Mom Misdiagnosed With Postpartum Psychosis After Childbirth When She Really Had Autoimmune Diseases and Multiple Sclerosis

My name is Kimberly and my story begins in 1978. I woke up one morning, unable to move my legs or left arm and unable to get out of bed. At the time, I was only 18 years old. I went to the hospital, was admitted for a week, and aside from my psoriasis, was discharged without a diagnosis.

As weeks went by, I continued to worsen. I developed red raised nodules on the shins of my legs. They were warm to the touch and very painful. The doctors were baffled and again sent me home without a diagnosis.

After a few weeks of horrific pain, my father carried me into a different hospital, where I was admitted with concern from the doctors there may have been fluid build-up in my ankles and I would never walk again.  Fortunately, there was no fluid. I spent a week in the hospital only to have them discharge me with a diagnosis of Sarcoidosis and Erthema nodosum. They thought it could have also been polio or rheumatic fever, and so I spent six months in a wheelchair. I was given a final diagnoses of psoriasis, sarcoidosis, Erthema nodosum, and lupus. Along with receiving steroid injections in my ankles, I took liquid painkillers just to be able to walk and function.

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Misdiagnosed bipolar: One girl’s struggle through psych wards before Stanford doctors make bold diagnosis and treatment

SAN JOSE — One day, Tessa Gallo was a typical sixth-grader, performing in school plays, running on the track team, goofing around with her two sisters and giggling with girlfriends at sleepovers.

The next, said her mother, Teresa, “She was psychotic and mentally retarded.”

In bizarre and frightening scenes, Tessa acted as frantic as a caged animal, darting out of the family car into traffic, jumping fences and hiding in neighbors’ bushes. At times she seemed catatonic, with food falling out of her mouth because she somehow couldn’t swallow. She repeated the same few sentences over and over, worried about her braces, wanting to go home.

And finally, she said nothing at all. For nine months, Tessa stopped talking. Not a word.

Doctors diagnosed her with bipolar disorder, prescribed psychiatric drugs that didn’t work and sent the San Jose family on a nightmarish odyssey through psych wards, group homes and isolation rooms.

Then, suddenly, more than 10 months into the Gallos’ terrifying ordeal, a pair of Stanford University doctors told the family that Tessa wasn’t bipolar at all. She was probably suffering from a tragically misdiagnosed condition that mimics mental illness in a way doctors are only starting to understand.

“I’ve seen cases like this before,” Dr. Jennifer Frankovich of Lucile Packard Children’s Hospital told the Gallos. “I think I can bring her back.”

Controversial diagnosis

What Frankovich, a pediatric rheumatologist, and Dr. Kiki Chang, a child psychiatrist, concluded was that Tessa likely had an infection or other trigger that caused her immune system to mistakenly attack her brain, dramatically changing Tessa’s behavior overnight. It’s a condition called PANS — pediatric acute-onset neuropsychiatric syndrome — that in some cases, if caught early enough, could be cured by commonly used antibiotics. Without early treatment, they say, children can suffer needlessly.

It would take a mother’s stubborn devotion and the conviction of two doctors willing to stake their reputation on a controversial treatment to bring Tessa back from the brink. At the same time, they believe cases like Tessa’s could help unlock the mysteries of the brain and reveal how something as common as an infection could be behind a growing number of psychological disorders.

PANS is so new and so misunderstood, that there are no reliable estimates of how many children are affected. A national PANS parent support group believes the number nationwide could be more than 150,000, or about a quarter of the children who have obsessive compulsive disorder or other tics.

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Visual hallucinations from retinal detachment misdiagnosed as psychosis.

J Psychiatr Pract. 2011 Mar;17(2):133-6. doi: 10.1097/01.pra.0000396066.79719.c5.

Abstract

Hallucinations are a common presenting symptom in schizophrenia and other psychotic disorders. In particular, auditory hallucinations, such as hearing voices, are the most common type of hallucination described in schizophrenia, while visual hallucinations are less frequently seen. Hallucinations are also present in disorders that are not primarily psychotic in nature, including mood disorders, substance-induced disorders, and psychosis due to a general medical condition. However, it is extremely important to rule out general medical causes of hallucinations, as they are often treatable and reversible, and if left untreated, the underlying non-psychiatric disorders causing them can lead to irreversible damage. We present a case in which a 48-year-old woman with schizophrenia began to complain of visual disturbances. Because of her delusional interpretation of these disturbances, they were initially attributed to psychosis, but the disturbances were in fact found to be the result of a retinal detachment.

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

ED Physicians Often Misdiagnose Psychosis Aaron Levin

Published online: November 03, 2006

 

Emergency department (ED) physicians frequently misdiagnose substance-induced psychotic disorder, an initial error often compounded by inappropriate follow-up treatment, according to a study in five New York hospitals.

A more detailed review of their cases found that 25 percent of patients in the study who were first diagnosed with a primary psychotic disorder actually had substance-induced psychotic disorder or no psychosis at all, wrote Bella Schanzer, M.D., M.P.H., now mental health director of the AIDS center at Montefiore Medical Center in New York, and four colleagues in the October Psychiatric Services. Schanzer was a research fellow in the Department of Psychiatry at Columbia University when she did this study.

Referral to inpatient hospitalization, use of antipsychotic medications, and referral to mental health or substance-abuse treatment varied according to the diagnosis made in the ED, despite later evidence that in some cases the initial diagnosis was incorrect.

The subjects received care in emergency areas that were solely focused on psychiatric illnesses, and all diagnoses were made by physicians, although not necessarily by psychiatrists, Schanzer told Psychiatric News.

Study results, the researchers said, “[highlight] the challenge of accurately diagnosing a first psychotic episode when it occurs in the context of substance use and underscore the potential for negative consequences if a diagnostic error is made.”

What might account for this pattern?

“Probably a combination of three factors: a complicated clinical presentation, lack of time in the ED, and gaps in physician training,” said Schanzer in an interview.

Patients coming to an emergency department in a psychotic state are hardly articulate reporters of their own medical history, including even whether they have taken drugs recently.

Also, the medical system doesn’t give patients adequate time to come off drugs, said Schanzer. DSM-IV calls for a month of observation after the patient ceases substance use, and hospital admissions averaged only 16 days.

Finally, psychiatric training devotes too little time to learning about addiction, she said. “Psychiatrists too often jump to a diagnosis of primary psychosis, rather than substance-induced because that’s how they were trained.”

In addition, patients were often not admitted to the same hospital where the ED was located. That limited the chance for feedback from the hospital’s more deliberate evaluation to the psychiatrists in the ED.

“We can’t even learn from the patients we admitted,” said Schanzer.

Schanzer and her colleagues studied patients from five Manhattan psychiatric emergency departments who were diagnosed with early-phase psychosis and had used drugs or alcohol in the previous 30 days.

They administered the Psychiatric Research Interview for Substance and Mental Disorders, the Positive and Negative Syndrome Scale, and urine toxicology screens at baseline, six months, and 12 months. Master’s-level clinicians or a physician interviewed patients at all three assessments. Additional information came from ED records, inpatient hospital records, caregivers, and reports from outpatient follow-up referrals.

A second set of expert diagnosticians looked over that information and made a “best-estimate longitudinal diagnosis.” These diagnoses were divided into substance-induced psychotic disorder, primary psychotic disorder, or no psychotic disorder.

Of the 302 patients in the total sample, 223 (74 percent) were diagnosed in the ED with primary psychotic disorder, 53 (18 percent) with substance-induced psychotic disorder, and 26 (9 percent) with indeterminate symptoms.

The best-estimate diagnoses, however, found that only 195 patients (65 percent) had a primary psychotic condition, 101 (33 percent) had a substance-induced psychosis, and six (2 percent) had no psychotic disorder.

Agreement between the two sets of diagnoses was only fair, wrote the researchers. Fifty-six patients classified as having primary psychotic disorder in the ED (false positives) actually had substance-induced disorder (52) or no psychotic disorder (4), according to the best-estimate standards. On the other hand, of the 53 patients initially diagnosed with substance-induced psychotic disorder, 11 (21 percent) had primary psychotic disorder by the best-estimate procedure.

Schanzer and colleagues expressed surprise at these results. They thought that ED psychiatrists would more likely diagnose a substance-induced psychotic disorder, since all the patients were known to have used alcohol, marijuana, or cocaine during the previous month, and most had positive urine drug screens.

Schanzer suggested that better diagnostic tools and improved training might redress some of this imbalance.

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Psychosis is more common than previously thought in frontotemporal dementia

FTD is a progressive condition so multiple aspects of cognition, function and behaviour may eventually become affected, and psychiatric states like apathy, depression, anxiety, irritability, agitation and aggression are not uncommon. In contrast, the set of symptoms known as psychosis appeared to be rare until recently.

Psychosis in dementia

Psychosis consists of hallucinations and delusions in a person who is then confused about reality. In other words, a person who appreciates that a hallucination is not real would not be said to be suffering psychosis. The everyday experience of individuals with psychosis is coloured by their hallucinations and delusions, which can drive how they act or think.

Psychosis is common in the major dementias. It is typical of Dementia with Lewy bodies, very common in Alzheimer’s disease and occurs, although to a lesser degree, in vascular dementia. It is also a frequent complication of Parkinson’s disease dementia. The psychosis in most dementias is typically dominated by visual hallucinations, with delusions often consisting of the reactions or rationalizations that follow. However delusions do occur as distinct phenomena, often taking the form of misinterpretations of real or imaginary objects, delusions of infidelity or abandonment, or beliefs such as thinking that spouses or relatives are duplicates of the original person.

Psychosis in FTD

Psychosis was previously believed to be rare in FTD. Seven years ago, investigators in California found psychosis in 2.3% of people with FTD observed for 2 years, much lower than the 17.4% rate seen in those with Alzheimer’s disease. The same year, a working group of the American Neuropsychiatric Association reviewed the medical literature, noting that 1) psychosis is uncommon in FTD, and 2) many subjects with FTD who had been erroneously diagnosed with schizophrenia or a related condition had never suffered hallucinations or delusions. Subsequently, a group in Australia linked psychosis in FTD to the youngest cases (in other words those developing illness before age 40).

A renewed interest in the symptoms of psychosis came when it was noticed that carriers of the C9ORF72 mutation, a major cause of genetic FTD discovered four years ago, frequently suffer psychosis. Indeed several reports describe psychosis, mania and suicidal depression as the first manifestation of the illness.

The latest reviews estimate that 10% of FTD cases suffer psychosis, with higher rates in carriers of the C9ORF72 and progranulin mutations. A group working in Sweden has found an even higher prevalence, 32%, in their cohort of patients that have come to autopsy, with an average age at onset of 58 years and high prevalence of dementia and psychiatric disorders in relatives. Psychosis was equally common in those with tau and TDP-43 pathology, and very frequent in those with FUS pathology, who were also the youngest cases. In contrast to the California study, the observation period was the entire duration of the illness, which may explain the higher prevalence here. Psychosis was common in those in whom neurodegeneration mainly affected the right hemisphere of the brain. In most of the people, the FTD diagnosis was missed during life, and misdiagnosis with a psychiatric disorder was common.

Summary

Psychosis in FTD is more common than we had appreciated, and it was the recognition of psychosis in carriers of the C9ORF72 mutation that highlighted this issue. The prevalence is uncertain but appears highest in hereditary cases and in those with very young onset. This is undoubtedly relevant to patient care, but the risk of missing a diagnosis of FTD, especially in younger patients, also raises diagnostic questions. More research is needed to clarify the prevalence of hallucinations and delusions, their relation to FTD onset and diagnosis, and to learn why and how they develop.

References

Jeste DV, Finkel SI. Psychosis of Alzheimer’s disease and related dementias. Diagnostic criteria for a distinct syndrome. Am J Geriatr Psychiatry. 2000;8(1):29–34.

Mendez MF, Lauterbach EC, Sampson SM, ANPA Committee on Research. An evidence-based review of the psychopathology of frontotemporal dementia: a report of the ANPA Committee on Research. J Neuropsychiatry Clin Neurosci. 2008;20(2):130–149.

Mendez M, Shapira J, Woods R, Licht E, Saul R. Psychotic Symptoms in Frontotemporal Dementia: Prevalence and Review. Dement Geriatr Cogn Disord. 2008 Jan 17;25(3):206–211.

Velakoulis D, Walterfang M, Mocellin R, Pantelis C, McLean C. Frontotemporal dementia presenting as schizophrenia-like psychosis in young people: clinicopathological series and review of cases. Br J Psychiatry. 2009 Apr 1;194(4):298–305.

Snowden JS, Rollinson S, Thompson JC, Harris JM, Stopford CL, Richardson AM, Jones M, Gerhard A, Davidson YS, Robinson A, Gibbons L, Hu Q, DuPlessis D, Neary D, Mann DM, Pickering-Brown SM. Distinct clinical and pathological characteristics of frontotemporal dementia associated with C9ORF72 mutations. Brain. 2012 Mar;135(Pt 3):693–708.

Sha SJ, Takada LT, Rankin KP, Yokoyama JS, Rutherford NJ, Fong JC, Khan B, Karydas A, Baker MC, DeJesus-Hernandez M, Pribadi M, Coppola G, Geschwind DH, Rademakers R, Lee SE, Seeley W, Miller BL, Boxer AL. Frontotemporal dementia due to C9ORF72 mutations: Clinical and imaging features. Neurology. 2012 Sep 4;79(10):1002–1011.

Shinagawa S, Nakajima S, Plitman E, Graff-Guerrero A, Mimura M, Nakayama K, Miller BL. Psychosis in frontotemporal dementia. J Alzheimers Dis. IOS Press; 2014;42(2):485–499.

Landqvist Waldö M, Gustafson L, Passant U, Englund E. Psychotic symptoms in frontotemporal dementia: a diagnostic dilemma? Int Psychogeriatr. 2015 Apr;27(4):531–539.

43% of Americans Risked Their Brain Health for Flu Shots – Did You?

By Dr. Mercola

About 43 percent of the U.S. population opted to get a flu shot last season, a trend that has unfortunately been steadily increasing in the last several years.

According to the U.S. Centers for Disease Control and Prevention (CDC), 8 million more people received the flu shot in 2010, which CDC director Dr. Thomas Frieden told Fox Newsi “is the most people who have ever been vaccinated in this country.”

Most likely, this is a direct result of the massive marketing campaign that is ongoing in the United States, encouraging every person 6 months and older to get a flu shot.

Full article here: http://articles.mercola.com/sites/articles/archive/2011/11/24/more-people-getting-flu-shots.aspx

Psychosis may be triggered by antibody reaction to brain protein

A new study published in the journal Biological Psychiatry investigates the role antibodies may play in cases of psychosis, suggesting that psychosis symptoms such as hallucinations and delusions may be triggered by an antibody response to a protein in the brain.
illustration of brain
According to the researchers, their findings provide “hope that major disability can be prevented for the subset of children experiencing acute psychosis with antibodies.”

It is well known that antibodies defend the body against bacteria and viruses, and that in some people antibodies also attack healthy cells, causing autoimmune disorders.

Less well known is the role autoimmune disorders may play inpsychosis. However, scientists have been aware of a link between immune abnormalities and psychosis for over 100 years.

Only recently, though, have scientists been able to pinpoint the specific mechanisms in the immune system that appear to influence psychosis symptoms, such as the mechanism identified in the new study.

The authors of the new study found an antibody reaction to the dopamine D2 receptor or the N-methyl-D-aspartate (NMDA) glutamate receptor among a subgroup of children experiencing their first episode of psychosis, but no similar antibody response among healthy children.

Full story at:  http://www.medicalnewstoday.com/articles/290534.php

 

Zika virus may cause broader range of brain disorders than previously believed

Study says five patients who tested positive for virus in Brazil reported difficulty with motor functioning while another had trouble with vision and memory

The Zika virus may cause a wider range of brain disorders than previously thought, according to a small study released on Sunday. Scientists already suspect the mosquito and sex-spread virus causes fetal brain disorder and temporary paralysis.

https://www.theguardian.com/world/2016/apr/10/zika-virus-brain-disorders-brazil-study

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