismissed after 47 days of hospitalization. Cariprazine was effective in targeting both the cognitive and affective symptoms of long-standing UP. In the long-term, cariprazine also improved remnant delusional ideas of somatic and persecutory types, enhancing the patient’s social life, ensuring her support network, and assisting her integration into the community. The patient did not report any side effects, and her blood test results were within the normal range.Conclusions Not all cases of schizophrenia are dramatic at presentation - some can have a chronic and insidious course predominated by negative symptoms. UP can lead to disastrous consequences for the patient’s biopsychosocial well-being, leading to future treatment resistance and disability. Although such cases of untreated psychosis seem to be from the past, we should be conscious of their existence and treat them with a patient-personalized and symptom-centered approach. Cariprazine was successful and effective in treating this patient with a remarkable course of UP.Disclosure of InterestNone Declared

Extended Delirium Treated as Psychosis

Abstract Delirium is a commonly seen neuropsychiatric disorder that may extend over time, lasting for more than 60 days, thus increasing the risk of cognitive and behavioral outcomes in patients. Electroconvulsive therapy (ECT) is one of the treatment modalities for behavior control but may be associated with rare complications such as tardive seizure, convulsive status epilepticus, and prolonged postictal confusion. We report a case of acute psychosis who was given consecutive 2 ECTs, after which she developed probable tardive seizure in the recovery period, followed by status epilepticus and extended delirium lasting for more than 2½ months, but was misdiagnosed as psychosis and treated with several antipsychotic medications. As there was no improvement in her condition, she was then transferred to a tertiary center for further management.

Differential diagnosis in chronic psychosis: a case report

IntroductionA colombian woman aged 62, with previous diagnosis of paranoid schizophrenia. She retired from working 2 years ago, when she started taking care of her sick husband full-time.ObjectivesTo describe a chronic psychosis case and discuss the treatment options and differential diagnosis.MethodsWe used the face-to-face interviews during her last hospitalization and her electronic medical history.We also made a brief research about the effectiveness of risperidone depot in Pubmed.ResultsPsychiatric historyShe’s had 3 hospitalizations, all of them coincided with stressful vital situations. The first one occurred when she was dealing with a job issue. In the second one she was having an economic conflict with her husband. And the third one has coincided with worries about her retirement pension and her caregiver burden.Current episodeShe came to my hospital emergency department distressed because she thought her husband and her were victims of an international drug trafficking plot. She said a colombian drug cartel had sent 9 prostitutes to her village in order to steal from them, by pretending they were cleaning assistants, as a reprisal against her husband, who used to be a military in Colombia . She explained the nature of this event with great details. Also, she said the electric company was involved and they had tried to intoxicate her.The psychopathological exploration was altered with a correct speech in its form but incoherent in its content. She presented a highly structured delusional plot of prosecution. No major affective disorders were detected. She suffered from reactive insomnia and anxiety.EvolutionAt first, it was torpid, she felt perspicacious and angry about the admission. Later, as the antipsychotic started to work, the symptoms improved and she became calm and collaborative. She has never criticized the delusion plot, but it was encapsulated, and the affective resonance disappeared.We tried oral aripiprazole and paliperidone but retired both due to bad tolerance. Then we tried risperidone, with good tolerance and response, and started her current monthly treatment with Risperidone 100 mg depot.After one year, she has kept stable with no relapses and good adherence to the treatment.Differential diagnosisThe patient meets every diagnostic criteria of Delusional disorder (F22), as she has never experienced hallucinations and the functionality has not significantly decreased through the years. Also, she doesn’t meet the second criteria for Schizophrenia (F20).ConclusionsIt is important to explore the evolution of a psychotic disorder in order to differentiate between a schizophrenia and a delusional disorder, as the prognosis differs significantly.Using Risperidone monthly depot can be a good option for treating a psychotic disorder (Sampson et al. Cochrane Database Syst Rev 2016. 14;4(4)).Disclosure of InterestNone Declared