Remission Of Psychotic Symptoms Research Articles

Tapered discontinuation vs. maintenance therapy of antipsychotic medication in patients with first-episode schizophrenia: Obstacles, findings, and lessons learned in the terminated randomized clinical trial TAILOR.

AimEvidence is insufficient regarding the consequences of discontinuing vs. maintaining antipsychotic medication in patients with first-episode schizophrenia. Our aim was to examine tapered discontinuation vs. maintenance treatment regarding remission of psychotic symptoms and impact on other areas.MethodsPatients included had a diagnosis of schizophrenia, were treated with antipsychotic medication, and were in remission of psychotic symptoms. Participants were randomized to tapered discontinuation or maintenance treatment with antipsychotic medication. Assessments were undertaken at baseline and after 1-year. The primary outcome was remission of psychotic symptoms without antipsychotic medication.ResultsThe trial was terminated due to insufficient recruitment. In total, 29 participants were included: 14 in the tapering/discontinuation group and 15 in the maintenance group. Adherence to maintenance treatment was poor. At 1-year follow-up, remission of psychotic symptoms without antipsychotic medication for 3 months was observed in five participants in the tapering/discontinuation group and two in the maintenance group.ConclusionDue to insufficient recruitment this study does not provide a conclusion on whether unfavorable outcomes or advantages follow tapering of antipsychotic medication. Recruitment and adherence to maintenance treatment encountered obstacles. Based on experiences from this trial, we discussed alternative study designs as consistent evidence is still needed on whether to continue or discontinue antipsychotic medication in remitted patients with first-episode schizophrenia.Clinical trial registrationhttps://www.clinicaltrialsregister.eu/ctr-search/trial/2016-000565-23/DK, EU Clinical Trials Register—EudraCT no. 2016–000565–23.

Emerging cycloid psychosis episodes during COVID-19 pandemic: a case series

Aims Cycloid psychosis (CP) is a clinical entity characterized by sudden onset of psychotic polymorphic symptomatology and fluctuant course. It has a reported rate of psychosocial precipitating factors ranging 30–65%. The aim of the study was to describe all cases of CP, admitted in our Psychiatry ward, during the first two months of the COVID-19 pandemic. Method In this retrospective and observational study, we reported a sample of eight patients who were treated as inpatients in the psychiatric ward of our hospital during the first two months of COVID-19 pandemic (mid-March to mid-May 2020) and compared it with previous years. All our patients fulfilled all four Perris & Brockington criteria for CP. We reported the sociodemographic, clinical and biological parameters. Results In our sample, all of the patients had maladaptive personality traits; the major external stressing factor was COVID-19; all our patients had short prodromal symptomatology, short Duration of Untreated Psychosis (DUP) and high score at the Positive Scale at Positive and Negative Syndrome Scale (PANSS-P) at hospital admission with the majority showing psychotic symptoms related to the actual COVID-19 pandemic. The predominant treatment during admission was olanzapine and a short time to full remission of psychotic symptoms was observed in all patients. Conclusion We found an increase in the admission of patients with CP during the first two months of the actual pandemic. Stress caused by the COVID-19 situation has possibly incremented the frequency of stress-related disorders and it has also influenced its clinical presentation.

Perceived stress, social functioning and quality of life in first-episode psychosis: A 1-year follow-up study.

Quality of life (QoL) has been widely studied in people with schizophrenia. In the early phases of psychosis, it remains often impaired even after the remission of psychotic symptoms. The aim of this study was to explore QoL and social functioning during the first year after a first-episode psychosis (FEP), and to study potential moderating effects of stress measures. Here, 61 FEP subjects and 55 healthy controls (HCs) were included. Sociodemographic data and clinical variables were collected through a semi-structured interview. Stress measures, social functioning and QoL were assessed with the Holmes-Rahe Social Readjustment Rating Scale, the Perceived Stress Scale, the Social Adaptation Self-Scale and the Euro-QoL-5D, respectively. Analysis of variance was employed with repeated measures and a mediation analysis at baseline and at 1-year follow-up was carried out. Patients reported lower QoL, poorer social functioning and more stress than HC. FEP patients significantly improved in QoL and stress measures over time, but not in social functioning. Perceived stress mediated the association between poorer social functioning and lower QoL. Social functioning at baseline may determine QoL over a 1-year follow-up period. Despite the improvement in most measures, patients do not achieve the level of well-being as the healthy group.

Aberrant striatal dopamine links topographically with cortico-thalamic dysconnectivity in schizophrenia.

Aberrant dopamine function in the dorsal striatum and aberrant intrinsic functional connectivity (iFC) between distinct cortical networks and thalamic nuclei are among the most consistent large-scale brain imaging findings in schizophrenia. A pathophysiological link between these two alterations is suggested by theoretical models based on striatal dopamine's topographic modulation of cortico-thalamic connectivity within cortico-basal-ganglia-thalamic circuits. We hypothesized that aberrant striatal dopamine links topographically with aberrant cortico-thalamic iFC, i.e. aberrant associative striatum dopamine is associated with aberrant iFC between the salience network and thalamus, and aberrant sensorimotor striatum dopamine with aberrant iFC between the auditory-sensorimotor network and thalamus. Nineteen patients with schizophrenia during remission of psychotic symptoms and 19 age- and sex-comparable control subjects underwent simultaneous fluorodihydroxyphenyl-l-alanine PET (18F-DOPA-PET) and resting state functional MRI (rs-fMRI). The influx constant kicer based on 18F-DOPA-PET was used to measure striatal dopamine synthesis capacity; correlation coefficients between rs-fMRI time series of cortical networks and thalamic regions of interest were used to measure iFC. In the salience network-centred system, patients had reduced associative striatum dopamine synthesis capacity, which correlated positively with decreased salience network-mediodorsal-thalamus iFC. This correlation was present in both patients and healthy controls. In the auditory-sensorimotor network-centred system, patients had reduced sensorimotor striatum dopamine synthesis capacity, which correlated positively with increased auditory-sensorimotor network-ventrolateral-thalamus iFC. This correlation was present in patients only. Results demonstrate that reduced striatal dopamine synthesis capacity links topographically with cortico-thalamic intrinsic dysconnectivity in schizophrenia. Data suggest that aberrant striatal dopamine and cortico-thalamic dysconnectivity are pathophysiologically related within dopamine-modulated cortico-basal ganglia-thalamic circuits in schizophrenia.

SA54 - DNA METHYLATION AND ADOLESCENT TRAJECTORIES OF PSYCHOTIC SYMPTOMS

Background Psychotic Symptoms (PS) are often distressing and can be predictive of schizophrenia, other psychiatric disorders and suicide attempts in adulthood, particularly if they persist during adolescence. Previous research in diagnosis-discordant monozygotic twin-pairs and patient-control samples has demonstrated that changes in epigenetic processes could be potential biomarkers of the emergence and persistence of PS. Investigation in large, pre-clinical population-based samples is urgently required. The aim of this study is to explore the association between DNA methylation and the emergence, persistence, and remission of PS in childhood and adolescence. Methods DNA methylation data (Illumina 450k) were obtained from the ARIES subsample of the ALSPAC birth cohort at birth, age 7, and age 15/17 (N=901). PS were assessed in private interviews with the participants at ages 12 and 18. EWAS were conducted to determine the association between DNA methylation at each time-point and reports of PS at ages 12 and 18, controlling for pregnancy and birth-related covariates and cell-type composition. Gene Ontology (GO) term enrichment analyses of the top probes were performed to identify important pathways. The top probes from each EWAS were used to investigate the role of DNA methylation in the persistence and remission of PS by comparing individuals with no history of PS, those whose symptoms persisted, and those whose symptoms remitted. Multilevel models were then constructed to test the association between the longitudinal methylomic trajectory of the top CpG sites and the trajectory of psychotic symptoms. Results from a replication of the top findings in an independent cohort will also be presented. Results A number of probes were differentially methylated (p Discussion Findings from this large, population-based study suggest that epigenetic processes at multiple stages of development may be associated with the emergence, remission, and persistence of PS in late childhood and adolescence. Research uncovering biomarkers associated with pre-clinical PS is important as it has the potential to facilitate early identification of individuals at increased risk and target preventive interventions.

Confused Connections? Targeting White Matter to Address Treatment Resistant Schizophrenia.

Despite development of comprehensive approaches to treat schizophrenia and other psychotic disorders and improve outcomes, there remains a proportion (approximately one-third) of patients who are treatment resistant and will not have remission of psychotic symptoms despite adequate trials of pharmacotherapy. This level of treatment response is stable across all stages of the spectrum of psychotic disorders, including early phase psychosis and chronic schizophrenia. Our current pharmacotherapies are beneficial in decreasing positive symptomology in most cases, however, with little to no impact on negative or cognitive symptoms. Not all individuals with treatment resistant psychosis unfortunately, even benefit from the potential pharmacological reductions in positive symptoms. The existing pharmacotherapy for psychosis is targeted at neurotransmitter receptors. The current first and second generation antipsychotic medications all act on dopamine type 2 receptors with the second generation drugs also interacting significantly with serotonin type 1 and 2 receptors, and with varying pharmacodynamic profiles overall. This focus on developing dopaminergic/serotonergic antipsychotics, while beneficial, has not reduced the proportion of patients experiencing treatment resistance to date. Another pharmacological approach is imperative to address treatment resistance both for response overall and for negative symptoms in particular. There is research suggesting that changes in white matter integrity occur in schizophrenia and these may be more associated with cognition and even negative symptomology. Here we review the evidence that white matter abnormalities in the brain may be contributing to the symptomology of psychotic disorders. Additionally, we propose that white matter may be a viable pharmacological target for pharmacoresistant schizophrenia and discuss current treatments in development for schizophrenia that target white matter.

Clozapine-Induced Agranulocytosis Revealing a Hemophagocytic Lymphohistiocytosis: A Case Report

Context: The aim of this report is to illustrate a case of hemophagocytic lymphohistiocytosis (HLH) that was revealed in the context of treatment-resistant first-episode psychosis. The incidence of this life-threatening condition is increasing in adults. Prompt diagnosis and treatment are important for an optimal patient outcome. Case Report: The patient was a 20-year old female who had been admitted to the inpatient unit of a Psychiatric Hospital for disorganized behavior with psychotic features. Clozapine had been introduced as the clinical picture did not evolve despite several trials of antipsychotics. As severe agranulocytosis developed, the patient was transferred to a general hospital. A diagnosis of HLH was suggested. Patient responded well to treatment, and remission of psychotic symptoms was observed. Conclusion: This case demonstrates the occurrence of HLH in a complicated clinical scenario involving psychotic experiences and the use of clozapine. Further studies are necessary to understand the potential environmental and pathological factors related to HLH

T54. TAILOR – TAPERED DISCONTINUATION VERSUS MAINTENANCE THERAPY OF ANTIPSYCHOTIC MEDICATION IN PATIENTS WITH NEWLY DIAGNOSED SCHIZOPHRENIA SPECTRUM DISORDERS IN REMISSION OF PSYCHOTIC SYMPTOMS

BackgroundSchizophrenia spectrum disorders have major implications for the individuals, their families and society.Antipsychotic medication is the cornerstone in the treatment of psychotic symptoms and is effective in the reduction of psychotic symptoms and of relapse after remission of psychotic symptoms. This is the reason for recommending maintenance treatment with antipsychotic medication in national and international guidelines for the treatment of schizophrenia, one year after remission of psychotic symptoms in first episode psychosis.The aim of the study is to investigate the effect of tapered discontinuation versus maintenance therapy with antipsychotic medication in patients with newly diagnosed schizophrenia or persistent delusional disorder and with minimum three months remission of psychotic symptoms, and to find minimal effective dose of antipsychotic medication. Negative symptoms, cognitive impairments and the side effects of antipsychotic medication can cause a serious and long-term burden for patients and can reduce their quality of life. The TAILOR study will investigate these important aspects.MethodsThe study is a randomized multicenter single blinded clinical trial. The aim is to include 250 patients from the outpatient early intervention program, OPUS, a 2 years manualized psychiatric treatment programme. At baseline patients must have 3 months remission of psychotic symptoms as documented by the SAPS (Schedule for Assessment of Positive Symptoms in Schizophrenia).The patients will be randomized to either tapered discontinuation or dose reduction of antipsychotic medication or treatment as usual stratified according to substance abuse. The intervention will last for 1 year, and follow up interviews will be made after 1,2 and 5 years.The patients will receive a user-developed mobile phone application to make daily registrations.ResultsThe study has been including patients since May 2017.The first data is expected in 2019.DiscussionThe TAILOR trial will contribute to knowledge about the effect of tapering/discontinuation of antipsychotic medication in early phases of schizophrenia spectrum disorders and hopefully the results may guide future clinical treatment regimens of antipsychotic medication.The trial is a complex medical intervention, and it raises ethical, practical and organizational challenges.When designing the TAILOR trial ethical questions were raised regarding blinding and the design of the intervention. In the trial only the researchers are blinded, neither clinicians nor patients, because they should be attentive of the high risk of relapse in the discontinuation group. The design gives the clinicians the possibility to adjust the dose of the antipsychotic medication to ensure sufficient treatment. Therefore, the trial only includes assessor blinding and the groups might end up being more similar than intended.In general, it is of ethical consideration that the trial participants in the tapering/discontinuation group will be subjected to a higher risk of relapse. On the other hand, it seems unethical if research were not to discover the group of patients who can discontinue antipsychotic medication without relapsing.Practical challenges will be sufficient recruitment or patient motivation and dropout.

Stability and development of psychotic symptoms and the use of antipsychotic medication - long-term follow-up.

Few studies have evaluated the development in the use of antipsychotic medication and psychotic symptoms in patients with first-episode psychosis on a long-term basis. Our objective was to investigate how psychotic symptoms and the use of antipsychotic medication changed over a 10-year period in a cohort of patients with first-episode psychosis. The study is a longitudinal prospective cohort study over 10 years with follow-ups at years 1, 2, 5 and 10. A total of 496 patients with first-episode psychosis were included in a multi-centre study initiated between 1998 and 2000 in Copenhagen and Aarhus, Denmark. At all follow-ups, a large proportion (20-30%) of patients had remission of psychotic symptoms without use of antipsychotic medication at the time of the follow-up. Patients who were in this group at the 5-year follow-up had an 87% [95% confidence interval (CI) 77-96%] chance of being in the same group at the 10-year follow-up. This stability was also the case for patients who had psychotic symptoms and were treated with antipsychotic medication at year 5, where there was a 67% (95% CI 56-78%) probability of being in this group at the consecutive follow-up. A large group of patients with psychotic illness were in remission without the use of antipsychotic medication, peaking at year 10. Overall there was a large degree of stability in disease courses over the 10-year period. These results suggest that the long-term outcome of psychotic illness is heterogeneous and further investigation on a more individualized approach to long-term treatment is needed.

A case of pharmacologic extrapyramidal syndrome

IntroductionMore than 60% of patients receiving intensive treatment with first generation antipsychotic manifest some type of clinically significant extrapyramidal side effects. Parkinsonian syndrome is the most common and is characterized by rigidity, tremors, akinesia and bradykinesia and usually improves with discontinuation of antipsychotic drug or anticholinergic association.MethodsIt is a 60-year-old man, married with two children. Initiates contact with mental health in 2013 with a diagnosis of adjustment disorder. In February 2014 he requires hospitalisation, establishing the diagnosis of delusional disorder and starting treatment with long-acting injectable paliperidone palmitate (100 mg/month) with remission of psychotic symptoms in a few days. When we receive the patient in our clinic, he presents parkinsonian extrapyramidal symptoms (UKU subscale: 18), with significant functional limitation. We decrease the dose to 75 mg/month and an anticholinergic was added without improvement of Parkinsonian clinic, so we decided to switch to long-acting injectable aripiprazole 400 mg/month, objectifying complete remission of extrapyramidal syndrome (UKU subscale: 0).ConclusionsThe mechanism of action of aripiprazole m LAI (partial agonist of D2 receptors in the brain) without decreases in the nigrostriatal dopamine pathway, of improving extrapyramidal effects associated one other antipsychotics.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Vitamin B12 deficiency induced psychosis – a case report

Vitamin B12 is one of the most essential vitamins affecting various systems of the body. Cases of neuropsychiatry disorders due to its deficiency are more common in elderly patients with prevalence of 10–20%. The most common psychiatry symptoms reported in the literature associated with vitamin B12 deficiency was depression, mania, psychotic symptoms, cognitive impairment and delirium. Here, we report a case of vitamin B12 deficiency in a 52-year-old male who presented with psychotic features: persecutory delusions, tactile and auditory hallucinations. Patient had neither recorded psychiatry history nor any drug abuse. Medical history includes hypertension, diabetes mellitus and glaucoma. The patient was not a vegetarian. All relevant laboratory evaluations and head CT were normal except vitamin B12. The patient was treated with antipsychotics (risperidone 3 mg/day) and intramuscular vitamin B12. One week after, there was total remission of psychotic symptoms. In the follow-up during the next four months, psychiatry symptoms did not recur at any time. This case reports a rare case of vitamin B12 deficiency induced psychosis. Although there was concurrent administration of an antipsychotic along with vitamin B12, it underlines the importation of evaluation of vitamin B12 and other potential reversible causes of psychosis.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Antipsychotic medication and remission of psychotic symptoms 10 years after a first-episode psychosis

BackgroundSeveral national guidelines recommend continuous use of antipsychotic medication after a psychotic episode in order to minimize the risk of relapse. However some studies have identified a subgroup of patients who obtain remission of psychotic symptoms while not being on antipsychotic medication for a period of time. This study investigated the long-term outcome and characteristics of patients in remission of psychotic symptoms with no use of antipsychotic medication at the 10-year follow-up. MethodsThe study was a cohort study including 496 patients diagnosed with schizophrenia spectrum disorders (ICD 10: F20 and F22–29). Patients were included in the Danish OPUS Trial and followed up 10years after inclusion, where patient data was collected on socio-demographic factors, psychopathology, level of functioning and medication. Findings61% of the patients from the original cohort attended the 10-year follow up and 30% of these had remission of psychotic symptoms at the time of the 10-year follow up with no current use of antipsychotic medication. This outcome was associated with female gender, high GAF-F score, participation in the labour market and absence of substance abuse. ConclusionOur results describe a subgroup of patients who obtained remission while not being on antipsychotic medication at the 10-year follow-up. The finding calls for further investigation on a more individualized approach to long-term treatment with antipsychotic medication.

Cases of remission of psychosis following resection of pheochromocytoma or paraganglioma

The author previously proposed that schizophrenia has similar cytokine expression compared to melanoma, a neural crest cell tumor. One possible tumor model of schizophrenia includes anti-NMDA receptor encephalitis, a paraneoplastic syndrome. While examining the possible relationship of neural crest cell tumors to schizophrenia, the author found several case reports of psychosis resulting from pheochromocytomas and paragangliomas, types of neural crest cell tumors that secrete catecholamines. In most cases, surgical resection of the tumors resulted in remission of psychotic symptoms, and some remissions were associated with reduced levels of peripheral catecholamine levels. These reports suggest, first, that the differential diagnosis of psychosis with autonomic instability should include these tumors. Second, the cases raise a theoretical question as to how these tumors might cause psychosis. On one hand, the elevated peripheral catecholamines caused by these tumors generally agree with aspects of the dopamine hypothesis of schizophrenia although the mechanism of how peripheral dopamine would cause psychosis is unknown. On the other hand, these tumors could possibly secrete an unidentified antibody to a receptor similar to what is observed in anti-NMDA receptor encephalitis.

Social cognition, functional capacity and symptoms in the longitudinal prediction of outcome in subjects with first-episode schizophrenia

BackgroundSeveral national guidelines recommend continuous use of antipsychotic medication after a psychotic episode in order to minimize the risk of relapse. However some studies have identified a subgroup of patients who can obtain remission of psychotic symptoms while not being on antipsychotic medication for a long period of time. This study investigated the long-term outcome and characteristics of patients in remission of psychotic symptoms with no use of antipsychotic medication at the 10-year follow-up.MethodsThe study was a cohort study including 496 patients diagnosed with schizophrenia spectrum disorders (ICD 10: F20 and F22-29). Patients were included in the Danish OPUS Trial and followed up 10 years after inclusion, where patient data was collected on socio-demographic factors, psychopathology, level of functioning and medication.FindingsAmong the patients, 30% had remission of psychotic symptoms at the time of the 10-year follow up with no current use of antipsychotic medication. This favorable outcome was associated with female gender, high GAF-F score, participation in the labor market and absence of substance abuse.InterpretationResults from several RCTs advise against discontinuation of antipsychotic medication, but our results from the 10-year follow-up indicate that a subgroup do obtain long-term remission while not being on antipsychotic medication. Hence, guidelines on antipsychotic medication do not pay sufficient attention to patients who discontinue antipsychotic medication and are still able to obtain remission of psychotic symptoms.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Pharmacological wash out for clozapine induced tics: A case report

Introduction Clozapine has been long used for the treatment-resistant schizophrenia. Its effectiveness in the vast schizophrenia symptoms is well established. However, its wide range of adverse effects has limited its use. Objectives/aims To present a new strategy in order to continue with clozapine treatment despite extrapyramidal adverse effects. Methods/case report Extrapyramidal symptoms are rarely reported with clozapine. Although, cases of patients with clozapine-induced tics have been described. We report the case of a 28 year-old patient with history of refractory schizophrenia that developed motor tics with clozapine 150mg total dose. Tics consisted on eye blinking, eyebrow elevation, mouth twitching, facial grimacing, lip licking, tongue protrusion and shoulder shrugging. Reduction of clozapine dose to 50mg qd was indicated to decrease the motor tics, however exacerbation of psychosis occurred. We added amisulpride and titrated it up to 600mg qd without response. By using the same principle of levodopa's washout in Parkinson disease and in order to establish a therapeutic threshold, we conducted a one-week clozapine washout. Results After this therapeutic manoeuvre, tics disappeared and no relapse was observed after clozapine reinitiation along with remission of psychotic symptoms. Conclusions Wash out might be a new strategy for treatment reinitiation after clozapine induced extrapyramidal side effects in patients with treatment-resistant schizophrenia. To our knowledge no previous report of this strategy has been reported, however further studies are needed to support its effectiveness.

First psychotic episode on the fifth decade? Differential diagnosis of psychotic symptoms, about a case

The postictal psychosis is a psychotic disorder that begins shortly after a crisis. Most often it affects patients with partial epilepsy and especially those with temporal lobe epilepsy. The postictal psychosis according to several publications can occur in up to 25% of patients with epilepsy. The psychotic disorder usually occurs within 24–48 hours after, be transient, with good response to treatment with antipsychotics and complete remission of psychotic symptoms. This case is for a woman of 58 years diagnosed with structural epilepsy after brain abscess left temporal intervened in childhood. The patient is being followed by neurology for complex partial seizures with secondary generalization in anti-epileptic treatment. The patient has previous studies of EEG, video EEG and brain MRI, evidence involvement of temporal lobe and hippocampus. The patient is brought to the emergency room after episode of sensory aphasia, unconsciousness and tonic-clonic limb movements, decreasing with diazepam. The patient, during the stay under observation, has auditory hallucinations, that generate anxiety must initiate being him quetiapina and clonazepam orally, yielding partially psychotic disorder, acute intracranial lesions are discarded and the patient is admitted by neurology. The evolution of psychotic disorder with antipsychotic down in a few weeks remaining asymptomatic. Epileptic psychosis is more common in refractory epilepsy. In all cases, you should make a joint approach between psychiatry and neurology, usually they have good response to antipsychotics.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Neurocognition and Duration of Psychosis: A 10-year Follow-up of First-Episode Patients.

A substantial proportion of schizophrenia-spectrum patients exhibit a cognitive impairment at illness onset. However, the long-term course of neurocognition and a possible neurotoxic effect of time spent in active psychosis, is a topic of controversy. Furthermore, it is of importance to find out what predicts the long-term course of neurocognition. Duration of untreated psychosis (DUP), accumulated time in psychosis the first year after start of treatment, relapse rates and symptoms are potential predictors of the long-term course. In this study, 261 first-episode psychosis patients were assessed neuropsychologically on one or more occasions. Patients were tested after remission of psychotic symptoms and reassessed 1, 2, 5, and 10 years after inclusion. The neurocognitive battery consisted of California Verbal Learning Test, Wisconsin Card Sorting Test, Controlled Oral Word Association Task, Trail Making A and B, and Finger Tapping. We calculated a composite score by adding the z-scores of 4 tests that were only moderately inter-correlated, not including Finger Tapping. Data were analyzed by a linear mixed model. The composite score was stable over 10 years. No significant relationship between psychosis before (DUP) or after start of treatment and the composite score was found, providing no support for the neurotoxicity hypothesis, and indicating that psychosis before start of treatment has no significant impact on the course and outcome in psychosis. We found no association between symptoms and the neurocognitive trajectory. Stable remission during the first year predicted neurocognitive functioning, suggesting that the early clinical course is a good predictor for the long-term course.

Epilepsia, psicose e religiosidade – Caso clínico

Os autores apresentam o caso de uma paciente de 61 anos, com antecedentes depressivos e história de síncopes, que desenvolve, no espaço de meio ano, alterações de comportamento pautadas por hiper-religiosidade, ideias delirantes de grandiosidade e fenômenos compatíveis com déjà vu. Nesse contexto, foi referenciada pelo médico de família para a urgência de psiquiatria, tendo sido realizada investigação orgânica e identificada epilepsia do lobo temporal após realização de eletroencefalograma. Foi medicada com valproato de sódio, na dose de 750 mg/dia, com esbatimento progressivo da sintomatologia psicótica. Com este trabalho, os autores pretendem sublinhar a importância da exploração orgânica dos sintomas neuropsiquiátricos, antes de atribuir um diagnóstico psiquiátrico ao paciente.

Metformin-induced Psychosis: a Case Report.

The psychiatric conditions secondary to substance use (whether legal or illegal drugs) are well characterized and include psychosis, mania, depression and behavior changes. We present a case of metformin-induced psychosis in a 79 years-old patient without any previous psychiatric history. She was brought to emergency room after suicide attempt by hanging. She had a one-month history of altered behavioral and presented paranoid delusional though. Hallucinations were excluded. A detailed clinical evaluation excluded dementia, late-onset chronic psychosis and primary mood disorders with psychotic symptoms and revealed that symptoms initiate few days after the introduction of metformin to treat her diabetes. After Metformin suspension, total remission of psychotic symptoms was obtained in one week and patient return to previous functionality. Psychosis secondary to metformin use is a very rare complication of oral antidiabetic drugs use but the awareness of this condition can lead to an earlier recognition and diagnosis.

Comparing time use in individuals at different stages of psychosis and a non-clinical comparison group

Social functioning difficulties are a common and disabling feature of psychosis and have also been identified in the prodromal phase. However, debate exists about how such difficulties should be defined and measured. Time spent in structured activity has previously been linked to increased psychological wellbeing in non-clinical samples and may provide a useful way of assessing social functioning in clinical settings.The current study compared hours in structured activity, assessed with the Time Use Survey, in three clinical groups at different stages of psychosis: individuals with at-risk mental states (N=199), individuals with first-episode psychosis (N=878), and individuals with delayed social recovery following the remission of psychotic symptoms (N=77). Time use in the three clinical groups was also compared with norms from an age-matched non-clinical group (N=5686) recruited for the Office for National Statistics UK 2000 Time Use Survey. Cutoff scores for defining social disability and recovery were examined.All three clinical groups spent significantly fewer hours per week in structured activity than individuals in the non-clinical group. Reduced activity levels were observed before the onset of psychosis in individuals with at-risk mental states. Additional reductions in activity were observed in the first-episode psychosis and delayed recovery groups compared to the at-risk mental state group. Assessing time spent in structured activity provides a useful way to assess social disability and recovery across the spectrum of psychosis.