bluuebunny/crossref_metadata_2025_split huggingface dataset:
First Time Presentation of Graves' Hyperthyroidism With Psychotic Symptoms: A Case Report
Authors: Ajewole Oluwatobi , Doku Victor 
Published: August 2024

AimsGraves’ disease, an autoimmune illness, is one of the most common causes of thyrotoxicosis and often presents with classic symptoms of hyperthyroidism. However, patients can rarely present for the first time with psychiatric symptoms, including psychotic and mood symptoms or a combination of both, and there is limited data on the most effective treatment.MethodsHere, we report the case of a 24-year-old black British female who had no previous psychiatric or medical history, presenting for the first time with one week history of poor sleep, disordered thought, and bizarre and violent behaviour towards family. Collateral history describes her premorbid personality as “anxious and perfectionist”, with the only recent stressors identified being preparations for her best friend's wedding. Her mental state on presentation was remarkable for tangential and circumstantial speech, incongruent affect, and lack of insight into illness. She was admitted to an acute adult ward under Section 2 of the Mental Health Act (MHA) after being “medically cleared” but before the results of her thyroid function tests were available.She was transferred back to the acute medical ward a day into psychiatric admission, where she was treated medically for thyrotoxicosis and discharged with the support of the Home Treatment Team after an almost complete recovery in her mental state. Initial symptoms recurred two weeks after discharge, culminating in another admission cycle initially to a psychiatric unit under the MHA, where she was treated with oral risperidone and a medical ward for further medical investigations. Her mental state improved significantly again, and she was discharged home to the concerted care of both a community mental health team and follow-up with the endocrinology team. On outpatient psychiatric review a year following discharge, the patient remains stable in her mental state and has achieved a euthyroid state with plans to taper off and withdraw risperidone gradually.ResultsThis case shows the importance of a thorough physical health assessment and investigation before making psychiatric management decisions. It also points out the drawback of the divide between physical and mental health services, the impact this has on patient care and experience within the National Health Service, and the mixed success of medical management in controlling psychiatric symptoms.ConclusionThis case describes the rare presentation and successful management of psychosis induced by thyrotoxicosis in a female patient with Graves’ disease. It highlights the need for prompt, interdisciplinary care to diagnose and safely manage such patients correctly.
Case Study: Pseudobulbar Affect During Recovery From Locked in Syndrome
Authors: Ankolekar Sunil J. , Parke Sheryl 
Published: August 2024

AimsWe would like to report a case of pseudo bulbar affect during recovery from locked in syndrome due to brainstem stroke.MethodsWe present a lady in her early 60s who developed pseudobulbar affect during recovery from locked in syndrome. MRI brain confirmed brain stem infarct. No personal or family history of mental illnesses was noted. Neurological examination on our rehabilitation unit confirmed dense weakness in all four limbs. She would cry even when family gave her good news or made jokes with her. This appeared to be the only method of expressing her emotions she had; however, it was unclear if this was aligned to her internal emotional experience.ResultsThrough clinical observation and using the Testing Emotionalism After Recent Stroke-Questionnaire (TEARS-Q) measure of emotionalism we identified that pseudobulbar affect was present, and intervention should be considered. The patient also stated that her crying was not always aligned with her emotional experience, but laughter was. The Clinical Outcome Routine Evaluation (CORE-10) was also used to screen out other potential psychological difficulties including depression. The assessment indicated she was experiencing low levels of psychological distress.We initiated fluoxetine and clonazepam was given to help with spasticity and sleep. Our non-pharmacological measures included sitting with the emotional expression and not asking her to stop, encouraging her to take deep breaths and modelling this and when she presented as calmer supporting her to identify if her emotional expression was in line with her internal emotional experience and using different communication strategies to explore this and support her to have her needs met. If the crying persisted mid communication, staff supporting her would reorientate her to what she had been attempting to communicate and encourage her to continue, which she would be able to do. All staff were asked to do this during their interactions with the patient to support identification of emotional alignment. Significant reduction in emotional misalignment was noted following the implementation and increased use of external communication aids. Within a few months her distressing crying episodes reduced and neurologically she improved.ConclusionPseudo bulbar affect is a distressing condition that can occur during recovery from locked in syndrome. Diagnosis can be confirmed by ruling out other common conditions like anxiety or depression. Treatment includes both non-pharmacological and pharmacological measures best provided by a specialist multidisciplinary team.
Huntington's Disease and Criminal Behaviour: An Exploration of Psychiatric Risk and Management in a High Secure Forensic Unit
Authors: Gupta-Jessop Thomas , Caldwell-Dunn Ellice 
Published: August 2024

AimsHuntington’s disease (HD) is an autosomal dominant neurodegenerative disorder characterised by a pathologically prolonged CAG nucleotide sequence in the huntingtin gene (HTT). Neuropsychiatric symptoms such as aggression, depression, impulsivity and psychosis are non-motor signs of HD. The association between HD and criminal behaviour is debated, and evidence lacking. This is particularly relevant in forensic psychiatry, which focusses on the risk assessment of mentally disordered offenders. This manuscript examines the antecedents of offending behaviour in a male diagnosed with HD during admission to a high secure unit, and the evolution of his risk profile from childhood to post-diagnosis. Additionally, through exploration of psychopharmacological management of psychiatric symptoms in HD, this study aims to further our understanding as to how we can best support people with HD in a forensic mental health setting.MethodsFollowing review of relevant literature on criminal behaviour in the context of HD, we report the case of a 41-year-old man with a background of dissocial personality traits admitted to a high security unit with symptoms of a delusional disorder; manifesting as paranoia, delusional beliefs and aggression. These were believed to be organically induced within the context of HD, a diagnosis confirmed through genetic testing six months following admission. The patient's symptoms were only partially responsive to first-line antipsychotics; however, good symptomatic control was achieved with clozapine and sodium valproate, enabling step-down to medium secure specialist services.ResultsIn HD patients, there may be a challenge of discerning whether offending behaviour relates to prodromal presentation or whether there are pre-existing antisocial attitudes or behaviour; an uncertainty which was present in this case and within the literature. The age of HD onset is inversely correlated with CAG repeat length, and a longer repeat length has been associated with criminal behaviour. This has the potential for use as a marker to determine the time point in which presenting features are attributable to HD. In this case study it was possible to determine through analysis of the CAG repeat length that the delusional disorder was likely linked to the onset of HD; however, dissocial personality traits were not.ConclusionA patient's background relating to the life-course persistence of violence, suicidality and psychiatric symptoms in patients with HD informs the process of formulating their risk profile. Changes to the risk profile also reflect the progressing stages of HD. This highlights the need for awareness of how HD may contribute or predispose to criminal behaviour and how interventions could be targeted during critical periods where they benefit most.
Nabilone as Part of the Holistic Treatment in Early Onset Alzheimer's Dementia: A Case Study
Authors: Saraswat Charvi , Lei Jiedi , Zacharia Tharun , Bonnici Mallia Anne M. 
Published: August 2024

AimsOptimal management of Behavioural and Psychological symptoms of Dementia (BPSD) remains challenging. This report describes using nabilone, a synthetic cannabinoid, in a 61-year-old woman with Alzheimer's dementia (AD) experiencing progressive BPSDs.MethodsAM was diagnosed with AD in February 2019 and prescribed donepezil and mirtazapine. In August 2021, her behaviour deteriorated, becoming paranoid, repeatedly pacing and developing expressive aphasia. Behaviours further declined leading to an admission to our dementia ward under the Mental Health Act 2007 in January 2022. AM showed limited response to medications including risperidone and mirtazapine which were switched to olanzapine and citalopram. “Controlled falls” were observed, during which AM placed herself suddenly onto the floor. In February 2022, she was witnessed having a self-terminating generalised tonic clonic seizure (GTCS) lasting 3 minutes and later witnessed having three more seizures. Computed tomography excluded acute intracranial pathology. She had no previous history of seizures. An electroencephalogram displayed focal slowing over the frontal region greater on the right and presence of sharp, transient, sharpened slow wave, triphasic waves and reported that epileptiform discharges can be seen in AD in the absence of epilepsy.Behavioural charts, Cohen Mansfield Agitation Inventory (CMAI) and Neuropsychiatric inventory (NPI) questionnaires were used to monitor response. Decision was made to trial Nabilone in April 2022 due to minimal improvement. Nabilone was started at 0.25 mg daily and up-titrated by 0.25 mg fortnightly based on the response. Over the subsequent month there was a measurable improvement. This was temporarily halted due to issues with nabilone supply, together with cessation of lorazepam, showing worsening in behaviours. Nabilone was eventually restarted and increased to 1 mg once daily with promising effect.ResultsThere was a notable qualitative improvement in AM's engagement and communication with family and staff. Prior to treatment the frequency of aggressive incidents ranged from 25–35, reducing to five to ten incidents per day. Controlled falls largely ceased. The NPI Caregiver distress score dropped from 21 to 8 over three months; Frequency and severity scores dropped from 73 to 40 during the same period. CMAI scores dropped from 86 to 64 over two months.ConclusionWe describe a measurable improvement in BPSDs and quality of life in a patient with severe AD. Reduction in irritability, agitation and improvements in sleep were observed after initiating nabilone. The mechanism of nabilone via CB1 agonism has shown to be neuroprotective and anti-inflammatory. This indicates a promising treatment for BPSDs.
Navigating the Balance: Treatment-Resistant Schizophrenia Relapse Risks Versus Clozapine-Related Cardiovascular Complications - a Case Report
Authors: Singh Hardeep , Blackman Alexandra 
Published: August 2024

AimsClozapine, known for its efficacy in treating treatment-resistant schizophrenia, offers significant benefits. However, its use also carries potential cardiovascular side effects, such as myocarditis early in treatment and cardiomyopathy with prolonged use. This case highlights the challenge of balancing the risks of treatment-resistant schizophrenia relapse against the potential cardiovascular complications associated with clozapine therapy.MethodsAn adult male with treatment-resistant schizophrenia was initially prescribed clozapine but switched to paliperidone depot due to compliance issues. However, he relapsed shortly after and had to be restarted on clozapine, albeit at a lower dose due to associated tachycardia, supplemented with risperidone. After two years on clozapine, he was diagnosed with cardiomyopathy, prompting a cardiology review. Clozapine was withheld, and risperidone dosage was increased, but he experienced a severe relapse. Despite the risks, multiple multidisciplinary meetings and approval from the medication optimization committee led to his re-commencement on clozapine due to the treatment-resistant nature of his illness and associated risks.ResultsClozapine, a benzisoxazole derivative, is used for treatment-resistant schizophrenia and aggressive behaviours. Its pharmacological action involves D2 and 5HT2A receptor antagonism, affecting serotonergic, dopaminergic, adrenergic, cholinergic, and histaminergic receptors. However, severe side effects like agranulocytosis, seizures, myocarditis, tachycardia, and cardiomyopathy can occur. Cardiomyopathy incidence is rare (0.02–0.1%) with a mortality rate of 17.9%. Proposed mechanisms include undetected myocarditis and persistent tachycardia-induced changes leading to ventricular dysfunction. Common findings in investigations include raised CRP, leucocytosis, eosinophilia, increased lactate, elevated troponin, non-specific ECG changes, and ventricular dysfunction on echocardiography.ConclusionClozapine poses rare but potentially fatal cardiac risks, including myocarditis and cardiomyopathy. Essential baseline investigations and close monitoring during the initial weeks are crucial. Persistent tachycardia may signal trouble. If suspected, serial monitoring of FBC, troponin, and CRP levels is recommended, with prompt management if confirmed with discontinuation of clozapine, as the cardiomyopathy is often reversible. A multidisciplinary approach involving cardiology is vital for optimal management. This is particularly crucial when weighing the risks of relapse in schizophrenia against the potential cardiovascular complications of clozapine therapy.
A Rare Case of rTMS Induced Schizophrenia Symptom Switch
Authors: Sobhani Aayushi , Pursnani Sachin , Chandi Anureet kaur , Bhardwaj Akansha , Kumar Nand 
Published: August 2024

Aims•This case study investigates a rare occurrence of symptom transition in a chronic schizophrenia patient following high-frequency repetitive transcranial magnetic stimulation (rTMS), aiming to understand the unexpected shift from predominantly negative to positive symptoms.•rTMS, known for inducing changes in neuronal activity based on Faraday's law, is believed to enhance cortical excitability through high-frequency stimulation.•Schizophrenia, a severe and chronic mental disorder, presents with both positive (e.g., delusions, hallucinations) and negative symptoms (e.g., apathy). Current treatments, predominantly antipsychotic drugs, often show limited efficacy, especially for negative symptoms. Non-invasive neuromodulation techniques like rTMS are emerging as potential interventions.MethodsThis case involves a 27-year-old banking executive with a 30 months illness duration primarily marked by negative symptoms over the past 3 months. Despite various antipsychotics, there was no improvement, leading to the initiation of high-frequency rTMS on the left dorsolateral prefrontal cortex (DLPFC) as an adjunct strategy for persistent negative symptoms. Surprisingly, after the 5th rTMS session, positive symptoms like delusions and hallucinations emerged. Serial assessments demonstrated a decrease in negative symptom domain scores on PANSS but an increase in positive symptom domain scores on PANSS.Results•Results suggest that 5 Hz rTMS over the left DLPFC may have contributed to the transition to positive symptoms. The discussion explores limited literature on rTMS-induced positive symptoms, with case reports dating back to 2004 indicating the possibility of such induction. Studies propose a link between higher pulse frequency, motor threshold intensity, left prefrontal cortex stimulation, and longer trial durations with the exacerbation of positive symptoms, possibly linked to dopamine changes in specific brain tracts.•Recent trials indicate potential improvement in positive symptoms, such as excitement, with low frequency rTMS of the temporo parietal area. However, the efficacy of rTMS varies with the stimulation site, with left prefrontal rTMS showing promise for negative symptoms and left temporo-parietal junction stimulation possibly reducing auditory hallucinations.ConclusionThis case report suggests that a subset of schizophrenia patients may experience a transient exacerbation of positive symptoms following rTMS. This underscores the need for increased awareness of potential side effects, serving as an exploratory study that calls for future research to refine these findings for a clearer understanding of rTMS-induced symptom switches in schizophrenia.
Effect of Escitalopram on Glycemic Control and C-Reactive Protein in Patients With Depression and Co Morbid Type 2 Diabetes Mellitus – a Study on Indian Population
Authors: Tiwary Shubhankar , G. Vishnuvardhan , Tripathi Richa , M. Manojprithviraj 
Published: August 2024

AimsThere is a bidirectional link between Depression and type 2 Diabetes mellitus (T2DM). Treatment of depression with selective serotonin reuptake inhibitors (SSRIs) may improve glycaemic control and may be beneficial for patients with comorbid depression and diabetes mellitus. The aim of the present study was to assess the effect of escitalopram on C-reactive protein (CRP) and glycaemic control in patients with comorbid T2DM and depression.MethodsA prospective interventional follow up study was conducted in a tertiary health care institute in urban India. Adult males and females who were diagnosed with Type 2 DM, having depression as per ICD-10 and treatment naïve for both the disorders were included for the study. Participants with other psychiatric disorders, on thyroid medication or on any medication that can have effect on CRP levels, having history of any infection/allergic or inflammatory conditions were excluded from the study. Sociodemographic details were collected. The severity of depression was assessed using Hamilton Depression Rating Scale (HDRS) at baseline. Escitalopram was started and titrated upto required doses for each patient. Levels of fasting blood glucose, post prandial blood glucose, HbA1c (Glycated Hemoglobin) and CRP were also measured at baseline. At the end of 3 months, severity of depression scores and blood levels of above mentioned parameters were measured and compared with their baseline values.ResultsA total of 125 patients (females-n = 70, males-n = 55) were included for the study. The mean age of the sample was 63.2 years (SD 10.6). Most of the participants were educated and employed. The mean HRDS score of the participants at baseline and at three months was 20.3 (SD 3.7) and 18.0 (SD 3.9) respectively. The mean HbA1C of the participants at baseline and at three months was 8.4 (SD 1.2) and 7.8 (SD 1.2) respectively. The mean CRP of the participants at baseline and at three months was 4.0 (SD 5.6) and 2.8 (SD 4.3) respectively. There was significant reduction in depressive symptoms (Z score= -6.894, P value <0.05), levels of HbA1C (Z score= -7.936, P value <0.05) and CRP levels (Z score= -6.158, P value <0.05) at follow up after treatment with escitalopram. No significant correlation was observed in these parameters across gender.ConclusionTreatment with escitalopram reduces the severity of depression and the ongoing inflammatory process amongst these patients.
Fahr's Disease (Primary Basal Ganglia Calcification) and Violence: Case Report and Literature Review
Authors: Yorston Graeme , Mumonyedi Sidney , Rehman Muhammad Abdur , Baig Ifrah Ali 
Published: August 2024

AimsBackground: Fahr's disease is a rare and complex neuropsychiatric disorder resulting from abnormal calcium deposition in the basal ganglia and cerebral cortex. It can have a profound impact on an individual's social functioning as well as causing a wide variety of neurological symptoms, cognitive deficits and motor impairment. A number of specific mutations have recently been identified in phosphate transporter and other genes, but around half of all cases have unidentified mutations. Impulsivity, aggression and violence may pre-date the other manifestations of the illness.MethodsCase Report: Patient X is a 58 year old man currently detained in an independent hospital locked rehabilitation unit following the breakdown of a care home placement. His first admission to hospital was at the age of 18 when he was diagnosed with mania. He had multiple further hospital admissions as well criminal convictions for acquisitive and violent offences. In 2005 he threatened to stab a stranger if he did not give him a cigarette and he was arrested and admitted to a medium secure unit under Section 37 with diagnoses of bipolar affective disorder and emotionally unstable personality disorder. He remained in secure hospital care until 2018 when concerns about Parkinsonian symptoms led to him being referred to a neurologist and a diagnosis of Fahr's disease being made on the basis of his CT findings. He was transferred to a locked rehabilitation service in 2019 but continued to exhibit challenging behaviour on a daily basis. After a reduction in the frequency and severity of his behaviour he was discharged to a care home, but this broke down after a few months as his assaultive and sexually inappropriate behaviour re-emerged.ResultsDiscussion: Fahr's disease is traditionally thought of as a late life neurological condition, but as with Huntington's disease neuropsychiatric symptoms of irritability, sexually disinhibited behaviour, impulsivity and aggression can occur early and may pre-date any neurological manifestations. Treatment is often difficult because of sensitivity to antipsychotic medication.ConclusionIt is important to consider neuropsychiatric conditions in the assessment of adults presenting with antisocial behaviours, especially when these are associated with a change in overall functioning and an absence of adolescent conduct disorder. There is as yet no specific treatment for Fahr's disease, but early identification allows appropriate risk management strategies to be adopted.