Misdiagnosis of schizophrenia in a patient with psychotic symptoms.

Misdiagnosis of schizophrenia in a patient with psychotic symptoms.

Abstract

OBJECTIVE:

A case is presented of a 37-year-old black woman with a 5-year history of a chronic psychotic illness, diagnosed as schizophrenia, who presented to the emergency room complaining of a severe headache, while appearing confused and experiencing visual and auditory hallucinations. The purpose of this case study is to illustrate the way in which the appellation of schizophrenia can be misapplied in a patient with a complicated medical history and poor follow-up evaluation and treatment.

BACKGROUND:

Patients with active psychosis are frequently unable to provide a coherent or comprehensive medical history. In the absence of obvious indications to the contrary, a diagnosis of a primary psychiatric illness is often assumed, especially if this label has been applied in the past. However, the differential diagnosis of psychosis is extensive.

METHODS:

This patient was given a complete psychiatric and neurologic evaluation, and aspects of the history that had been lost or ignored were uncovered and reevaluated.

RESULTS:

A diagnosis other than schizophrenia was made and another treatment, other than antipsychotic drugs, was initiated. The patient responded rapidly with improved cognitive function and resolution of her psychotic symptoms.

CONCLUSIONS:

This case serves to illustrate how the absence of a careful clinical assessment and historical case review, in patients who have been previously labeled as schizophrenic, can perpetuate misdiagnoses and inappropriate treatments. It highlights the importance, especially in patients with an incomplete medical history, of ruling out all organic causes of psychosis to avoid inappropriately labeling someone as having a psychiatric illness.

http://www.ncbi.nlm.nih.gov/pubmed/12464752

The Mind Of A Mass Murderer: Charles Whitman, Brain Damage, And Violence (VIDEO)

On August 1, 1966, Charles Whitman murdered his mother and his wife before traveling to the campus of the University of Texas, climbing inside the tower, andkilling fourteen others. He was dubbed the infamous UT sniper, but his story involves much more than Marine Corps training and a proclivity for violence. In fact, Whitman complained of headaches and an altered mental state in the days and weeks leading up to the killings. His own suicide note read that “I do not really understand myself these days. I am supposed to be an average reasonable and intelligent young man. However, lately (I cannot recall when it started) I have been a victim of many unusual and irrational thoughts.”

 

Whitman knew that something was wrong. His note further reads, “After my death I wish that an autopsy would be performed on me to see if there is any visible physical disorder.” And indeed there was. Whitman was found to have aglioblastoma, a type of brain tumor, pressing against regions of the brain thought to be responsible for the regulation of strong emotions.

 

See full story here

Inhaled Steroid–Induced Mania in an Adolescent Girl: A Case Report

To the Editor: Beclomethasone is a synthetic, halogenated glucocorticoid with anti-inflammatory and vasoconstrictive effects. Its inhaled form is used for the treatment of asthma, allergic and nonallergic rhinitis, and viral croup.1 It accomplishes this by inhibiting leukocyte infiltration and suppressing the humoral immune response. The mechanism of the anti-inflammatory properties of corticosteroids is believed to involve phospholipase A2 inhibitory proteins and lipocortins, which regulate the biosynthesis of inflammatory mediators such as prostaglandins and leukotrienes.2 Excretion of beclomethasone is mainly fecal, and, generally, the drug is well tolerated. The risk of adrenal suppression is more associated with the usage of systemic steroids.3

Psychiatric symptoms associated with corticosteroid therapy include mood swings, mania, hypomania, and depression.4 Mania and hypomania are more common than depression.4 The association of adverse psychological side effects with the use of oral and systemic steroids has been well documented in both the adult and the pediatric populations.413 To our knowledge, there are at least 6 case reports published in which the isolated use of inhaled corticosteroids (beclomethasone dipropionate and budesonide) led to the development of psychiatric symptoms in the pediatric population.12,1419 In most cases, symptoms occurred in the first week, and the most commonly reported symptoms are insomnia, aggressiveness, uninhibited behavior, mania, irritability, and increased energy.12,1419 In most cases, the symptoms resolved after discontinuation of the drug, switching to another drug, or decreasing the dosage.12,1419

Case report. Ms A, a 16-year-old white girl with no significant past psychiatric history, presented to an outpatient psychiatric clinic in 2010 with acute mania. The patient had grandiosity (“God gave me the mission to save the world”), flight of ideas, impulsivity (self-mutilating behavior), racing thoughts, pressured speech, decreased need for sleep, and high energy. On mental status examination, she reported a euphoric mood and described delusions of grandiosity. She denied experiencing any hallucinations. She had pressured speech and her affect was mood-congruent.

 

read more here:  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3184585/

Zika May Increase Risk of Mental Illness, Researchers Say

A pregnant woman waits for an examination for mosquito-borne viruses like Zika at a maternity ward in Honduras. Experts say the Zika virus closely resembles some infectious agents that have been linked to autism, bipolar disorder and schizophrenia. CreditJorge Cabrera/Reuters

A baby with a shrunken, misshapen head is surely a heartbreaking sight. But reproductive health experts are warning that microcephaly may be only the most obvious consequence of the spread of the Zika virus.

Even infants who appear normal at birth may be at higher risk for mental illnesses later in life if their mothers were infected during pregnancy, many researchers fear.

The Zika virus, they say, closely resembles some infectious agents that have been linked to the development of autism, bipolar disorder and schizophrenia.

Schizophrenia and other debilitating mental illnesses have no single cause, experts emphasized in interviews. The conditions are thought to arise from a combination of factors, including genetic predisposition and traumas later in life, such as sexual or physical abuse, abandonment or heavy drug use.

But illnesses in utero, including viral infections, are thought to be a trigger.

“The consequences of this go way beyond microcephaly,” said Dr. W. Ian Lipkin, who directs the Center for Infection and Immunity at Columbia University.

Among children in Latin America and the Caribbean, “I wouldn’t be surprised if we saw a big upswing in A.D.H.D., autism, epilepsy and schizophrenia,” he added. “We’re looking at a large group of individuals who may not be able to function in the world.”

Zika Virus Rumors and Theories That You Should Doubt

Here is a look at the most prominent rumors and theories about Zika virus, along with responses from scientists.

Researchers in Brazil are investigating thousands of reports of microcephalic births. While there is no solid proof that Zika virus is the cause, virologists studying the outbreak strongly suspect it.

Continue reading the main story

Stress Hormone’s Link With Psychosis

Summary: Patients at risk for psychosis have different levels of cortisol after waking than healthy controls, a new study reports.

Source: James Cook University.

JCU Associate Professor Zoltan Sarnyai said it was the first meta-analysis study to compare the level of cortisol in a waking patient’s body with the stage of schizophrenia they are suffering.

Dr Sarnyai said it means doctors may be able to eventually identify those who will develop full-blown psychosis from amongst those who present with early stages of the disease.

“Only some 20 to 30 per cent of individuals who are at high-risk of developing psychosis due to their clinical presentation or family history actually do so. Identifying those people early is where the cortisol measurement comes in.

“Biomarkers are very few and far between in psychiatry, so even though a huge amount of work is still needed, this could become a valuable technique,” said Dr Sarnyai.

Researchers at the Psychiatric Neuroscience Laboratory at the Australian Institute of Tropical Health and Medicine (AITHM) at JCU, conducted a meta-analysis of 11 studies.

The resulting paper, published in Neuroscience & Biobehavioral Reviews, shows that patients have different levels of the stress hormone after awakening (Cortisol Awakening Response, CAR) relative to healthy controls.

Read more here:

http://neurosciencenews.com/cortisol-schizophrenia-psychology-4369/

 

A case of sudden psychosis

CASES THAT TEST YOUR SKILLS
A case of sudden psychosis
After her mother dies, Ms. T develops mania and disorganized behavior. She has a seizure and becomes increasingly agitated. Is this grief or something else?
Vol. 8, No. 11 / November 2009
Anthony Cavalieri, MD,
Cathy Southammakosane, MD, and
Christopher White, MD, JD, FCLM

Dr. Cavalieri is a general psychiatry resident, University of Cincinnati. Dr. Southammakosane is a pediatrics/psychiatry/child psychiatry resident, Cincinnati Children’s Hospital Medical Center. Dr. White is assistant professor of psychiatry and family medicine and medical director, University Hospital Psychiatric Consultation Service, University of Cincinnati, OH.

This week’s quiz:
Managing conduct disorder

More »
CASE: New-onset psychosis
Ms. T, age 26, presents to the psychiatric emergency room after a 1-week change in behavior. According to her family, Ms. T began to experience hyperactivity, increased rate of speech, and decreased sleep after her mother passed away 1 week ago. On the day of presentation, Ms. T had returned to work after a week’s hiatus. Coworkers brought her to the hospital when Ms. T threw herself on the floor and flailed about. Family members report that Ms. T had been complaining of headache that day and during the preceding week. In the emergency room, the patient is intrusive and easily distractible, although able to give a history.
Ms. T has no psychiatric history. Her family history is positive for bipolar spectrum illness. Our initial consideration is that Ms. T is experiencing mania or psychotic symptoms triggered by the recent loss of her mother. Ms. T is evaluated in the medical emergency room to rule out a primary medical illness. Standard labs and head CT are normal, so she is returned to the psychiatric emergency room. She becomes severely agitated and requires multiple IM antipsychotics—2 courses of haloperidol, 10 mg; 2 courses of ziprasidone, 20 mg; and olanzapine, 10 mg. She is admitted to the inpatient psychiatric service with a diagnosis of psychosis not otherwise specified.
Soon after admission, Ms. T suffers a witnessed generalized tonic-clonic seizure and is transferred to the internal medicine service. After the seizure she is awake but minimally responsive. She does not display purposeful movements, opens her eyes but can follow the examiner only on occasion, and displays periodic facial grimacing. In addition, Ms. T is intermittently hypoxic—requiring supplemental oxygen via nasal cannula—and febrile, with persistent tachycardia. Electroencephalography (EEG) shows nonconvulsive status epilepticus involving the bilateral temporal regions.
Ms. T is transferred to the neurosurgical intensive care unit for monitoring and IV anticonvulsants. Subsequent EEGs demonstrate generalized slowing but no epileptiform activity. An infectious workup is negative. Head MRI shows bilateral cerebellar T2/FLAIR increased signal, which is a nonspecific finding. Cerebrospinal fluid (CSF) studies show lymphocytic pleocytosis and oligoclonal bands. These findings suggest a CSF humoral immune response; an extensive laboratory workup is otherwise largely unremarkable ( Table 1 ).
The authors’ observations

We consider that Ms. T may have schizophrenia. Schizophrenia onset is insidious, often with prodromal symptoms occurring months to years before diagnosis. 1,2 In Ms. T, the onset of the disturbance was brief; her family noted a change in behavior for only 1 week before presentation. Given this history, brief psychotic disorder remains high on the differential diagnosis because Ms. T’s disorganized speech and behavior occurred seeming in relation to her mother’s death.
Bipolar disorder is characterized by strong heritability, with risks increasing if there is a first-degree relative with the illness. The hallmark of bipolar I disorder is a manic episode, which presents as:
decreased need for sleep
grandiosity
flight of ideas
reckless or thoughtless behaviors
increased energy
increased productivity
expansive or irritable mood.
This diagnosis seems to fit well with our patient, who for 1 week had increased rate of speech, hyperactivity, and decreased need for sleep. She also has a positive family history of bipolar illness. Often patients with bipolar disorder experience a prodrome characterized by periods of depressed mood and periods that appear similar to mania but are not as obvious or severe. 1,2 Ms. T lacks this history.
Clinical Point
Mania syndromes secondary to seizure disorders present atypically with irritability and hyperactivity
Psychiatric symptoms secondary to seizure disorder are well documented. Cognitive, mood, anxiety, and psychotic phenomena may occur in up to 50% of patients with seizures. 3 Typically, these symptoms are categorized as occurring during a seizure, after a seizure (post-ictal), or between seizures (interictal).
Manic syndromes secondary to seizure disorders present in an atypical manner with irritability and hyperactivity. Psychotic syndromes, on the other hand, appear with more classic schizophrenia-type symptoms:
paranoia and persecutory delusions
auditory and visual hallucinations
amotivation
apathy
flattened affect
disorganization. 3
Ms. T had no history of witnessed seizure activity; however, the observed seizure early in her admission warranted exploring a possible underlying general medical condition.
Paraneoplastic syndromes may be associated with mood changes and other psychiatric symptoms. 4-6 Diagnosis is contingent on discovering the primary neoplasm, with or without specific paraneoplastic antibodies. Treatment is tailored to the oncologic process.

Read more here: http://www.currentpsychiatry.com/home/article/a-case-of-sudden-psychosis/019272cbf20042550059b93486284b42.html

Mental Illness or Allergy?

Exploring allergy symptoms: emotional, behavioral and mental

by Tarilee Cornish, Nutritional Consultant

When most of us think of allergy, we think of common symptoms such as sneezing, itchy eyes, hives, asthma and nausea. These are all immediate physical reactions but there are many different types of allergic responses possible. Some reactions take several days to show up, and some allergies don’t necessarily affect the respiratory system, digestive tract or skin.

Did you know that food and/or chemical allergies can create emotional, behavioral and mental symptoms such as panic attacks, compulsive behavior, depression, psychotic episodes, or hallucinations? They can also contribute to many less severe mental and emotional symptoms such as anxiety, irritability, inability to concentrate, or feelings of being in a mental “fog”. A surprising number of people have been able to eliminate such troubling symptoms simply by removing the allergens from their diet or living environment.

read more here