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Psychopathological profile of patients with Lichen Simplex Chronicus, is there a therapeutic window?

Maria Arteaga, MD – Fellow of CL- Psychiatry, Pontificia Universidad Católica de Chile

Jorge Carreño, n/a – Head CL-Psychiatry unit., Complejo Asistencial Barros Luco

Marianne Cottin, PhD(c) – Doctoral student, University of Chile

Pablo Toro, Dr. med – Head CL-Psychiatry unit. Associate Professor, Pontificia Universidad Católica de Chile


Background: Lichen Simplex Chronicus (LSC) is a chronic skin condition characterized by eczema caused by repeated and excessive scratching strongly  linked with  emotional factors. It mostly affects female patients, with a peak incidence between ages 35 and 50 years with an estimated prevalence between 2-12% (1-2). Treatment of LSC centers on the discontinuation of the itch-scratch cycle. Traditional therapies include topical corticosteroids, intralesional corticosteroids and antihistamines. A psychosocial approach is commonly used, but isn’t standardized.  

Objective: To describe the psychopathological profile of patients with LSC  before and after treatment with standard dermatological care along with a psychological intervention.

Methods: LSC outpatients and healthy volunteers were recruited from the university outpatients clinic. Psychiatric scales (pre/post intervention) were given, including the Symptom Checklist-90-Revised (SCL-90-R), State-Trait Anxiety Inventory (STAI) and NEO Five Factor Inventory (NEO-FFI).  All patients received standard dermatologic treatment and psychological intervention with behavioral therapy adapted from a program for trichotillomania (9 sessions). The study was approved by the ethics committee of the faculty of medicine at Pontificia Universidad Católica de Chile 

Results: 12 LSC patients (mean age= 46 years, 33% women) and 11 healthy volunteers (mean age= 46 years, 27% women) completed the study. Pre intervention: Hostility item of SCL-90 was significantly higher in the LSC compared to the control group (mean 0.42, SD=0.26 and 0.11, SD= 0.19 respectively: p < 0.01).  STAI: State Anxiety Scale (mean 41,66, SD= 27.05 and 19,36 SD=14.49; p< 0.05) and Trait Anxiety Scale (mean 33,16, SD=23.63 and 15.18, SD=12.38) were significantly higher in the LSC group as well. No differences were found in NEO-FFI. Post intervention: Results are being analysed statistically. 

Discussion: Higher levels of hostility and anxiety found in LSC patients is in concordance with previous reports (3). Despite the association of LSC and psychopathological traits, we found no studies focusing on specific social interventions (i.e. psychotherapy) for LSC patients.  It is necessary to complete the patients follow up to objectify the results of psychological intervention.

Conclusion/Implications: The psychopathological characterization of LSC patients  shows they are more hostile and anxious, therefore psychological interventions should be directed towards these traits.

References:  


  1. Lotti T, Buggiani G, Prignano F. Prurigo nodularis and lichen simplex chronicus. Dermatol Ther. febrero de 2008;21(1):42-6.

  2. Cleveland DEH. LICHEN SIMPLEX CHRONICUS. Can Med Assoc J. octubre de 1933;29(4):368-74. 

  3. Konuk, N., Koca, R., Atik, L., Muhtar, S., Atasoy, N., & Bostanci, B. (2007). Psychopathology, depression and dissociative experiences in patients with lichen simplex chronicus. General hospital psychiatry, 29(3), 232-235. 



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Bed Is a Battleground: A Qualitative Study Exploring Sleep Disturbance and Options for Treatment in People with Inflammatory Bowel Disease

Amy Green, MBChB MRCPsych – Consultant Liaison Psychiatrist, Southmead Hospital, Bristol

Maria Barnes, BSc PhD – Senior Research Associate, University of Bristol

Claire Durant, BSc PhD – Senior Research Associate, University of Bristol

Aileen Fraser – Lead Inflammatory Bowel Disease CNS, United Hospitals Bristol NHS Foundation Trust

Amanda Beale – Consultant Gastroenterologist and Honorary Senior Lecturer, Bristol Royal Infirmary, United Hospitals Bristol (UK)

Jonathan Davies, MBChB MRCPsych PhD – Academic Clinical Lecturer, University of Bristol

John Potokar, MBChB MRCPsych MD – Consultant Senior Lecturer, University of Bristol


Background and significance: Sleep disturbances in Inflammatory Bowel Disease (IBD) are prevalent (49%) (1), increase during acute relapse (70-80%) and affect quality of life (2). Little is known about the cause or nature of these disturbances, or how to help these patients. Hypnotic medications may be poorly tolerated, and are inappropriate for long-term use. Cognitive Behavioral Therapy for insomnia (CBTi) has proven efficacy in treating insomnia associated with chronic illness and pain (3). The efficacy and acceptability of psychological interventions for sleep disturbances in people with IBD has not been investigated and nature of sleep problems people with IBD encounter is not understood. This study explored the following topics: the causes and nature of sleep disturbance experienced by people with IBD, the acceptability of a psychological intervention aimed at improving sleep and the views of IBD clinicians regarding these disturbances, including how a psychological intervention could be provided.

Methods: This study used qualitative methodology to explore sleep disturbances in IBD. This method provides rich descriptions about feelings and thought processes, providing unique insight into areas about which little is currently known. Fifteen patients with IBD and sleep disturbance and four IBD clinicians were interviewed.

Results: Some patients had sleep disturbance prior to the onset of their IBD symptoms; all had disturbance since. Themes identified were: consequences of their IBD, psychological factors, behavioral factors and barriers to getting help.

Discussion: Patients described bed, not as a place of rest, but a battleground where IBD always wins. This battle involves a complex interplay between IBD symptoms, behaviors to manage IBD and psychological factors, suggesting that CBTi could help. Patients and clinicians reported limited knowledge of how to treat sleep problems in IBD and described barriers to access and engagement with an intervention.

Conclusion/implications: This study highlights the degree of sleep disturbance experienced by people with IBD, the complexity of the problem, the limited understanding of it and the current barriers to treating it. It raises awareness of sleep disturbances specific to IBD among patients and clinicians. Findings suggest a psychological intervention tailored to sleep problems for people with IBD may be beneficial. This study will inform the design of such an intervention and determine practical strategies to help patients beat their IBD related insomnia.

References:


  1. Graff LA, Vincent N, Walker JR, Clara I, Carr R, Ediger J, et al. A population-based study of fatigue and sleep difficulties in inflammatory bowel disease. Inflammatory bowel diseases. 2011;17(9):1882-9.

  2. Ranjbaran Z, Keefer L, Farhadi A, Stepanski E, Sedghi S, Keshavarzian A. Impact of sleep disturbances in inflammatory bowel disease. Journal of gastroenterology and hepatology. 2007;22(11):1748-53

  3. Currie SR, Wilson KG, Pontefract AJ, deLaplante L. Cognitive-behavioral treatment of insomnia secondary to chronic pain. J Consult Clin Psych. 2000;68(3):407-16.










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The Perfect Mimic: Factitious Disorder Posing as Type III Hereditary Angioedema

Ranjit Chacko, MD – Psychiatrist,Professor of Psychiatry, Houston Methodist Hospital

Connie Hsiao – Medical Student, Texas A&M College of Medicine

Emma Welch – Medical Student, Texas A&M College of Medicine

Marissa Witt-Doerring, MD – Psychiatry Resident, PGY-4, Baylor College of Medicine


Background

In this case report, we reflect on the challenge of recognizing factitious disorder, the consequences of delayed recognition, and the need for interdisciplinary education regarding diagnosis and management of factitious disorder.

Case

A 36-year-old Caucasian female is undergoing treatment for angioedema crisis on an internal medicine service. She reported a history of type III Hereditary Angioedema (HAE) in 2009 followed by recurrent angioedema crises resulting in frequent hospitalizations, intubations with ventilator requirements, and eventual tracheostomy placement. She also carries a history of deep vein thromboses and pulmonary embolisms resulting in chronic anticoagulation. She currently has a permanent pacemaker after several unsuccessful cardiac ablations for atrial fibrillation in the setting of frequent episodes of endocarditis and bacteremia. The psychiatry consult-liaison service was consulted to explore the possibility of feigned symptoms when her reported angioedema crises persisted in an atypical pattern (only during night shift, beyond expected duration) despite treatment. Confirmation of the primary team’s suspicion of factitious disorder was made through a review of medical records combined with discussions with patient’s past and current treatment providers.

Discussion

HAE is a rare condition that presents with recurrent episodes of angioedema affecting the skin, gastrointestinal tract, and upper airways without associated urticaria or pruritus. Type III HAE, unlike the more common types I and II, is not associated with any diagnostic biomarkers. It is a clinical diagnosis; the only objective signs such as bowel wall inflammation and/or laryngeal edema can be identified during acute crises. This patient made repeated complaints of upper airway tightness and chronic epigastric pain leading to her original diagnosis. Despite multiple upper airway scopes and gastrointestinal imaging, no signs of angioedema were ever found. It is challenging to differentiate true type III HAE from those seeking to falsify symptoms. The inability to make this distinction can unnecessarily expose the patient to invasive procedures and treatments with significant side effects.

Conclusion

This case report highlights the challenges faced in diagnosing factitious disorder that may lead patients to undergo unnecessary procedures. Furthermore, similar case reports have been described, underscoring a consideration of factitious angioedema for any case of refractory type III HAE.

References


  1. Caselli I et al. Epidemiology and evolution of the diagnostic classification of factitious disorders in DSM-5. Psychol Res Behav Manag.2017 Dec 11;10:387-394.

  2. Feldman MF et al. Factitious angioedema: a mimic of refractory “angioedema”. J Allergy Clin Immunology. 2014 Nov-Dec;2(6):795-7.

  3. Miranda AR et al. Hereditary angioedema tyoe III (estrogen-dependent) report of three cases and literature review. An Bras Dermatol. 2013 Jul-Aug; 88(4): 578–584.

  4. Zuraw BL. Hereditary angioedema with normal C1 inhibitor: Four types and counting. J Allergy Clin Immunology. 2018 Mar;141(3):884-885.




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Personalized Treatment Interventions for Depression in Patients with Heart Failure

Waguih IsHak, MD, DFAPA – Professor and Clinical Chief of Psychiatry, Cedars-Sinai Medical Center


Background/Significance: Heart Failure (HF) affects more than 26 million adults worldwide. Depressive symptoms in HF patients have a prevalence of at least 48% (Gottlieb 2004). Due to the heightened prevalence of depression in cardiovascular patients, the American Heart Association (AHA) recommends screening patients for depression (Lichman 2008).

Methods: We conducted a systematic review to identify effective ways to treat depression in heart failure patients and now we are conducting a PCORI-funded trial comparing Antidepressant Medication Management using the Collaborative Care Model to Behavioral Activation Psychotherapy.

Results: SSRIs have been shown to be safe for use in HF, however trials of sertraline and escitalopram, the most commonly prescribed antidepressants inheart disease, have failed to show superiority to placebo in 12-week and 24-month randomized clinical trials (RCTs) respectively (Angermann 2016). However, when antidepressants are delivered in the context of personalized Collaborative Care, their evidence has been well established in HF as demonstrated by high-quality RCTs (Bekelman 2018). CBT effectiveness in the treatment of depression in HF has been demonstrated by high-quality RCTs (Jeyanantham2017). The evidence shows that psychotherapy has been faced with access/compliance challenges due to the nature of HF course. Therefore, remote delivery methods such as telephone/telemedicine/web-based delivery have shown great promise (Mohr 2012). Moreover, personalized psychotherapy such as behavioral activation (BA) which is as effective as CBT (Richards 2016) and requires much less training, seem to be more applicable in this population.

Discussion: C/L psychiatrists are best positioned to make recommendations on evidence-based treatment of depression in heart failure. Successful treatment could have a significant impact on functioning, HRQoL, overall health, caregiver burden, Morbidity (as evidenced by frequency of ED visits, readmissions, total days spent in the hospital), and Mortality.

Conclusion: Treatment of depression in heart failure patients is challenging, however antidepressant medication management in the context of Collaborative Care, as well as remotely delivered psychotherapy such as CBT or BA carry significant potential.



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The Role of C-L Psychiatry in Puberty Suppression Treatment of Transgender Youth

Michael T. Ingram, Jr., MD – C-L Fellow, University of California, Los Angeles

Jose Aguilar, Jr, MD – Assistant Clinical Professor, University of California, Riverside School of Medicine


Background: An increasing number of transgender children and adolescents are seeking gender-affirming medical interventions in recent years. One treatment option involves the use of Gonadotropin-releasing hormone (GnRH) agonists to reversibly inhibit puberty and allow transgender adolescents to experience puberty as their identified gender with cross sex hormone therapy (CSHT). Effective treatment requires a multidisciplinary team to address the unique medical and physical health needs of this marginalized population. Unfortunately, many psychiatrists are inexperienced or uncomfortable managing transgender patients and some outright refuse treatment. The increasing prevalence of depression, anxiety, trauma, self-harm, suicide, and substance use disorders in transgender youth highlights an emerging role for C-L Psychiatry in advocating for this underserved population.

Methods: We searched PubMed and PsychINFO databases for citations in English reviewing the most updated guidelines for treating transgender youth. We then searched the same databases for studies reporting on psychological outcomes of puberty-suppression treatment. In addition, we consulted experts at a major academic medical center with a dedicated transgender youth clinic for guidance on developing a collaborative care model that can be implemented at any hospital or clinic setting.

Results: The World Professional Association for Transgender Health (WPATH) and Endocrinology Society (ES) guidelines on treating transgender people are the most internationally recognized guidelines. Both guidelines recommend a mental health evaluation prior to initiating puberty suppression treatment at Tanner stage 2. Puberty suppression should continue until age sixteen when adolescents are eligible for CSHT (WPATH SOC, 2012). Only four published cohort studies were found addressing the psychological outcomes of puberty suppression treatment, but each study showed significant improvements in general functioning, decreased behavioral and emotional problems, and alleviation of depressive symptoms after puberty suppression treatment.

Discussion: The dearth of evidence informing current guidelines on the treatment of transgender youth underscores the need for further research. Nevertheless, preliminary studies on psychological outcomes are showing promising results. As more children and adolescents seek gender affirming medical and psychological care it will be imperative for physicians from all specialties to collaborate, advocate, and become educated on current issues in Transgender health care delivery. C-L psychiatrists are in a unique position to help manage and advocate for the complex medical and psychological needs of this diverse population.

References:




  1. de Vries AL, McGuire JK, Steensma TD, Wagenaar EC, Doreleijers TA, Cohen-Kettenis PT. Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics. 2014 Oct;134(4):696-704.

  2. Costa R, Dunsford M, Skagerberg E, Holt V, Carmichael P, Colizzi M. Psychological Support, Puberty Suppression, and Psychosocial Functioning in Adolescents with Gender Dysphoria. J Sex Med. 2015 Nov;12(11):2206-14. doi: 10.1111/jsm.13034




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Synergistic Effect of Interpersonal Trauma and HIV Infection on Cortical Thickness and Daily Functioning Despite Viral Suppression

Suad Kapetanovic, MD – Assistant Professor of Clinical Psychiatry, University of Southern California

Gina Norato, ScM – Statistician, National Institutes of Health/National Institute of Neurological Disorders and Stroke

Govind Nair, PhD – Investigator, NINDS

Lillian Ham, BA – Research assistant, National Institutes of Health

Joseph Snow, PhD, ABPP-Cn – Staff Scientist, NIMH

Elizabeth Horne, BS – Postbaccalaureate IRTA, NINDS

Brian Agan, MD – Deputy Science Director, USU Infectious Disease Clinical Research Program, HJF

Anuradha Ganesan – Physician, USUHS

Ryan Maves, MD, FCCP, FIDSA – Program Director, Infectious Diseases Fellowship, Naval Medical Center San Diego

Bryan Smith, MD – Staff Clinician, National Institutes of Health


Background/Significance: Interpersonal trauma (IPT) is highly prevalent among HIV-infected (HIV+) individuals but its effect on neuro-cognition is poorly understood. This cross-sectional analysis evaluated the effects of IPT on cognitive task performance, daily functioning, cerebral cortical thickness, and selected basal ganglia (BG) regions in a US-based cohort of aviremic HIV+ adults, with (HIV+IPT+) and without IPT exposure (HIV+IPT-), and socio-demographically matched HIV-negative controls with (HIV-IPT+) and without IPT exposure (HIV-IPT-). We hypothesized there would be a combined effect of HIV and trauma exposure on the outcomes of interest.

Methods: Enrollees completed brain MRI studies, a semi-structured psychiatric interview, a neurocognitive battery, and three measures of daily functioning. Demographic and clinical characteristics of the four groups were described, and pairwise between-group comparisons performed using chi-square tests, ANOVA, or t-tests. Linear or Poisson regressions evaluated relationships between group status and the outcomes of interest, in 6 pairwise comparisons, using Bonferroni correction for statistical significance.

Results: Among 187 participants (mean age 50.0 years, 63% male), 102 were HIV+IPT+, 35 HIV+IPT-, 26 HIV-IPT, and 24 IPT+HIV-. Compared to the remaining three groups, the HIV+IPT+ group had more Activities of Daily Living (ADL) declines, higher number of impaired Patient’s Assessment of Own Functioning Inventory (PAOFI) scores, and lower cortical thickness in multiple cerebral regions.  Attention/working memory test performances were significantly better in HIV-IPT- compared to HIV+IPT+ and HIV+IPT-. BG MRI volumes were not significantly different in any between-group comparisons.

Discussion: These results suggest that HIV+ individuals who are survivors of IPT are at risk for neuroHIV complications despite viral suppression, as observed on measures of cortical thickness, cognition, and daily functioning. Reduced regional cortical thickness (i.e., orbitofrontal, cingulate, primary motor and sensory cortex, temporal and frontal lobes) has been reported in a cohort of aviremic HIV+ individuals, as compared to HIV-negative controls, but the study did not account for effect of IPT. Possible mechanisms may include alterations in neuro-immune-endocrine pathways that have been associated with both HIV and trauma, such as alterations in neuro-immune-endocrine pathways that can lead to glial dysfunction and synaptic disintegration and resulting cortical thinning. 

Conclusion/Implications: We observed synergistic effect of IPT exposure and HIV infection on daily functioning, cognition and cortical thickness in aviremic HIV+ individuals. Longitudinal studies are indicated to determine the causality and direction of this effect. Mechanistic studies are needed to further elucidate pathways which may lead to neuroprotective interventions. Future neuroHIV studies must account for the effect of IPT exposure. Studies evaluating relationship between IPT exposure and poor HIV health behaviors and clinical outcomes should consider cortical thinning, impaired daily functioning and lowered attention/working memory performance as key variables of interest



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Case Report: Delusional Parasitosis in Von Hippel Lindau Syndrome

Andrew Malanga, DO – PGY4 Psychiatry, The Ohio State University Wexner Medical Center

Katherine Brownlowe, MD – Assistant Professor, The Ohio State Wexner Medical Center


Background: Delusional Parasitosis is a rare syndrome characterized by fixed and false delusions of parasitic infestation despite lack of findings on exam. This syndrome has not been previously reported in Von Hippel-Lindau Syndrome (VHL). This syndrome results in central nervous system hemangioblastomas, peripheral hemangiomas and subsequent tumorectomy, any of which may induce aberrant sensory signaling lending towards induction of the typically endorsed formications (tactile hallucination). Additionally, the variable locations of tumor occurrence may cause vulnerability to circuit disruption and subsequent neuropsychiatric phenomena.

Case History: Patient is a 47 year old female with a history of Von Hippel-Lindau Syndrome (multifocal hemangioblastomas including eyes, cerebellum, brainstem, and upper spinal cord; multiple surgeries including left posterior cerebellar tumor removal), blindness (spontaneous retinal detachment at age 16), neuropathy (associated with dysesthesia, hyperalgesia and allodynia), and multiple other general medical conditions. Initially she was diagnosed with MDD and PTSD. At follow-up, the patient described a sensation of (insect?) hooks being inserted into her skin by an undetermined infestation. She stated she contracted this from a trash can within the previous years. She described an ability to “pull out the legs” from her skin and a sensation of string-like fibers between her fingers and the site of removal. She noted showering 2.5 hours daily to address this as well as excessive excoriation. Her caregiver, although reportedly initially concerned for psychiatric etiology, had also become convinced of the likelihood of infestation. She reported previous dermatological intervention including negative biopsies and ivermectin treatment. She remained convinced that her dermatologist should be able to identify microscopic organisms under magnification. Upon review of outside records, concerns were raised for delusional parasitosis months earlier by dermatology. Interestingly, concerns for skin sensations/discomfort had been raised by the patient years earlier; at that time she had insight into this likely being of neurological and/or iatropic etiology secondary to opioid pain medication.

Conclusion: Delusional parasitosis in VHL is a previously undescribed phenomenon in the literature. In our patient, etiology may be multifactorial, with contribution from CNS hemangioblastomas, partial cerebellectomy, opioid pain Rx, B12 deficiency, and hypothyroidism. The role of the cerebellum in psychosis is also relatively newly described, and the burden of cerebellar pathology due to VHL and its treatment at least have led to the patient’s vulnerability for this syndrome. Treatment is challenging and requires tactful psychoeducation discussing the complexity of the condition. Given the multifactorial nature of the condition and its treatment, collaboration between all providers in various specialities (dermatology, neurology, neurosurgery, pain management, primary care) is paramount for successful treatment. Consult-Liaison psychiatrists are ideal to provide coordination diagnosis and of treatment for those patients with complex, rare, and multifactorial conditions.



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Case Report: Determining Capacity to Electively Deactivate an Automatic Implanted Cardioverter-defibrillator in a Patient with a History of Depression

Shamik Mukherji, MD – Consultation Liaison Psychiatrist, Long Island Jewish Medical Center Northwell Health


An Automatic Implanted Cardioverter-Defibrillator (AICD) is a life saving device for indications such as severe left ventricular dysfunction or ventricular tachyarrhythmias 1. The placement of AICD’s is associated with increased rates of shock related anxiety, post-traumatic stress, depression, and lower health-related quality of life 2,3,4. We present a case in which a 52 year old male with a history of depression and severe left ventricular dysfunction presents to the hospital with a request that his AICD be deactivated. This patient received 8 defibrillations from the AICD in the 2 weeks prior to admission, all of which were determined to be appropriate shocks. Psychiatry was consulted to determine the degree to which the patient’s depression may be contributing to his decision, and to determine the patient’s medical decision-making capacity to deactivate his AICD. Following Applebaum’s criteria for medical capacity assessment, the patient was able to express clear and consistent choice, a high degree of understanding and appreciation of the relevant parameters of this choice, and good reasoning with good contingency planning 5. He thus demonstrated capacity to make the decision to deactivate his AICD. The patient’s decision was indeed informed by shock-related anxiety, with a final determination that the patient’s quality of life was negatively affected by continued activation of the AICD. After medical capacity assessment, deactivation was performed. This case highlights the degree to which the psychological and psychiatric implications of AICD placement should be considered when determining if a patient is a good candidate for such a device.


    1. Aronow WS, Sorbera C, Chagarlamudi A, Tabandeh H, Gupta S, Cohen M. Indications for and long-term survival in patients with automatic implantable cardioverter-defibrillators. Cardiol Rev. 2005 Jan-Feb;13(1):50-1.

 


    1. Hamner M, Hunt N, Gee J, Garrell R, Monroe R. PTSD and automatic implantable cardioverter defibrillators. Psychosomatics. 1999 Jan-Feb;40(1):82-5.

 


    1. Habibović M, Denollet J, Pedersen SS; on behalf of the WEBCARE investigators. Posttraumatic stress and anxiety in patients with an implantable cardioverter defibrillator: Trajectories and vulnerability factors. Pacing Clin Electrophysiol. 2017 Jul;40(7):817-823.

 


    1. Perini AP, Kutyifa V, Veazie P, Daubert JP, Schuger C, Zareba W, McNitt S, Rosero S, Tompkins C, Padeletti L, Moss AJ. Effects of implantable cardioverter/defibrillator shock and antitachycardia pacing on anxiety and quality of life: A MADIT-RIT substudy. Am Heart J. 2017 Jul;189:75-84.

 


    1. Appelbaum PS. Clinical practice. Assessment of patients' competence to consent to treatment. N Engl J Med. 2007 Nov 1;357(18):1834-40. Review.




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Critical Care Psychiatry: Scope of Practice for Psychiatric Consultation in the Intensive Care Unit

Alyssa Rautenberg, MD – Psychiatry Resident, Cambridge Health Alliance

Clare Herickhoff, MD – Psychiatry Resident, Harvard Longwood Psychiatry Residency Training Program

David Gitlin, MD, FACLP, DFAPA – Vice Chair for Clinical Programs, Brigham Health, Brigham and Women's Hospital

Nomi Levy-Carrick, MD, MPhil – Psychiatrist, Division of Medical Psychiatry, Dept of Psychiatry, Brigham and Women's Hospital


Background: Psychiatrists are minimally utilized in intensive care units (ICUs) despite high levels of psychiatric comorbidity, increasing awareness of post-ICU syndromes (PICS) (Huggins, 2016) and demonstrated benefit of a unique proactive psychiatric consultation model in the ICU, including decreased length of hospital stay (Bui, 2018). The ACGME Program Requirements for Graduate Medical Education in Consultation-Liaison (CL) Psychiatry do not currently include an ICU-specific curriculum. The scope of practice of critical care psychiatry has not been clearly defined, and doing so would support optimized training for and utilization of critical care psychiatric consultation.

Method: Descriptive statistical analyses were conducted on an IRB-approved retrospective chart review of 124 patients who had a proactive psychiatric consultation during hospital admission at a metropolitan tertiary care center that included ICU level of care. The proactive model includes an attending CL psychiatrist embedded on ICU rounds who decided together with the ICU team whether psychiatric consultation was indicated. Our primary outcome is recommendations made by a CL psychiatrist. Secondary outcomes include patient demographics and history, consultation indication, psychiatric diagnoses made by the CL psychiatrist, and continuity of care. 

Results: The majority of patients (62.9%) had pre-existing psychiatric diagnoses. The majority of patients had respiratory failure (56.4%) and patients are often mechanically ventilated at the time of consultation (33.1%). The majority of patients also have delirium (69.4%). The psychiatrist made recommendations addressing sedatives and opioid analgesics (28.2%), as well as regarding further neurologic workup of altered mental status (20.2%). The psychiatrist served a liaison role with the ICU medical team, as well as with patients and families (13.7%). After delirium, the most common diagnoses made by the psychiatrist were Adjustment Disorders (20.2%), Depressive disorders (20.2%), and Substance-related disorders (20.2%).  Psychiatry followed nearly half (49.2%) of patients when transferred to the medical ward. Recommendations were made for follow-up psychiatric and neuropsychiatric care (33.8%) for patients who did not have mental health providers prior to admission. 

Discussion: Our findings illustrate the scope of practice of a proactive psychiatric consultation model in critical care. We propose that 3 domains, which emerge from these findings, may represent important elements of critical care psychiatry as a subspecialty field. These include the uniqueness of consultations in the critical care environment (including frequent mechanical ventilation, co-management of opioids and analgesics, high rates of delirium, and recommendations regarding neurologic workup of altered mental status). Additionally, critical care psychiatrists serve as liaisons with critically ill patients and their families, and are uniquely positioned to identify and intervene for patients and families at risk for PICS and PICS-F. We propose curricular elements for subspecialty psychiatric training which address these components of critical care psychiatry. 

Conclusions: The emergence of critical care psychiatry as a subspecialty field reflects growing recognition of the potential optimization of outcomes through early psychiatric intervention in the ICU. This study describes a scope of practice which contains unique elements (including management of mechanically ventilated patients, high rates of delirium, and co-management of opioids and sedatives), and illustrates an important liaison role with the critical care team, patients and their families. Critical care psychiatrists are also uniquely positioned to identify and potentially intervene for patients and families at risk for PICS and PICS-F. This scope of practice has implications for further psychiatric curricular development which could bolster the utilization and effectiveness of psychiatry in this setting. Further research is needed to assess generalizability of these findings, and the role of critical care psychiatry in the management of post-intensive care syndromes.

Huggins EL, Bloom SL, et al. A Clinic Model: Post-Intensive Care Syndrome and Post-Intensive Care Syndrome. AACN Adv Crit Care.2016;27(2):204-211

Bui M, Thom RP, Hurwitz S, et al. Hospital Length of Stay With a Proactive Psychiatric Consultation Model in the Medical Intensive Care Unit: A Prospective Cohort Analysis. Psychosomatics 2018;S0033-3182(18)30413-4



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Wernicke-Korsakoff Syndrome in a Patient with Celiac Disease and Obsessive Compulsive Disorder: A Case Report

Malya Sahu – Medical Student, Sidney Kimmel Medical College at Thomas Jefferson University

Marissa Beal, DO – Psychiatry resident, Thomas Jefferson University Hospital

Keira Chism, MD – Assistant Professor, Jefferson University

Madeleine Becker, MD, FACLP – Director, Graduate Medical Education, Department of Integrative Medicine
Consultation Liaison Psychiatry, Department of Psychiatry and Human Behavior, Thomas Jefferson University Hospital


Background:

Wernicke-Korsakoff syndrome (WKS) is a neurological condition resulting from thiamine deficiency. While most often associated with alcohol use, various other psychiatric disorders play a role in the development of WKS and the diagnosis may be overlooked in these patients.



Case:

A 44-year-old woman with celiac disease on a gluten-free diet and unclear psychiatric history presented with acute-onset altered mental status, including disorientation, confabulations, and tangential speech. Initial lab work-up was unrevealing, including CSF studies. Further history obtained from family was notable for symptoms of obsessive compulsive disorder including obsessive behavior about gluten contamination, compulsive checking of labels leading to an increasingly restricted diet and subsequent weight loss of 60 lbs in the year prior to admission. MRI demonstrated symmetric hyperintensity of bilateral medial thalami consistent with Wernicke’s encephalopathy. Treatment with IV thiamine resulted in marked improvement of sensorium despite continued memory deficits.



Discussion:

There are few case studies citing food restriction secondary to underlying psychiatric diagnoses such as depression, schizophrenia and anorexia nervosa to be associated with WKS (Dias, 2017; Tsai, 2004; Oudman, 2018). We present a unique case of a patient with celiac disease and a co-occurring diagnosis of OCD. An exacerbation of her underlying symptoms of OCD led to increased paranoia and restriction of food, causing weight loss, malnutrition, and subsequent development of WKS. The initial cause of her encephalopathy was unclear, but thorough history taking and exam helped to obtain a diagnosis. Treatment with IV thiamine can prevent long term neurologic deficits so it is essential to diagnose and treat promptly. It is important to be aware of the potential for thiamine deficiency in patients with psychiatric illness to reduce long term deficits.



Conclusion:

This case highlights WKS in a patient with celiac disease and a severely restricted diet secondary to symptoms of OCD. It is important to include WKS on the differential for encephalopathic patients who have a restricted diet and an underlying psychiatric diagnosis and gather robust collateral history to ensure timely diagnosis and treatment within this vulnerable patient population. Treatment is low risk with IV thiamine, effective in reversing the neurological symptoms, and can prevent progression to permanent cognitive deficits and mortality if diagnosed quickly.


References:

Dias, S P. (2017). Wernicke’s Encephalopathy Due to Food Refusal in a Patient with Severe Depressive Disorder. Journal of the Neurological Sciences, 375: 92–93.


Oudman, E. (2018). Preventing Wernicke's encephalopathy in anorexia nervosa: A systematic review. Psychiatry and Clinical Neurosciences, 72(10): 774-779.

Tsai, H. Y., Yeh, T. L., Wang, S. M., Chen, P. S., & Yang, Y. K. (2004). Starvation‐induced Wernicke's encephalopathy in schizophrenia. Psychiatry and Clinical Neurosciences, 58(3): 338-339.



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Is That a Sewing Needle in the Left Ventricle? A Rare and Complex Presentation of Self-embedding in a Patient with Schizophrenia

Seema Sannesy, MD – Psychiatrist, Eating Recovery Center

Kelly Harrington, MD, MS – PGY-2 psychiatry resident, University of New Mexico

Emiliano Valles, MD – Assistant Professor, University of New Mexico

Cynthia Geppert, MD, MA, MPH, MBE, DPS, MSJ, FACLP, DFAPA, FASAM, HEC-C – Ethics Consultant, VA National Center for Ethics in Health Care Psychiatric Consultant, New Mexico V, VA National Center for Ethics in Health Care




Background: Self-embedding behavior is a recently recognized form of foreign-body insertion which involves the repeated insertion of solid objects into the soft tissues of the limbs, abdomen, chest, neck, or groin. The small number of publications on embedding behaviors involve psychiatric patients inserting foreign objections through natural body orifices. Even fewer articles have reported mediastinal self-embedding and very rarely are cases in which cardiac surgical intervention is necessitated discussed.

Case: Mr. Z is a 32-year-old male with Schizophrenia, who was 2.5 weeks overdue for his Paliperdone Palmitate 234 mg injection, when he self-presented to the emergency department complaining of severe midsternal pain. He had a history of inserting sewing needles into the soft tissues of his abdomen, chest, neck, and extremities. Initial evaluation included electrocardiogram, cardiac enzymes, and chest x-ray. Mr. Z left the emergency room against medical advice. Emergency medical services brought him back after his troponin returned at 0.763 and the radiologist noted a “new foreign body projecting over the cardiac silhouette” suggesting a possible intracardiac foreign body. Bedside echo was concerning for migration of what was later established to be a needle in the left ventricle. During emergent cardiothoracic surgical consultation, the need for further imaging and likely surgical removal of the needle was explained to Mr. Z. However, he refused Psychiatric consultation the following day noted Mr. Z to be acutely agitated, delusional, and without capacity to refuse diagnostic evaluation or possible surgical intervention. Mr. Z’s father provided surrogate consent for the open-heart surgery which successfully removed the intraventricular sewing needle. After surgical stabilization, Mr. Z was transferred to the inpatient psychiatric unit for treatment before being discharged home.

Discussion: This case illustrates several key points in consultation-liaison psychiatry 1) the potential severe complications of self-embedding behaviors, here requiring open-heart surgery 2) the possibility for delayed diagnosis and intervention given the difficulty in coordinating the surgical and psychiatric care of patients with serious mental illness who self-embed 3) the importance of psychiatric consultation-liaison involvement in providing guidance to surgical teams treating adult patients with acutely psychotic symptoms lacking capacity to consent to invasive surgical interventions.

Conclusion: A high level of clinical investigation is required to obtain timely diagnosis and appropriate interventions in self-embedding behaviors. In this case a needle embedded in the ventricle was discovered for which the recommended intervention was emergent surgical removal. Obtaining the expertise of the psychiatric consult service to evaluate the patient’s decision-making capacity and to liaison with cardiac surgery were shown to be key components in the optimal management of cardiac injury due to a self-embedded needle in a patient with schizophrenia.

Mannarino et al (2016). Self-Embedding Behavior in Adults: A Report of Two Cases... Journal of Forensic Sciences,62(4), 953-961.



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Global Immune Cell Analysis Reveals Plasma B-cell Infiltration in the Frontal Lobe of Patients Experiencing Cognitive Impairment and Encephalitis Secondary to HIV Infection

Ashley Harvin, MD – Resident Physician, Virginia Commonwealth University

Roxanne Sholevar, MD – Resident Physician, Virginia Commonwealth University Health System

Christopher Kogut, MD, MSW – Associate Professor and Director of Residency Education, Virginia Commonwealth University


Background/Significance: In addition to opportunistic infections, a major driver of morbidity and mortality due to HIV infection is caused by central nervous system (CNS) pathology. Aberrant immune responses have long been implicated in CNS pathology secondary to HIV infection1. This study performs a top-down, unsupervised analysis of global immune cell infiltration in the brains of HIV-1 infected patients experiencing neurocognitive impairment vs healthy controls and patients with HIV infection but no neurological symptoms.

Methods: We analyzed publicly available microarray data1 within the NIH Gene Expression Ominobus (GEO)2 of twenty-four human subjects and separated into four groups: 1) Uninfected controls; 2) HIV-1 infected subjects with no substantial neurocognitive impairment (NCI); 3) HIV-1 infected with substantial NCI without HIV encephalitis (HIVE); 4) Infected with substantial NCI and HIVE. Arrays were analyzed using robust multichip averaging analysis (RMA). Immune cell populations were evaluated using CIBERSORT support vector regression. Statistical significance was assessed using a standard student t-test with a p value < 0.05 deemed significant.

Results: Plasma B-cells were the most robustly upregulated immune cells in the frontal cortex of patients with neurocognitive impairment alone (p = 0.003), and in patients with neurocognitive impairment and encephalitis (p=0.007) compared to healthy control patients. Additionally, patients with HIV-1 infection alone but without cognitive sequelae demonstrated negligible plasma cell presence, similar to healthy control patients (p=0.80). These changes were maintained in samples of white matter. Little difference in immune cell infiltration was detected in the basal ganglia.

Discussion: Our top-down analysis of immune cell infiltration in healthy patients, HIV-1 infected patients, and patients with cognitive sequelae of HIV-1 reveals that a humoral response and plasma cell infiltration in the frontal lobe and white matter is robustly upregulated in patients experiencing cognitive symptoms secondary to HIV. These data potentially implicate antibody production and plasma cell secretion as drivers of immune responses in the brain known to cause neurocognitive impairment and encephalitis. In addition to opportunistic infections, CNS pathology is a major player in morbidity and mortality secondary to HIV infection. Thus, our data suggests that targeting the humoral response in the brain in the future may potentially modulate the morbidity of HIV infection.

Conclusion/Implications: Plasma cell infiltration is robustly upregulated in patients with HIV-1 infection experiencing neurocognitive impairment and patients with neurocognitive impairment and encephalitis relative to healthy controls, and patients with HIV-1 infection but no cognitive sequelae. Future efforts to modulate the humoral response in the brain may reduce the morbidity associated with HIV-1 infection.



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Antidepressants After Bariatric Surgery: A Case Report and Literature Review

Todd Simmons, MD – PGY-3 Psychiatry Resident, Pine Rest Christian Mental Health Services/Michigan State University

Heidi Vrolijk, MD – PGY-2 Psychiatry Resident, Pine Rest Christian Mental Health Services/Michigan State University

Madhavi Nagalla, MD – Attending Psychiatrist/ Associate Program Director for Psychiatry Residency Program at Pine Rest, Pine Rest Christian Mental Health Services/ Michigan State University


Antidepressants after Bariatric Surgery: A Case Report and Literature Review

Background

Obesity and depression are highly co-morbid; with studies showing 20-50% of patients undergoing bariatric surgery in the United States have a history of mood disorder. Antidepressants are frequently prescribed to these patients, and unlike medications for hyperlipidemia, diabetes, and hypertension, antidepressants are often continued or increased after bariatric surgery (Lloret-Linares, 2015; Roerig, 2015). With the increasing prevalence of obesity and bariatric procedures, consult-liaison psychiatrists are likely to see an increasing number of consults for these patients (ASMBS, 2017).

Case:

We present a patient who had Roux-en-y gastric bypass and was continued on duloxetine for depression. The patient had worsening depression after being titrated to 60mg of duloxetine and augmentation with bupropion XL 300mg. Duloxetine was increased from 60 to 90mg due to a concern of decreased bioavailability of medication and bupropion XL was continued. After 4 weeks, the patient presented back to the clinic with improvement in depressive symptoms.

Results/Product:

Our literature review will include a review of antidepressant efficacy in patient’s status-post bariatric surgery. We will focus our review on selective serotonin reuptake inhibitors (SSRI) and serotonin-norepinephrine reuptake inhibitors (SNRI) use in this population. Our review will also include examining the various bariatric surgery techniques and their effects on the pharmacokinetics of antidepressants, specifically SSRI and SNRI. Finally, we will present the evidence, or lack thereof, for transitioning to immediate release formulations when available and obtaining drug levels.

Conclusion and/or Implications

Antidepressant use in patients status post bariatric surgery is common and current guidelines are lacking clear directives on how to approach these patients. With increasing numbers of patients receiving bariatric surgery, consultation-liaison psychiatrists must become more familiar with appropriate treatment of this population.

References


  1. Lloret-Linares, C; Bellivier, F; Heron, K: Besson, M. (2015) Treating mood disorders in patients with a history of intestinal surgery: a systematic review. International Clinical Psychopharmacology. 30 (3): 119-128.

  2. Roerig, J. L., and Steffen, K. (2015) Psychopharmacology and Bariatric Surgery. Eur. Eat. Disorders Rev., 23: 463– 469.

  3. American Society for Metabolic and Bariatric Surgery (ASMBS). (2017). Estimate of Bariatric Surgery Numbers, 2011-2017. Retrieved from https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers






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Tuberculosis Psychosis: Tuberculosis Meningoencephalitis Presenting as Major Depressive Disorder with Psychotic Features

Sarah Slabaugh, DO – PGY-II, John Peter Smith Hospital

Aisha Gillan – Medical Student - Year 4, University of North Texas Health Science Center

Zachary Herrmann, DO – PGY-III, John Peter Smith Hospital

Dustin DeMoss, DO, FAPA – Associate Program Director/Assistant Clinical Professor, John Peter Smith Hospital Psychiatry Residency Program


Background: The prominence of autoimmune encephalitis presenting with psychiatric symptoms is well-described in literature (Kayser, 2014). Primary psychiatric presentation of meningoencephalitis is uncommon (Mouhadi, 2017). This report examines a case of tuberculosis meningoencephalitis whose chief complaint was psychiatric. This case also highlights how cultural and language barriers can affect complex clinical presentations.

Case: 46-year-old Spanish-speaking Mexican male with history of polychondritis on immunosuppression treatment and no past psychiatric history presented involuntarily to the psychiatric emergency room after being found walking naked in traffic. The patient’s mental status exam was significant for flat affect, command auditory hallucinations, and suicidal and homicidal ideation. Patient’s medical work-up was negative and he was admitted to psychiatry. He was diagnosed with major depressive disorder with psychotic features and was discharged 18 days later after stabilizing on citalopram, mirtazapine, and risperidone. Over the following 6 weeks he presented to the emergency room three times and was eventually admitted for altered mental status. Magnetic resonance imaging revealed multifocal areas of enhancement of cortical and subcortical structures as well as dural/leptomeningeal enhancements over the bilateral frontoparietal convexities. Cerebral spinal fluid revealed elevated adenosine deaminase level and diagnosis of tuberculosis meningoencephalitis was made. Psychotic symptoms improved with rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) treatment.

Discussion: Rarely does encephalitis present with psychiatric symptoms alone (Cancino Botello, 2016). A primary medical etiology should be considered in a patient with no previous psychiatric history, new onset hallucinations, and negative urine drug screen and workup should include infectious and autoimmune processes (Laher, 2018). Diagnosis and treatment were delayed due to language and cultural barriers and this illustrates the need to prioritize thorough medical workup in cross-cultural patients as culture is widely thought to influence the form, content, and extent of psychiatric symptoms that are experienced in the immigrant population (Weisman, 2000).

Conclusion: This case illustrates the importance of prioritizing a medical differential diagnosis of a first-time psychiatric presentation in a non-English speaking adult. This is especially true when there is an underlying medical illness and cultural barriers may be complicating the presentation.

References:

Cancino Botello, M. C., et al. Psychiatric symptoms as onset of anti-NMDAR encephalitis. European Psychiatry.
2016; 33:S525.

Kayser MS, Dalmau J. Anti-NMDA receptor encephalitis, autoimmunity, and psychosis. Schizophrenia Research. 2014; 176(1):36–40.

Laher AE, et al. First-presentation with psychotic behavior to the Emergency Department: Meningitis or not, that is the question. American Journal of Emergency Medicine. 2018; 36(11):2068-2075.

Mouhadi K, Boulahri T, Rouimi A. Tuberculosis meningoencephalitis revealed by psychiatric disorders: about a case. Pan African Medical Journal. 2017; 27(206).

Wesiman AG, et al. A comparison of psychiatric symptoms between Anglo-Americans and Mexican-Americans with schizophrenia. Schizophrenia Bulletin. 2000; 26(4);817-24.




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Changing Practices for Psychiatric Assessment and Post-discharge Follow up Among Post-cardiac Arrest Patients

Rafael Tamargo, MD MBA – Resident Physician, UPMC - Western Psychiatric Hospital

John Saunders, MD – Assistant Professor, Baylor College of Medicine

Darcy Moschenross, MD, PhD – Assistant Professor of Psychiatry, University of Pittsburgh Medical Center/Western Psychiatric Hospital

Pierre Azzam, MD, FACLP – CL Psychiatry Fellowship Program Director, University of Pittsburgh Medical Center

Morgan Faeder, MD, PhD – Assistant Professor of Psychiatry, University of Pittsburgh School of Medicine

Priya Gopalan, MD – Assistant Professor of Psychiatry, University of Pittsburgh Medical Center, Western Psychiatric Hospital


Background: Cardiac arrest is associated with elevated rates of depression, PTSD, cognitive impairment, and other psychiatric sequelae. Over 40% of post-arrest patients experience psychiatric sequelae and approximately 20% report worsened quality of life as a result (Naber, 2018). Only recently has the incidence of these conditions been elucidated, resulting in increasing attention to the psychiatric needs of post-arrest patients both in the hospital and after discharge, but further characterization of associated diagnoses and successful treatment strategies are needed. 

Methods: A manually-collected database of 3,281 psychiatric consults at UPMC facilities in 2013 was queried to identify patients for whom psychiatric consults were placed following cardiac arrest. 27 such cases were identified. For comparison over time, a second case series was identified by isolating psychiatric consults from 2016-2018 in which diagnostic codes related to cardiac arrest were used, resulting in 82 cases. Descriptive statistics on consulting service, medical comorbidities, psychiatric diagnoses, and post-discharge psychiatric trajectory, including further diagnoses and outpatient follow up, were collected.

Results: Twenty-eight post-cardiac arrest patients were evaluated by the Psychiatric Consult-Liaison service in 2013. Average patient age was 48.6 years old. The mean number of medical comorbidities was 7.2. Average length of stay was 22.4 days, with average time to psychiatric consult 10.1 days and average time to discharge after psychiatric consult 12.3 days. Among these, 36% of consults originated from the Cardiology service, 32% from Internal Medicine, 11% from General Surgery, and the remaining 21% coming from Transplant, Cardiothoracic Surgery, Pulmonology, Otolaryngology, and Physical Medicine and Rehab services. The most common psychiatric diagnoses after consult were depression and delirium, comprising 20% of diagnoses each. Anxiety disorders, non-alcohol substance use disorders, and cognitive impairment accounted for 18%, 14%, and 12% of diagnoses, respectively. Patients averaged two diagnoses each. Only one patient in this group was diagnosed with PTSD. Five patients (19%) died before hospital discharge. Among those who survived to discharge, six (27%) attended outpatient psychiatric follow up within six months and 16 (73%) did not. 

By comparison, in the 2016-2018 cohort of 82 patients, average patient age was 56.1 years old. Average length of stay was 26.6 days, with average time to psychiatric consult 13.7 days and average time to discharge after psychiatric consult 13.2 days. General Surgery and Cardiology accounted for the largest proportion of consults, at 16% each. The most common psychiatric diagnoses after consult were again depression and delirium. Anxiety disorders followed at 18%. Five patients (4%) were diagnosed with PTSD or trauma-related disorders. Twenty patients (24%) died before hospital discharge. Among those who survived to discharge, 8 (13%) attended outpatient psychiatric follow up within six months and 54 (87%) did not.

Discussion: Cardiac arrest is associated with increased rates of psychiatric sequelae, but post-discharge psychiatric treatment is limited. We investigate psychiatric trajectory of these patients after discharge and changes in practice with increasing awareness of these risks. A broader range of consulting services engaged the Psychiatry CL service in the care of post-arrest patients. Substance use disorders and major neurocognitive disorders were diagnosed less in the later cohort, while bipolar disorder and trauma-related disorders represented a larger portion of the later cohort. Six-month outpatient psychiatric follow up rate among survivors of cardiac arrest decreased by half over the period studied. There is a significant need for a more robust referral process. Further investigation will seek to characterize reasons for or against consulting Psychiatry CL, appropriate screening tools and timing, and predictors of outpatient follow up. 

Reference:
Naber, D., & Bullinger, M. (2018). Psychiatric sequelae of cardiac arrest. Dialogues in clinical neuroscience, 20(1), 73–77.



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Depression and the Capacity to Refuse Hemodialysis

Dax Volle, MD – Resident Physician, UCLA

Maya Smolarek, MD – Resident Physician, UCLA

Isabella Morton, MD, MPH – Resident Physician, UCLA

Keerthan Somanath


Background/Significance:

Capacity is a core feature of the decision to withdraw life-sustaining treatment. Depression may impair capacity to make such decisions. This case report highlights salient aspects of the capacity evaluation of a patient with depression who chose to stop hemodialysis (HD).

Case:

28 y/o male with MDD, ESRD due to FSGS s/p failed DDRT on HD, and HCV with multiple admissions for sequelae of missed HD and one psychiatric hospitalization for MDD/SI presented for dyspnea after multiple missed HD sessions.

Creatinine was 15.40 and he was altered and agitated. HD was initiated and creatinine stabilized to 9. Psychiatry consulted after patient stopped HD sessions and reported SI. During consult, patient reported plan to stop HD as well as several weeks of depressed mood, insomnia, anhedonia, worthlessness, anergia, amotivation, and inattention.

He understood the benefit of continuing HD (sustained life) and the risks (death) and alternatives (HD continuation, transplant) of stopping HD and indicated preference to stop while acquiescing that he would not wish to die if his depression were treated.

After three days without HD patient developed hyperkalemia and ECG changes which were felt to be imminently life threatening. Psychiatry ruled that patient lacked capacity to stop HD and non-voluntary HD was started.

This patient was ultimately psychiatrically hospitalized, treated, and discharged. Before he was lost to follow-up 6 months ago he was still receiving HD.

Discussion:

Depression may lead to ‘Concretized Emotion-Belief Complexes’ where rigid beliefs may cause a breakdown in the appreciation component of capacity as individuals are rendered unable to appreciate non-negative future possibilities.

If appreciative ability remains intact, depressed individuals may still lack ‘decisional authenticity’ as their decisions may not reflect their ‘true’ autonomous self as they do not possess a minimal level of concern for their own welfare. Without this, any claim of capacity is jeopardized as patient is not accountable for their decision to receive treatment or not.

Conclusion/Implications:

Our conclusions were based on our determination that depression was rendering the patient unable to manipulate information rationally, especially as he acquiesced that he would not wish to die if depression were treated. This raised concern that a negativistic outlook prevented him from fully appreciating the ramifications of his choice to discontinue treatment.

This case highlights not only the interplay between depression and the capacity to withdraw life-sustaining treatment, but also the complex considerations that consultant psychiatrists must explore before making recommendations regarding capacity in such cases.
References:

Hindmarch T, Hotopf M, Owen GS. Depression and decision-making capacity for treatment or research: a systematic review. BMC Med Ethics. 2013;14:54

Baruth J, Lapid M. Influence of Psychiatric Symptoms on Decisional Capacity in Treatment Refusal. AMA Journal of Ethics. 2017, Volume 19, Number 5: 416-425



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A Case of Misdiagnosed Catatonia in Systemic Lupus Erythematosus

Jaime Thomas, DO – PGY-3 Resident, Albert Einstein Medical Center

Inder Kalra, MD – Consultant Psychiatrist, Albert Einstein Healthcare Network


Introduction

Catatonia is a condition with a collection of symptoms characterized by disturbances in motor behavior due to neurotransmitter dysfunction. Generally, the presentation of catatonia is quickly diagnosable by psychiatrists due to its overt and unique presentation in patients with psychiatric disorders. However, similar appearing presentations secondary to other medical conditions are also seen, and when found are common in neurological disorders. Systemic lupus erythematosus (SLE) is an autoimmune disorder that can cause inflammation in multiple organs of the body including the central nervous system (CNS). Progressive SLE can lead to many neuropsychiatric symptoms in patients. This case discusses the recognition and management of symptoms given the overlap of presentation and the use of a dopamine agonist, Sinemet (Carbidopa-Levadopa).

Case Description

A previously healthy 15 year old Cambodian female presented to the hospital with fatigue, intermittent fevers, and progressive weakness. Lab testing showed positive antibodies revealing SLE. Due to progressing blurry vision and diagnosis of chorioretinitis, a steroid implant was placed in her left eye. Post-operatively, she developed catatonia symptoms of posturing, mutism, immobility, negativism, hypomimia, and rigidity. Intensive treatments for SLE were initiated and Ativan and Amantadine were started to manage what was thought to be catatonia. She had partial response to symptoms. There were concerns of SLE affecting the CNS leading to Parkinson like extra-pyramidal symptoms. A trial of Sinemet was initiated with improved response in symptoms.

Discussion

Catatonia symptoms develop due to dysfunction of neurotransmitters. These neurochemical abnormalities include low GABA activity in the frontal cortex, low dopamine (D2) activity in the basal ganglia, and high glutamate activity (NMDA) in the parietal cortex. CNS lupus can lead to Parkinson like symptoms from decreased dopamine that present similarly as catatonia. Treatment with Amantadine which has dopamine agonistic activity, aids in neuro-recovery in TBI and catatonia. Sinemet is a precursor to dopamine that crosses the blood brain barrier and acts as dopamine in the brain. With this patient, Ativan and Amantadine showed partial response, and trial with Sinemet showed improved response. This case presents challenges in recognition and management of catatonia in the context of a neurological disorder and highlights the utility of Sinemet in this setting.




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A Case of Delirious Mania: More Than a Refractory Diagnosis; Reflections on Treatment, Ethical Responsibilities and Challenges of Interdisciplinary Care

Cybele Arsan, MD – Resident Physician, Dartmouth Hitchcock Medical Center

Catherine Baker, BA – Medical Student, Geisel School of Medicine at Dartmouth

Jordan Wong, MPH – Medical Student, Geisel School of Medicine at Dartmouth

Samuel Kohrman, MD – Resident Psychiatrist, Dartmouth-Hitchcock Medical Center

Robert Scott, MD, PhD – Psychiatrist, White River Junction VAMC

Anne Felde, MD – Staff psychiatrist, VA Medical Center, White River Junction VT

Theodore Stern, MD, FACLP – Director, Thomas P. Hackett Center for Scholarship in Psychosomatic Medicine, Massachusetts General Hospital/Harvard Medical School

James K. Rustad, M.D. – Assistant Professor of Psychiatry, Geisel School of Medicine at Dartmouth


Background: Delirious mania is a condition featuring a combination of mania and fluctuating sensorium. It is an underdiagnosed disorder with an extensive differential diagnosis. Additionally, caring for affected individuals can be challenging because: (i) effective treatment strategies can take extended amounts of time, and (ii) patients can display aggressive behaviors.
Case: We describe the case of Mr. H, a 61-year-old man with delirious mania. Mr H. first presented as a transfer from an outside hospital for management of continued mania and delirium after a 12-day admission for presumed lithium toxicity. At our institution, Mr. H continued to showed signs of fluctuating consciousness with confusion, grandiose thinking, playful language patterns, and poor sleep despite treatment with high doses of olanzapine and valproate. After a thorough evaluation including blood work, imaging, and a lumbar puncture failed to identify potential medical etiologies of his condition, the team decided that Mr. H’s presentation was attributable to delirious mania. Multiple treatments in addition to olanzapine and valproate were attempted during his hospital course, as well as benzodiazepines and intensive care unit (ICU) sedation, none of which led to significant improvement in mental status. ECT was recommended, but the family declined treatment out of a desire to respect Mr. H’s previously stated preference against ECT. Mr. H’s prolonged agitation caused significant strain and multiple injuries to support staff, requiring daily meetings among all members of the treatment team. Fortunately, after several weeks of fluctuating clinical status, haloperidol was ultimately effective in stabilizing Mr. H’s condition.
Discussion: The diagnosis of delirious mania is a diagnosis of exclusion that requires the clinician first rule out medical, neurological, drug side effects, and other psychiatric etiologies. There is no clear consensus regarding the best treatment for the disorder. Some cases of delirious mania have been successfully treated with ECT, but ECT laws vary by state, and there is controversy about the administration of involuntary ECT for life-threatening conditions such as delirious mania. Because the disorder is challenging to treat and often follows a prolonged clinical course, successful interprofessional teamwork-characterized by sound leadership and frequent communication- is crucial for safe, effective patient care.





-Fink M: Delirious mania. Bipolar Disord, 1999; 1(1): 54–60. -Karmacharya R, England M, Lou, Öngür D: Delirious mania: Clinical features and treatment response. J Affective Disord, 2008; 109(3): 312–316. -Fox FL, Bostwick JM: Propofol sedation of refractory delirious mania. Psychosomatics, 1997; 38(3), 288–290. -Nagalla, M. L., Akinyemi, E., Hosanagar, A., Demskey, P., & Nafiu, I. (2014). Manic Delirium - Treatment Considerations. The American Journal of Geriatric Psychiatry, 22(3), S77. -Martin, J. S., Ummenhofer, W., Manser, T., & Spirig, R. (2010). Interprofessional collaboration among nurses and physicians: making a difference in patient outcome. Swiss Medical Weekly, 140, w13062.



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Altered Mental Status Due to Golimumab: A Case of Tnf-alpha Inhibitor Induced Lupus-like Syndrome

Jason P. Caplan, MD, FACLP, FAPA – Professor of Psychiatry, Creighton University School of Medicine - Phoenix

Evan Cordrey, BA – MS4, Creighton University School of Medicine: Phoenix Regional Campus

Dawn Benford, MSN, PMHNP-BC – Psychiatric Nurse Practitioner, St. Joseph's Hospital and Medical Center


Introduction:

Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease for which first-line treatment is disease-modifying antirheumatic drugs (DMARDs). If these medications are unsuccessful, tumor necrosis factor alpha (TNF-alpha) inhibitors, sometimes known as anti-TNF-alpha medications, typically serve as second-line treatment. Since TNF-alpha plays a role in the native immune system, these medications can trigger the production of autoantibodies and a subsequent autoimmune response mimicking the symptoms of systemic lupus erythematosus (SLE) and, in rare circumstances, lead to major life-threatening organ damage including inflammation of the brain (cerebritis). This phenomena has previously been documented as TNF-alpha inhibitor induced lupus-like syndrome (TAILS).



Case Presentation:

We report a case of a 69 year-old woman with a chronic history of RA who was switched from methotrexate monotherapy to the anti-TNF-alpha medication golimumab. Within 6 months of starting this medication she developed gradual polyneuropathy, limb paresthesias, pancytopenia, and eventual cerebritis requiring an intensive care unit (ICU) admission. Upon psychiatric consultation, patient demonstrated psychomotor retardation, confusion, and global aphasia. Patient was oriented only to self for most of her ICU admission. Despite stopping golimumab, the patient had seroconversion of antinuclear antibodies (ANA), anti-double-stranded DNA, and anti-Sjögren’s-syndrome-related antigen A (Anti-SSA). Extensive neurological, neoplastic, vascular and infectious work-up were not revealing of any other cause of her autoimmunity, leading to the conclusion this was a drug-induced form of lupus cerebritis. Further weight was added to this hypothesis when the patient rapidly recovered after 48 hours of high dose methylprednisolone.



Discussion:

To our knowledge, this is the first reported case of golimumab-induced autoimmune cerebritis. Previous reports of automimmunity with this agent have only presented with cutaneous forms of this lupus-like syndrome. Autoimmune cerebritis has previously been reported with other anti-TNF-alpha agent such as adalimumab and have included a variety of neuropsychiatric symptoms including seizures and clonus.



Conclusion:

This case highlights that TAILS can present with a variety of CNS symptoms without the cutaneous involvement typically associated with a lupus-like syndrome. and should be considered in the differential diagnosis of neuropsychiatric symptoms in a patient using anti-TNF-alpha medications including golimumab.




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FLNC Variant in a Patient with Schizophrenia and Recurrent Neuroleptic Malignant Syndrome and Catatonia

Paul A. Parcon, MD, PhD – Resident Physician, University of Arkansas for Medical Sciences

Jeffrey Clothier Clothier, MD, DFAPA – Professor, Department of Psychiatry, UAMS DEPT OF PSYCHIATRY

Amy Grooms, MD – Assistant Professor, University of Arkansas for Medical Sciences

Lou Ann Eads, MD – ASSOCIATE PROFESSOR, UAMS

Kent Mckelvey, Jr, MD – Rockefeller Chair in Clinical Genetics, University of Arkansas for Medical Sciences


Background: Neuroleptic Malignant Syndrome (NMS) is marked by sudden onset of rigidity, elevated temperature, autonomic dysfunction, and confusion. Altered homeostasis of intracellular calcium is one proposed etiology.

Method: We present a 52 year old female with a diagnosis of ‘catatonic schizophrenia’ and epilepsy, who presented on several occasions with high CK (up to 30,730 IU/L), rigidity and fevers. Workup included inconclusive LP, MRI studies, negative autoimmune encephalitis labs. Treatment with various neuroleptics including clozapine, lithium and other mood stabilizers had limited success. Over the years she has a cognitive and physical decline. The NMS reactions occurred with antipsychotics including clozapine. She had an episode free period during while treated with ECT. Her overall course was one of decline.

Evidence of mitochondrial dysfunction was indicated by an elevated lactate:pyruvate ratio of 58 and elevated lactate and ammonia (Parikh, 2015). Exome analysis of nuclear and mitochondrial DNA was done. There were two alleles identified as potentially pathogenic. The first was a variant of TPO (Thyroid Peroxidase enzyme gene). The second gene was FLNC gene (Filamin C). Filamin C is an actin-binding like protein responsible for the condition known as myofibrillar myopathy type 5 (MFM-5), a condition that presents ages 37 to 57 (Furst, 2013). The patient was heterozygous for a variant that included a substitution of arginine for proline at position 1526. The location was on Chromosome 7q32.1. This variant has not previously been reported. In-silico analyses of the structure predicted a deleterious effect.

Pimavanserin was started. The anticonvulsant was changed to levetiracetam due to the minimal impact on mitochondria compared to other anticonvulsants (Mithal, 2017). The pimavanserin was partially effective and low dose clozapine was added. Clozapine has a minimal impact on mitochondria among antipsychotic agents (Anglin, 2012). There is less rigidity and a more muscle control noted. She is now able to verbalize more easily and is calmer. CKs and the serum lactate have normalized.

Discussion: Filamin C which is expressed primarily in the skeletal and cardiac muscles. As a structural protein, variants can be expressed as an autosomal dominant conditions (Furst, 2013). A review of the literature identified a small cohort in Belgium that had co-occurrence of frontotemporal dementia with the MFM-5. (Janssens, 2015)

Conclusion: The mitochondria are important in intracellular calcium homeostasis. Calcium is important in muscle contractions. The impact of psychiatric medications on mitochondrial function is variable (Anglin, 2012). Selection of the least toxic agents along with cardiac monitoring is important.

References:
1. Furst, DO, et al: Filamin C-related myopathies: pathology and mechanisms. Acta Neuropathol (2013) 125:33–46
2. Janssens, J et al: Investigating the role of filamin C in Belgian patients with frontotemporal dementia linked to GRN deficiency in FTLD-TDP brains, Acta Neuropathologica Communications (2015) 3:68.



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