with Bipolar I disorder, whom was later diagnosed as having Huntington’s disease. Case: ST, 40 year-old woman. She was withdrawn from university due to her illness for several times. Her first symptoms started at the age of 14 by irritability, impulsivity, quarrelsomeness, stealing money from friends and coming home late at night. Within two years insomnia, violent behavior towards family, hypersexuality and excessive alcohol use occured. She received a diagnosis of Bipolar I disorder at the age of 25 presenting with insomnia, marked emotional lability, irritability, impulsivity and poor self care. She was administered mood stabilizors (lithium, valproate) and atypical antipsychotics (olanzapine, risperidone and quetiapine). Also she received 6 ECT trials for manic symptoms and she was hospitalized for three times during the course. However, none of these treatments were found effective. When she was 36 years old, her motor symptoms began with unilateral upper extremity tremor which was considered as an extrapyramidal side effect. One year later she had abnormal gait and posture, two years later she had marked difficulty in walking, dysarthria and choreic movements in her upper extremities. Finally 6 months before her last evaluation, her speech became hesitated and facial grimaces and mannerisms appeared. She was quite irritable, quarrelsome, she had insomnia and marked psychomotor agitation. During this period, involuntary movements were also observed in her father, who was 65 years old and he had a diagnosis of Huntington’s Disease. He had obsessive–compulsive symptoms before the presentation of motor disturbances. Detailed family history revealed that her grandmother also had dementia and involuntary movements before she died. Her neurological examination revealed that her ocular saccades were slow, she had generalized choreiform movements involving arms, legs, neck, lips and the trunk, dystonia of hands and feet and an ataxic gait. She had no insight for her psychiatric and motor symptoms. Neuropsychological test results showed short term memory, attention deficits as well as executive dysfunction. Genetic counseling of the patient revealed a pathological CAG repeat expansion (17/47) in Huntington’s gene. Finally the patient received a diagnosis of dementia due to Huntington’s disease. Conclusions: The presenting case highlights the importance of investigating family history in psychiatric patients with atypical presentations and treatment resistance. Genetic counseling is very important in families with such inherited neurodegenerative disorders presenting with psychiatric symptoms.
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