We describe a case of delusional psychosis that was terminated by neurosurgical removal of a large arachnoid cyst. The patient was suffering his first psychotic episode and had symptoms typical of schizophrenia.
The case underscores the importance of considering that an arachnoid cyst can induce psychopathological symptoms, even those of schizophrenia. Indeed, such symptoms may be the cyst’s only clinical manifestation.
In addition, the case highlights the importance of doing a structural imaging test when confronted with a first episode of psychosis, especially if the episode is relatively late in appearance. Such imaging may lead to a diagnosis that in turn can enable a definitive neurosurgical resolution of the psychosis.
The patient was a 37-year-old Caucasian man who was the second of three siblings. He was married, the father of two sons, and worked in his family’s business. He came, as an outpatient, to our department because he was suffering psychopathological symptoms of psychotic characteristics.
The patient’s family members reported that two months before the first consultation he started coming out with strange ideas: he thought that people he passed in the street somehow knew him and were following him in order to harm him or his family. He also expressed unusual beliefs, such as, that his digital television tuner stopped working in his presence and that radio commentaries of court cases were really subliminal messages directed at him. In association with these perceptions, he suffered an anxiety crisis with a sense of his imminent death and somatic symptoms (trembling, palpitations and feelings of suffocation); he was treated with Alprazolam 1.5mg/day. His state of mind worsened, and in the three weeks prior to the first consultation he suffered apathy, anhedonia and desperation. Two weeks before the first consultation, his family doctor prescribed him Alprazolam 0.5 mg/day, Alprazolam retard 1 mg/day, and Escitalopram 15 mg/day, but no improvement was reported.
Although the above symptoms clearly began two months before the first consultation, the patient’s wife reported that for the previous year the patient had been especially worried about some judicial proceedings in which he was implicated.
With regard to personal antecedents, the patient was diagnosed with serious depression with intention to self-harm when 14 years old. This depression remitted without medication within six months. Coinciding with the depression, there was an episode of involuntary movements of the left arm. The patient did not report any addictions or substance abuse. The patient had no history of head trauma or other medical or metabolic conditions.
In the first consultation, the patient was partially disoriented in time but oriented in space and person. He was confused, of labile attention, and with slowed speech. He gave answers unrelated to questions, was slow to answer even simple questions and suffered blocking in his thinking. He presented delusional interpretations and intuitions and a delusional paranoid reference of events to himself. He showed sadness, emotional lability, apathy, anhedonia, but did not express thoughts of death or self-harm. He reported anxiety and had somatic manifestations of this (paraesthesias, palpitations, trembling in the hands, and diaphoresis) and a sense of restlessness. We did not detect any alterations in sensory perception or in the experience of self-identity. The patient reported fragmented sleep with nightmares. His appetite was normal.
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