Cause Of Psychosis Research Articles

Clinical characteristics and treatment of psychosis in Parkinson's disease: A narrative review.

Parkinson's disease (PD) is a chronic, progressive, neurodegenerative disorder whose clinical presentation consists of motor and non-motor signs and symptoms. Among the non-motor symptoms, psychosis can occur in the later stages of the disease. Psychosis in PD (PDP) is a common, complex, and significantly disabling disorder associated with poorer quality of life, accelerated cognitive decline, need for hospitalization or institutionalization, and mortality. Hallucinations are a significant symptom of PDP, sporadic at first but more frequent in the later course of the disease, and significantly disrupt daily activities. Appropriate and timely screening of psychotic manifestations is necessary for adequate therapeutic procedures. After the exclusion of comorbid conditions as a possible cause of psychosis, correction of antiparkinsonian therapy may be required, and if necessary, the introduction of antipsychotics. The latest therapeutic recommendations include the use of pimavanserin, if available, otherwise second-generation or atypical antipsychotics. Although PDP has long been recognized as a possible complication in the course of the disease, further clinical studies are needed to fully understand its etiopathogenesis and pathophysiological mechanisms.

Bartonella species bacteremia in association with adult psychosis.

The potential role of pathogens, particularly vector-transmitted infectious agents, as a cause of psychosis has not been intensively investigated. We have reported a potential link between Bartonella spp. bacteremia and neuropsychiatric symptoms, including pediatric acute onset neuropsychiatric syndrome and schizophrenia. The purpose of this study was to further assess whether Bartonella spp. exposure or infection are associated with psychosis. In a blinded manner, we assessed the presence of anti-Bartonella antibodies by indirect immunofluorescence assays (IFA), and infection by amplification of bacterial DNA from blood by quantitative polymerase chain reaction (qPCR), digital PCR (dPCR), and droplet digital PCR (ddPCR) in 116 participants. Participants were categorized into one of five groups: 1) controls unaffected by psychosis (n = 29); 2) prodromal participants (n = 16); 3) children or adolescents with psychosis (n = 7); 4) adults with psychosis (n = 44); and 5) relatives of a participant with psychosis (n = 20). There was no significant difference in Bartonella spp. IFA seroreactivity between adults with psychosis and adult controls unaffected by psychosis. There was a higher proportion of adults with psychosis who had Bartonella spp. DNA in the bloodstream (43.2%) compared to adult controls unaffected by psychosis (14.3%, p = 0.021). The Bartonella species was determined for 18 of the 31 bacteremic participants, including infection or co-infection with Bartonella henselae (11/18), Bartonella vinsonii subsp. berkhoffii (6/18), Bartonella quintana (2/18), Bartonella alsatica (1/18), and Bartonella rochalimae (1/18). In conjunction with other recent research, the results of this study provide justification for a large national or international multi-center study to determine if Bartonella spp. bacteremia is more prevalent in adults with psychosis compared to adults unaffected by psychosis. Expanding the investigation to include a range of vector-borne and other microbial infections with potential CNS effects would enhance knowledge on the relationship between psychosis and infection.

Differential diagnosis of acute psychosis after cocaine consumption: a case report

IntroductionPsychosis is a common clinical presentation of mental disorder in many psychiatric patients, however, an etiological diagnosis is important when it occurs for the first time in a patient. Regarding a case seen in the Emergency Department recently, with major depression and acute cocaine use, a differential diagnosis was made after adequate organic screening. When presenting delusion of infestation after the consumption of the substance, the main hypothesis was what we call Ekbom syndrome. However, among other possibilities we consider a toxic psychosis or a major depression with psychotic symptoms.ObjectivesReview the different causes of acute psychosis and the importance of a good clinical history to achieve a specific diagnosis. Perform a differential diagnosis between the main causes of psychosis in a patient with depression who has recently consumed cocaine.MethodsPresentation of the case and review of the available literature on the risk of developing psychosis after cocaine use and depression concomitantly.ResultsThere is a low number of reported cases of delusional infestation after acute cocaine use, being more likely toxic psychosis or major depression with psychotic symptoms. A good anamnesis, with systematic questions about toxic habits, can lead us to a more accurate main hypothesis.ConclusionsWe mark the importance of a systematic anamnesis to achieve a better diagnosis, as well as a correct study by the clinician of the specific syndromes described in phenomenology such as Ekbom syndrome, to make a correct association of ideas in the differential diagnosis.Disclosure of InterestNone Declared

Inflammatory based psychotic symptoms: when psychosis means encephalitis

AbstractSchizophrenia, as one of the most common disorders from the psychotic spectrum is most commonly detected in the phase of first psychosis and may pose a diagnostic challenge, as commonly comprise a heterogeneous group of schizophrenias, with distinct clinical presentations. If it detected in its prodromal phase without clearly developed psychotic symptoms, the diagnosis is even more unreliable, as the transition to full blown psychosis in the next two years happens in 15-40% of more, depending probably on a variety of cumulative environmental risk factors (including childhood trauma, the use of high-potency cannabis, urbanicity, season of birth). Moreover, the first episode psychosis may underlie for example the first manic episode, brief intermittent psychotic symptoms in persons with borderline personality disorders, acute reaction to trauma, the use of cannabis and psychostimulants and different organics causes, such as endocrinologic disorders and autoimmune encephalitis. Therefore, in everyday clinical practice, the diagnosis of first episode psychosis always requires an assessment of possible causes of psychosis, and also factors that may influence prognosis and treatment. Usual assessment include detailed anamnestic and heteroanamnestic data, physical examination, standard blood laboratory findings, drugs in urine/ blood, EEG and CT/MR scan. The absence of typical risk factors for schizophrenia, as well as the absence of premorbid symptoms and developmental course typical for schizophrenia, abrupt course of psychotic symptoms, symptoms such as disorientation, catatonia, speech disturbances, alteration of consciousness, neurologic signs, autonomic dysfunction and laboratory aberrations may be especially indicative for organic cause and possibly encephalitis and require further confirmation with the analysis of cerebrospinal liquor with antineuronal antibodies.Disclosure of InterestNone Declared

Postpartum Psychosis and Maternal Filicide- Case Report and Literature Review

IntroductionPostpartum period is defined as the 12 weeks following the birth of a child as per ACOG guidelines. This period is crucial for women to physically and emotionally adapt to major changes in their lives. If concerns are not addressed properly it can result in fatal outcomes such as filicide and suicide in context of untreated mental illness with postpartum onset. Postpartum psychosis is considered a psychiatric emergency and literature shows that up to 4.5% of patients with depressive symptoms with psychosis commit filicide. However, postpartum psychosis is not recognized as a formal psychiatric disorder in DSM-5, leading to a delay in identification and treatment of the condition in a timely fashion.ObjectivesThe primary purpose of the case report is to inform the clinical picture and the legal implications associated with postpartum psychosis, a poorly understood and underdiagnosed psychiatric illness and to emphasize the importance of considering other psychiatric illnesses with peripartum onset that affect maternal and pediatric population wellbeing.Methods A comprehensive review of literature using databases, such as PubMed and Google Scholar as well as observation of the patient in the Emergency Department by the psychiatry team.Results We present the case of a female in her 20s, mother of two toddlers, with a history of PTSD and postpartum depression, who was brought to our Emergency Department for stabbing her children in the context of a psychotic episode. The patient endorsed persecutory delusions and religious preoccupation, stating that she was experiencing “demonic energy inside” and that demons were speaking through her sons. Upon further assessment, it was noted that symptom onset was during the peripartum period, initially with depressed mood, and later with psychotic features. Organic causes of psychosis were ruled out with an extensive workup. Patient was transferred to an inpatient forensic unit for further stabilization. From a legal perspective, literature review shows that mothers may face the death penalty in the US in contrast with other countries such as England for instance. In the context of the current case, the plausible diagnoses are MDD with psychotic features or the first psychotic episode with peripartum onset that was left untreated resulting in a fatal health and legal outcome.ConclusionsAs postpartum psychosis is not currently recognized as an independent diagnosis under the DSM-5, further attention is warranted for such critical psychiatric condition that afflicts the lives and well-being of the maternal and pediatric populations globally. Postpartum psychosis affects mothers despite their past psychiatric history, socioeconomic status, educational level, and supportive network. Thus, it is essential to target proper and timely identification of symptoms and address those to prevent filicide and maternal suicide.Disclosure of InterestNone Declared

The revised Psychosis Attachment Measure: further psychometric evidence

PurposeDisorganised attachment is a key concept in understanding the development of psychosis. However, existing questionnaires of adult attachment do not adequately measure this construct hindering future research into the psychosocial causes of psychosis. The most widely measure of adult attachment in people experiencing psychosis is the Psychosis Attachment Measure (PAM). The measure has recently been revised to include disorganised attachment items. This study develops previous research by providing a rigorous examination the psychometric properties of the revised questionnaire (PAM-R).MethodsA total of 407 participants with self-reported experiences of psychosis completed a battery of questionnaires which included the PAM-R and other measures which were conceptually related to the concept of disorganised attachment.ResultsConfirmatory factor analysis (CFA) indicated a three-factor solution with factors corresponding to anxious, avoidant, and disorganised attachment. The majority of the fit statistics were acceptable with the exception of the RMSEA statistic. Internal consistency and test–retest reliability were good for all subscales. The disorganised subscale correlated in expected directions with other measures of attachment, dissociation, trauma, and psychotic experiences.ConclusionThe PAM-R is a valid and reliable measure of adult attachment. It is a practical assessment tool for clinicians and researchers to measure insecure and disorganised attachment patterns that is acceptable to people experiencing psychosis.

Adrenocorticaal carcinoom als uiterst zeldzame oorzaak van psychose, hypokaliëmie en metabole alkalose

Adrenocortical carcinoma: an extremely rare cause of psychosis, hypokalemia and metabolic alkalosis Adrenocortical carcinoma (ACC) is an utmost rare malignancy with a generally poor prognosis due to the fact that most ACCs are diagnosed in a late stage. The case of a 40-year-old female patient diagnosed with liver-metastasized ACC after an acute psychotic episode in the presence of severe hypokalemia and metabolic alkalosis is presented. Despite the treatment with ketoconazole followed by an adrenalectomy and adjuvant therapy with mitotane, the patient showed rapid clinical deterioration. Palliative care was initiated about a month after her admission. She died a few weeks later. This article summarizes the current literature on the epidemiology, clinical presentation, diagnosis, treatment and prognosis of ACC.

How first-episode psychosis patients' subjective beliefs about their childhood trauma's causal effect provide support for potential schizophrenia subtypes

BackgroundChildhood and adolescent trauma is a risk factor for developing psychosis-spectrum disorders. The current study aimed to assess how childhood trauma might predict psychosis symptomatology, and how patients' beliefs of whether trauma is the cause of psychosis might affect this association. MethodsNinety-six first-episode psychosis patients were assessed for childhood traumatic experiences with the Brief Betrayal Trauma Survey, and for psychosis symptoms with the Positive and Negative Syndrome Scale. ResultsNon-interpersonal trauma predicted higher positive symptoms, whereas more trauma domains experienced predicted lower negative symptoms. Almost half of the participants believed trauma to be related to psychosis, were 12 times more likely to reexperience trauma through psychosis, and had higher excitative and emotional symptoms. Non-interpersonal trauma also predicted higher positive symptoms in this group. Those who did not believe trauma to be the cause of psychosis had higher negative symptoms, and a negative dose-response was found for negative and disorganised symptoms, in which more trauma domains experienced predicted lower scores. ConclusionsResults imply two traumagenic pathways to psychosis, one characterised by positive, excitative, and emotional symptoms, and one negative subtype, characterised by negative and disorganised symptoms. Clinical implications for how findings might contribute to better treatments are discussed.

An extremely rare cause of psychosis, hypokalemia, and metabolic alkalosis

An extremely rare cause of psychosis, hypokalemia, and metabolic alkalosis

The association between visual hallucinations and secondary psychosis: a systematic review and meta-analysis

ABSTRACT Introduction: Visual hallucinations are often considered to be suggestive of a secondary cause of psychosis, however, this association has never been assessed meta-analytically. We aimed to compare the presence of visual hallucinations in patients with psychosis due to a primary or secondary cause. Method: We conducted a meta-analysis of case-control studies directly comparing primary and secondary psychosis. A random-effects model, following the DerSimonian and Laird method, was used to pool studies and generate overall odds ratios (OR), 95% confidence intervals (CI) and prediction intervals (PI). Results: Fourteen studies (904 primary and 804 secondary psychosis patients) were included. Visual hallucinations were significantly associated with secondary psychosis (OR = 3.0, 95% CI = 1.7-5.1, p < 0.001) with moderate between-study heterogeneity (I2 = 70%). Subgroup analysis by type of secondary psychosis (organic, drug-induced, mixed) was non-significant. Analysis of the content of visual hallucinations (51 primary and 142 secondary psychosis patients) found hallucinations of inanimate objects were significantly more likely to be associated with secondary psychosis (OR = 0.1, 95% CI = 0.01-0.8, p = 0.03). Conclusions: Visual hallucinations were strongly associated with a secondary cause of psychosis. The presence of visual hallucinations in a patient presenting with psychosis may serve as a potential “red flag” for a secondary cause and warrant further investigation.

SAT492 Hypothyroidism Induced Psychosis: A Rare Initial Presentation Of Severe Hypothyroidism

Abstract Disclosure: M. Shaukat: None. M. Mack: None. E. Galarza: None. R. Saeed: None. L.E. Arzeno-Tejada: None. Introduction: Hypothyroidism presents as slowing of bodily functions that become more severe as the disease progresses. Common presentations of hypothyroidism are lethargy, constipation, hair and skin changes and mental slowing. We present a rare presentation of hypothyroidism induced psychosis, also called myxedema psychosis or more commonly, myxedema madness, triggered by lenalidomide. This, per our review, has only been reported a handful of times in prior literature. Case Description: 64-year-old male with a history of follicular Non-Hodgkins Lymphoma, currently on rituximab/lenalidomide who was brought to the Emergency Department (ED) for concerns of hallucinations, paranoia and manic episodes for three days. In the ED, his vitals were stable. Computed Tomography (CT) head was normal. Lab work revealed an elevated TSH at 51.70 uIU/ml (normal 0.30-5.0 uIU/ml), free T3 &amp;lt;0.1 pg/ml (normal 2.0-4.4 pg/ml) and free T4&amp;lt; 0.1 ng/dL(normal 0.7-1.7 ng/dL). Thyroid peroxidase antibody was 9 IU/ml (normal &amp;lt;34.0 IU/ml). He was started on intravenous levothyroxine and as needed haloperidol to which he responded well in about forty-eight hours. During this time, he got a MRI of his brain that was normal. He was examined by neurology who did not recommend any further neurological workup. He continued IV therapy for 4 weeks after which he was switched to oral levothyroxine. His chemotherapy regimen has been changed to bendamustine/rituximab and he was discharged to a psychiatric facility for two weeks. He continues to be on oral levothyroxine and is currently doing well. Discussion: Hypothyroidism is described as decreased activity of the thyroid gland that results in retardation in growth and development of children and adults and common initial presentations of hypothyroidism include lethargy, hair loss, skin changes, cold sensitivity, weight gain and constipation. The most common psychiatric association of hypothyroidism is depression. Studies have also shown that there is an association between hypothyroidism and bipolar disorders. Other psychiatric manifestations include loss of memory, labile emotions and forgetfulness. However, in around 5 to 15 percent of the patients, the initial presentation of hypothyroidism is psychosis, also termed myxedema psychosis. The exact mechanism is uncertain, and the evidence is based on experimental animal models, but it is believed that the effects on the brain are due to increased dopamine levels and tyrosine hydroxylase activity in hypothyroid patients, mostly in the limbic system where most emotional and behavioral responses are processed. Prompt diagnosis with thyroid function tests along with removal of the offending agent is important in these cases since the cause of psychosis is reversible and early treatment has promising results. Presentation Date: Saturday, June 17, 2023

Brief case report: A case of FOLFIRI-Induced psychosis.

Key points Psychosis may occur due to the FOLFIRI chemotherapy regimen. An exhaustive approach to confounding elements of a patient's medical history should be taken to rule out competing causes of psychosis. Both 5‐FU and Irinotecan may be implicated in psychosis, though which agent in particular is the cause is unclear. Risperidone assisted in resolution of this patient's psychosis whilst Olanzapine and Quetiapine did not. Both 5‐FU and Irinotecan have pharmacologic traits that may induce changes in mental status.

1020 Modafinil Induced Psychosis

Abstract Introduction Modafinil has been used for the treatment of numerous different conditions, including daytime somnolence (EDS). Modafinil is a non-amphetamine central nervous system (CNS) stimulant with wakefulness-promoting properties. There have been few reported cases of psychosis associated with modafinil use, however a large majority of those were seen in patients with a history of primary psychiatric disturbances. Report of case(s) We present a case of a 48 year old female coming for evaluation of excessive daytime somnolence. She completed polysomnography and a multi sleep latency test (MSLT) which revealed mildly elevated AHI, but no sleep onset rapid eye movements (SOREMPs). A diagnosis of idiopathic hypersomnia was subsequently made and 200mg of modafinil up to twice daily was prescribed for her. Patient initially tolerated the modafinil well, however she began having delusions and she subsequently required psychiatric evaluation. These delusions primarily consisted of her believing she was under surveillance and had conspiracy theories against her. She also described having auditory hallucinations as well, especially voices telling her about these conspiracy theories. She also demonstrated poor insight into her medical condition as she refused to discontinue modafinil. Upon evaluation, routine labs including complete blood count, chemistry profile and urine drug screens were completed to rule out any secondary causes of psychosis. It was therefore recommended by psychiatry to discontinue modafinil as there was concern that the delusions were occurring secondary to medication use. The patient's psychotic delusions seemed to dissipate after this. A multidisciplinary meeting was held regarding management of patients' excessive daytime sleepiness (EDS) and a decision was made to begin the patient on pitolisant, a histamine receptor antagonist. The patient was able to achieve great benefit with this medication. Conclusion The presented case illustrates a patient who began having psychosis after beginning modafinil 200mg twice daily. Psychosis is a much more rare side of modafinil and providers should become aware of it. Therefore, patients who are prescribed modafinil should be carefully followed for psychosis development, even when they are previously healthy and have no history of any primary psychiatric conditions. Support (if any)

Self-disorder explained: Yasunaga's "Phantom Space Theory" on schizophrenia.

The present article revisits the theoretical model of schizophrenia by Hiroshi YASUNAGA (1929-2011). Yasunaga restated ego disturbance in schizophrenia as the "Pattern Reversal" between selfhood and otherness, based on British philosopher Wauchope's concept of "pattern." This concept is meant as asymmetrical relatedness (A/B) within a pair of concepts, such as life and death, quality and quantity, and self and other, prioritizing the former (A side) over the latter (B side). When applied to the pair of self and other, the pattern is vital for human experiences, and its disruption fundamentally alters every lived experience. Subsequently, Yasunaga extended the theory of pattern and invented his original "Phantom Space Theory," in which he postulated "Phantom Space," an experiential space that constitutes system a (A-side-led and consciously determined distance) and system a' (B-side-dominated and extra-consciously given distance). He then constructed a kind of neural system model composed of systems a and a', and thereby schematically presented a novel viewpoint on experiences of self and the outside world. The theory further illustrated how the hypothesized imbalance (Phantom Space shrinkage or diminished elasticity of system a') causes symptoms of schizophrenia, such as ego disturbances, auditory hallucinations, and other unspecific symptoms. This article then examines the clinical and theoretical implications of Yasunaga's psychiatric works. Phantom Space Theory is a non-stigmatizing account of schizophrenia because it does not presuppose personal or existential causes of psychosis. The relationship between Phantom Space Theory and dual-process theory is also explored.

Study Outcomes Among Patients with Parkinson’s Disease Treated for Psychosis Residing in the Long-Term Care Setting and Newly Initiating Pimavanserin or Off-Label Atypical Antipsychotics

AbstractIntroductionPsychosis is a common feature of Parkinson’s Disease (PD), with an estimated 50% of PD patients experiencing psychosis (i.e., hallucinations [H] or delusions [D]) at some time during the course of their illness. Pimavanserin (PIM) is the only medication approved in the US for the treatment of H&amp;D associated with Parkinson’s disease psychosis (PDP); however, off-label atypical antipsychotics (AAP) are continuously used. Currently, there are very few real-world studies which evaluate the patient characteristics and clinical outcomes among PD patients residing in the long-term care (LTC) setting within the US, newly initiated on PIM or other AAPs to treat psychosis.MethodsA national LTC database consisting of diagnoses (DX), pharmacy orders (RX), and EHR data linked with the Minimum Data Set (MDS) was used to identify PD patients with a PD DX and 1 PD RX from 01/01/2017 to 09/30/2021 retrospectively. Patient groups were created: PIM group (patients with a PIM RX); AAP group (patients with an AAP RX [and no PIM RX]); and no treatment (No Tx) group (no PIM or AAP RX). All patients were required to have at least 100 days in LTC to be labelled as a resident (≤7 days between discharge and admission were included as LTC stay). Psychosis diagnosis was required at any time for the AAP and No Tx groups. Other medical causes of psychosis beyond PD were not excluded. The index dates were the first RX identified during the study time period for the PIM and AAP groups; and the psychosis DX date for the No Tx group. Incident treatment patients were defined as having no history of PIM or AAP in the 6 months prior to the index date. Patient/clinical characteristics, treatment patterns, and study outcomes were reported using means (SD) and frequencies during the post index period.ResultsThere were: PIM group (N=3,120; N=870 incident), AAP group (N=5,880; N=2,396 incident), and No Tx group (N=1,802). The PIM and AAP groups had an average of 415 days and 383 days between the admitting date and the date of RX. The mean age among all groups was 76–77 years and 48–50% were female. PIM group patients were observed to be sicker with higher rates of concomitant dementia, depression, diabetes, and hypertension versus the AAP group or No Tx group. Initial treatments in the AAP group were mostly quetiapine (49%), risperidone (21%), or olanzapine (12%). The descriptive analysis during the 6 months post index showed the outcomes for the incident AAP group to have: higher proportion of falls and aggression events; higher incidence of new DX (physical changes, anxiety disorders, cognitive decline, insomnia, depression, and anticholinergic effects); and higher proportion of new medication orders (anticonvulsants, antidepressants, and benzodiazepines) compared with the incident PIM group.ConclusionsIn this descriptive LTC retrospective analysis, incident PIM patients were shown to have better outcomes versus the AAP group. These findings are subject to study limitations.FundingAcadia Pharmaceuticals Inc.

Can COVID-19 Cause Acute Psychosis in Pediatric Patients? A Case Report

AbstractObjectivesTo demonstrate that COVID-19-associated acute psychosis, though rare, can happen in the pediatric patient population. Patients with new-onset psychosis should be tested for COVID-19 infection, and other organic causes of psychosis should also be considered (e.g., delirium, medication-induced psychosis, and catatonia).MethodPatient X, a 14-year-old female with no known past psychiatric history, presented to the local emergency room following odd behavior for 3 days and having tested positive for COVID-19 2 weeks prior. The patient’s mother reported odd behaviors, including the patient claiming her fish was calling her name and her name was being repeated on TV. She had been moving slowly with occasional staring. The patient’s mother reported episodes in which the patient was repeating phrases over and over and where she would require redirection to a task. When the patient planned to have a bath, her mother noted that she was naked in her room while looking for something and then needed redirection to go take a bath. She did not have any episodes of agitation. A thorough psychiatric evaluation indicated she was experiencing visual hallucinations. Her vitals were within normal ranges, except for a mildly elevated heart rate. The patient was admitted for further testing, assessment, and management. She was started on chlorpromazine 10 mg daily as needed for psychosis.ResultA complete blood count with differential (CBC), complete metabolic panel (CMP), and thyroid function results were all within the normal range. Urine drug screening was negative. EKG, CSF analysis, chest X-ray, and brain MRI showed no significant abnormalities. Mild background slowing was noted on EEG, with no interictal/epileptiform discharges or any delta brushes. Therefore, a tentative diagnosis of COVID-19-associated psychosis was made. Treated with chlorpromazine 10 mg daily, the patient gradually improved with no hallucinations or bizarre behavior. She was discharged after 5 days and was not prescribed any medication at discharge. Nine days after discharge, the patient was seen by a pediatric neurologist. She did not report any hallucinations or delusions, but her mother reported that the patient moved slowly and had difficulty identifying common objects. An autoimmune panel, physical exam, and repeat EEG were all unremarkable. The neurologist concluded that her psychosis was most likely post-viral sequelae. The patient continued to improve and returned to school over the span of 2 months.ConclusionAcute psychosis after COVID-19 infection is a new and emerging diagnosis with no consensus on management strategies for pediatric or adult patient populations. This case highlights the need for clinicians to be vigilant of subtle, fluid psychotic symptoms, in addition to patients’ general mental well-being. We do not have research regarding the long-term consequences of acute psychosis episodes. Further studies are needed to investigate the neuropsychiatric etiology of post-COVID-19 psychosis and the optimum treatment for this group of patients.FundingNo Funding

Approach to schizophrenia.

Schizophrenia is the most common of a group of psychotic disorders that occur in approximately 3% of the population over the lifespan. It has clear genetic antecedents, which are shared across the spectrum of psychotic disorders; however, a range of other biological and social factors influence the onset and treatment of the disorder. Schizophrenia is diagnosed by a characteristic set of symptoms (positive, negative, disorganisation, cognitive and affective) accompanied by a functional decline. Investigations are used to exclude other organic causes of psychosis and to provide a baseline for the negative effects of pharmacological treatments. Treatment requires a combination of pharmacological and psychosocial interventions. Physical health is poor in this group of people and this is not helped by inconsistent care from health services. Although earlier intervention has improved the immediate outcomes, the longer-term outcome has not significantly shifted.

IVIG for Treatment-Resistant Psychosis For a Child with Turner Syndrome

AbstractPsychosis is defined as the presence of false beliefs or false perceptions. In children some causes of psychosis include psychiatric diagnosis such as schizophrenia and autism. However, it may also be secondary to medical conditions like various forms of encephalitis. Studies have shown that IVIG has been efficacious in the treatment of psychosis in the setting of autoimmune encephalitis.A 9-year-old girl with a past medical history of Turner Syndrome, developmental delay, epilepsy, growth hormone deficiency, metabolic bone disease, and autism (ASD) presented with auditory and visual hallucinations that began June 2020. She began with her hearing voices that repeated the word “dead” and told her that she would not live. The hallucination later took the form of a man that would mock her, laugh about her parents dying, and tell her to kill them. The patient had associated symptoms of insomnia, anxiety, sadness, and increased anger. On her initial admission, CSF studies including culture and gram strain were unremarkable. NMDA, VHKC, and GAD65 antibodies were negative. At this time the hallucinations were thought to be due to ASD and she was prescribed Risperdal 0.25mg twice a day. Unfortunately, this did not improve her symptoms and from the time period of June 2020 to May 2021 she subsequently underwent trials of Risperdal, Zyprexa, Invega, Abilify, Thorazine, Haldol, and Clozaril. However, the symptoms persisted. Zoloft was prescribed, which was efficacious for anger and dysphoria. Trazodone, melatonin, and Remeron were tried for the treatment of insomnia, but did not cause enough improvement to continue the medications. Due to progression of command hallucinations with “the man” instructing her to hurt others, the patient was admitted July 2021 for administration of IVIG. Repeat CSF studies and brain MRI were unremarkable. From July 29, 2021 to August 1, 2021 she received three doses of IVIG which resulted in improvement of psychosis. Prior to administration, she was seeing “the man” throughout the day every single day, was sleeping only 3–4 hours a night, and having nightmares everyday. On evaluation 2 weeks after IVIG, she was only seeing “the man” 1–2 time a day, sleeping 6–8 hours a night, having nightmares 1–2 times a week, and her mood had improved.This case illustrates the potential use of IVIG for the treatment of treatment-resistant psychosis. Although the cause of this patient’s symptoms remains unclear, there were clear benefits from the administration of IVIG that were not seen with trials of antipsychotics.FundingNo Funding

Case presentation: Very early combined first-line immunotherapy and surgery in tumor-associated anti N-methyl-d-aspartate (NMDA) receptor encephalitis associated with improved outcome

IntroductionAnti N-methyl-d-aspartate receptor (anti-NMDA-R) encephalitis is a potentially reversible cause of psychosis. Nearly all patients (&gt;95.5%) quickly develop additional neurological symptoms, and only about 50 percent fully recover, often with latency. At symptom onset, patients commonly present with isolated psychosis, making it challenging to distinguish the disease from a primary psychiatric disorder: The median time from symptom onset to immunotherapy in adults is 28 days (IQR 14–49), and from symptom onset to surgery in tumor-associated cases 1.4 months (IQR 0.7–2.6). Steroids, intravenous immunoglobulins (IVIG), or plasmapheresis are recommended as first-line immunotherapies.ObjectivesTo highlight a case with improved outcome after very early combined first-line immunotherapy (steroids plus IVIG) and surgery in tumor-associated anti-NMDA-R encephalitis.MethodsWorkup of the clinical case followed by a review of the literature.ResultsWe present the case of a 33-year-old woman with sudden onset of anxiety and jealousy ideas, which within a few days, developed a manifest psychosis with formal thought disorders, paranoid and guilt delusions, distrust, and orientation disorders in the absence of additional neurological deficits. A lower abdominal tumor suspicious of an ovarian tumor was detected sonographically five days before the onset of the first symptoms. Lumbar puncture and abdominal computer tomography were performed within 30 hours after hospital admission, confirming the diagnosis of tumor-associated anti-NMDA-R encephalitis with autoantibodies in CSF and serum at a very early clinical stage. First-line immunotherapy with steroids (methylprednisolone 1000mg, day 6 to 10 after symptom onset) was started immediately and combined with IVIG therapy (0.35g/kg, day 9 to 13 after symptom onset). Surgery of the ovarian tumor was performed on day 14 after admission, with histology revealing an immature teratoma. The neuropsychatric examination on day 1 after surgery showed complete remission of clinical symptoms, which persisted during clinical follow-up after 1 and 4 months.ConclusionsThe present case highlights the role of early CSF diagnostic and tumor assessment if autoimmune encephalitis is suspected. Very early first-line immunotherapy with steroids and IVIG, complemented by tumor surgery, was associated with improved outcome in this case with anti-NMDA-R encephalitis. Further studies are warranted to evaluate the generalizability of the finding.Disclosure of InterestNone Declared

Approach to acute psychosis in older adults.

Approach to acute psychosis in older adults.