Borderline Personality Disorder With Atypical Traits in a 30-Year-Old Female: A Case Report.

In this paper, we report an atypical presentation of borderline personality disorder (BPD) in a 30-year-old female with a history of childhood molestation and trauma and a prior diagnosis of post-traumatic stress disorder (PTSD). The patient was hospitalized due to anxiety, depression, and guilt over her relapse into alcohol use disorder. During her hospital stay, we diagnosed her with BPD based on psychiatric examination, clinical interviews, and patient history. While the patient exhibited some of the typical characteristics of BPD, such as an instability of interpersonal and romantic relationships, there were numerous findings that were atypical of BPD. These include a demonstration of mature defense mechanisms such as sublimation and altruism, high levels of occupational functioning, strong maternal caregiving behavior, and no history of self-harm. Further analysis of the patient's personality traits helped us identify that this presentation could be best characterized as a high-functioning internalizing subtype of BPD as identified in prior literature.

Psychiatric Disorder in a Patient With Beckwith-Wiedemann Syndrome: A Case Report.

Patients with Beckwith-Wiedemann syndrome (BWS) often suffer from pheochromocytoma and hypoglycaemia and are vulnerable to disorders associated with the hypothalamic-pituitary-adrenal axis (HPA), such as major depressive disorder, generalised anxiety disorder, borderline personality disorder, etc. Features of pheochromocytoma even overlap with features of anxiety disorders, panic disorders, etc. These patients undergo multiple major surgeries under general anaesthesia at a very young age due to recurrent tumours that can affect their behavioural and emotional development. Depriving them of much-needed medical and emotional support negatively impacts their physical and psychological well-being. In this case report, we present the case of a 23-year-old woman with Beckwith-Wiedemann syndrome (BWS) who underwent major surgeries such as partial pancreatectomy, adrenalectomy, osteotomy, and paraganglioma resection at an early age. She was neglected by her parents and spent her childhood in an abusive environment. All these factors could have increased her vulnerability to mental health problems. She was diagnosed with borderline personality disorder, major depressive disorder, unspecified trauma, stressor-related disorders, cannabis use disorder, and cannabis-induced psychotic symptoms. This report emphasises the role of medical comorbidity in a patient presenting with borderline personality disorder.

Chronic Refractory Insomnia in a Patient With Undiagnosed Bipolar Disorder and Long-Standing Traumatic Brain Injury.

Traumatic brain injury (TBI), a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain. TBI can result when the head suddenly and violently hits an object or when an object pierces the skull and enters brain tissue. TBI can be classified into primary and secondary brain injury. Primary injury refers to the structural damage caused upon impact. Secondary injury refers to the damage from subsequent cellular processes following a prior injury, such as excitotoxicity, free radical generation, calcium-mediated damage, hypoxia, and increased intracranial pressure. Unsurprisingly, these mechanisms can produce structural, biochemical, and genetic changes implicated in sleep disturbance. A coup-contrecoup injury typically occurs at the base of the skull in areas of bony prominences, hence, the anterior temporal and inferior frontal regions, including the basal forebrain, are frequently injured. Because the basal forebrain contributes to sleep initiation, injury to this region can lead to insomnia symptoms. In this report, we present a case study of a 41-year-old Caucasian male who experienced a TBI at the age of seven due to a motor vehicle accident. The left frontotemporal lobe was affected as a result of the incident. He was admitted to the emergency room in March 2023 for safety concerns in the context of extreme anger and irritability, which could endanger others and himself. Additionally, he struggled with chronic insomnia. The chart review showed that the patient's chronic insomnia was poorly controlled and probably contributed to the current presentation. The patient was observed in the days following admission while various medication changes were attempted to treat his chronic insomnia. Unique limitations were encountered in managing this patient's insomnia, as he has multiple drug allergies, including some of the commonly used medications to treat insomnia. A particularly unique observation was that the medications that finally worked for this patient had anticholinergic side effects. They are usually contraindicated in post-TBI patients. However, it was beneficial to use them in this case, which can be explored further.

Psychological Testing in a Complex Case: Psychosis in Co-occurring PTSD, Gender Dysphoria, and Bipolar Disorder.

This case report investigates the concurrent presence of post-traumatic stress disorder (PTSD) and bipolar disorder (BD) in the transgender population. We present a case involving a 21-year-old female-to-male transgender individual (preferred pronouns - they/them). The patient had a history of psychosis, trauma, gender dysphoria (GD), inconsistent hormone (testosterone) treatments, and a self-attributed diagnosis of "associative identity disorder" with 21 distinct "identities." They had two emergency admissions in quick succession, both characterized by analogous symptoms. Contributing factors included a recent discontinuation of antipsychotic medications and a history of cannabis use. Their family history included BD in the patient's mother and schizophrenia in their paternal grandfather. The differential diagnoses considered were brief psychosis, BD, PTSD, and substance-induced mania/psychosis. A notable improvement in the patient's clinical presentation was observed during their hospital stay. Their therapeutic regimen comprised olanzapine, hydroxyzine, topiramate, trazodone, and lithium carbonate extended-release. Additionally, the patient underwent psychological testing. This progress solidified the primary diagnosis as PTSD coexisting with BD, manifesting episodes of mania and psychosis. This report highlights the critical role of psychological evaluations in assessing symptoms in patients with multiple psychiatric co-morbidities. Our findings emphasize the importance of a comprehensive, multidisciplinary approach for accurate diagnosis and efficacious treatment of such intricate cases.

Diagnostic Dilemma and Management Difficulties in a Young Patient With Psychosis and Benign Chorea: A Case Report and Review of the Literature.

Psychosis presents with hallucinations, delusions, disorganized speech, abnormal psychomotor behavior, and negative symptoms. It most commonly appears in the setting of schizophrenia, although it could also appear in bipolar disorder, major depression, post-traumatic stress disorder (PTSD) and even in medical conditions and substance use. In young people, the diagnosis of psychosis can present as a challenge due to the overlap of psychotic conditions and other emotional, behavioral, and developmental disorders. In this case report, we present the case of a 19-year-old female with a history of bipolar disorder, oppositional defiant disorder (ODD), depression, anxiety, PTSD, and schizophrenia-spectrum disorder who was admitted to an inpatient psychiatric facility after presenting with acute onset of confusion.

Synergistic Effects of Psychotropics Leading to Extraordinary Weight Gain.

A 22-year-old woman had significant weight gain after being on two atypical antipsychotics, an antiepileptic, and an antidepressant for 12 months, with her weight increasing from 70 kg to 160 kg, or by 90 kg, over 16 months. This case report examines the possible synergistic effects of psychotropics, particularly two atypical antipsychotics, leading to adverse side effects, particularly severe obesity, in the context of other examined pharmacological and non-pharmacologic risk factors. Psychotropic monotherapy is the advised prescribing treatment guideline. The extraordinary weight gain resulting in severe obesity in this case demonstrates just one of the many concerns for psychotropic polypharmacy from the same sub-class of psychiatric drugs leading to increased morbidity and mortality in the psychiatric population.

Feasibility of Adjunctive Bright Light Therapy for Depressive Symptoms on an Acute Psychiatric Floor.

BACKGROUND: Bright light therapy (BLT) has been increasingly used as an experimental treatment in non-seasonal unipolar depression. While clinical trials have demonstrated the efficacy of BLT in ameliorating depression for outpatients, studies examining BLT in the psychiatric inpatient setting are currently lacking. AIM: The purpose of this study is to explore whether BLT as adjunctive treatment for depressive symptoms on an acute psychiatric floor is feasible and explore associated changes in depressive symptoms. METHODS: An observational, cross-sectional study was conducted at State University of New York (SUNY) Upstate 4B acute inpatient psychiatric unit. BLT was administered to participating patients as adjunctive therapy to their psychopharmacological and psychotherapy treatments on a daily basis throughout their hospitalization. Beck Depression Inventory-II (BDI-II), Hamilton Rating Scale for Depression (HAM-D), and Outcome Questionnaire-45.2 (OQ-45.2) were administered before commencing BLT and after their last BLT session. Changes to the aforementioned measures before and after BLT treatment, the dose response of measure changes based on number of sessions, and the hospital length of stay along with the secondary factors such as age, gender, other psychiatric comorbidities, social factors, and psychiatric medications were analyzed. RESULTS:  BLT is feasible on acute psychiatric inpatient floor with adherence of 94% and has very few side effects. The repeated measures of depression and functioning demonstrated significant decrease in depression and improvement in functioning. Although not statistically significant, clinical meaningful dose-response relationship was found between a number of BLT sessions and improvement in depressive symptoms with five BLT sessions being an optimal amount for depression amelioration. CONCLUSION: BLT combined with the ongoing psychopharmacological treatment was well tolerated and easy to administer. It offers a simple, safe, and cost-effective approach to augmenting depressive treatment on an acute psychiatric floor.

Deliberate Foreign Body Ingestion in a 35-Year-Old Woman With Borderline Personality Disorder and Several Psychiatric Comorbidities.

Deliberate foreign body ingestion (DFBI) is a rare psychopathological disorder that involves the swallowing of non-nutritive objects to cause self-harm. It is most commonly associated with borderline personality disorder (BPD). Very scant literature has been published on the psychopathological understanding or psychopharmacological interventions. Mostly, gastroenterological and surgical management regarding the removal of the foreign body has been discussed in the literature. DFBI can be very challenging in terms of the treatment of the patient and the morale of the health providers - it exhausts the patient and the family and evokes frustration among the medical staff due to its resistance to remission. By presenting the case of a patient in this article, we will discuss what is known about the poorly understood DFBI and the challenges and difficulties encountered while treating these patients. Further, we will discuss how a biopsychosocial approach can be used in treating these patients.

Diet Quality and Mental Health Amongst Acute Inpatient Psychiatric Patients.

This is the first study that explored the self-reported dietary habits of acute psychiatric inpatients. We found that 75% of the psychiatric inpatients have an unhealthy diet, which correlates with higher body mass index (BMI) and lower education level. We also found an increased sugar consumption in inpatients with schizophrenia. The link between nutrition and mental health has been explored to a limited extent owing to the cumbersome nature of conducting research that involves specific dietary intervention and follow up. Yet, there is existing literature linking poor diet with impaired mental health and poor recovery from depression, amongst other disorders. Good nutrition can be exemplified with diets like the Mediterranean diet with a focus on certain food groups that provide the nutrients linked to neurotransmitters and a fairly new concept of the gut-brain axis. A Mediterranean-style dietary intervention supplemented with fish oil improves diet quality and mental health in people with depression. A randomised controlled trial published in the nutritional neuroscience journal yielded a positive outcome and improvement in the overall well-being of the patients enrolled. We explored the dietary habits of acute inpatients. After gathering a detailed diet history, their food habits were compared to a Mediterranean dietary index to assess their dietary patterns. Additionally, variables such as socio-economic characteristics, physical activity, income, BMI, and educational achievement were taken into consideration, with the intention to understand the effect of these factors on a diet consumed by acute patients and the relationship of the diet with their mental wellbeing. Ultimately, this study aims at an important aspect of preventive mental health, i.e., improved dietary habits (e.g., Mediterranean diet) may contribute to more rapid symptoms resolution and acute stabilization on a short-stay inpatient unit.

Shifting Trends in Admission Patterns of an Acute Inpatient Psychiatric Unit in the State of New York.

Introduction Deinstitutionalization has led to various changes in the utilization of healthcare services. The increased focus on treating patients within the community has led to variations in the utilization patterns of inpatient units. Shifts in demographic variables and disease-related, system-based, and economic factors have been observed. Due to the paucity of recent literature, this study was planned to assess the characteristics and treatment patterns in an acute inpatient psychiatric unit of a university hospital. Methods A retrospective observational study reviewing electronic medical records of patients in the context of demographic, disease-related, treatment-related, and system-based data was conducted over five years. Quantitative data were analyzed through descriptive statistics. Linear regression was used to study each variable across time. Results There was an increase in neurodevelopmental disorders (p = 0.024), substance use disorders (p = 0.041), and trauma and stressor-related disorders (p = 0.012), with a decrease in depressive disorders (p = 0.047). The use of restraints (p = 0.035) has increased significantly during the same period. Conclusion This study gives us an insight into the changing trends in patient characteristics which have the potential to inform the creation of improved services.

Awareness of treatment needs and length of stay amongst psychiatric inpatients.

INTRODUCTION: Inpatient psychiatric units experience significant pressure from third party payers to keep length of stay (LOS) to a minimum despite having to treat more severely ill patients. However, there is a paucity of empiric data for guiding treatment decisions that maximize therapeutic outcome while minimizing LOS. We therefore endeavored to begin utilizing a newly created psychometric instrument that assesses patient psychological factors, which we propose will allow for LOS prediction and individualization of therapeutic outcome. MATERIALS AND METHODS: The Goals Questionnaire (GQ), created to determine awareness of treatment needs, was administered to newly admitted patients. Linear regression analyses were conducted to ascertain the relationship between the GQ score and LOS, as well as the effects of confounding factors. RESULTS: A significant and inverse relationship was found between the GQ score and LOS (ß=-4.4; p=0.007) that was dependent upon (i.e., had a significant interaction with) age and substance use disorders. There was minimal confounding from common administrative, legal, and clinical factors. CONCLUSIONS: The GQ may have utility for inpatient treatment teams, providing information that can be used to maximize and individualize therapeutic outcome while minimizing LOS.

Obesity and psychotropics.

Weight gain is on the rise in the United States as is the diagnosis and treatment of mental disorders. These two phenomena are distinctly separate but tend to overlap in that most psychotropic agents approved for use in the United States are associated with the potential to induce weight gain. Metabolic disorders such as diabetes, hypercholesterolemia, and hypertension are also on the rise and often associated with weight gain and clearly associated with certain psychotropic medications. This article serves to provide a succinct review regarding the epidemiology, etiology, and treatment options for psychotropic-induced obesity.

Obesity in adults with serious and persistent mental illness: a review of postulated mechanisms and current interventions.

BACKGROUND: An epidemic of overweight and obesity in the United States has had profound effects on the health of the general population, with consequent development of metabolic syndrome and related morbidity and mortality. However, these effects have been more widespread among adults with serious and persistent mental illness. METHODS: A literature search was conducted using the PubMed and Ovid databases. Terms used, in varying combinations, were schizophrenia, schizoaffective disorder, bipolar disorder, obesity, atypical antipsychotic, diabetes mellitus, hyperlipidemia, and metabolic syndrome. Of 103 articles generated, 71 were deemed pertinent to the current study. One reference was decided upon based on personal communication. RESULTS: Both nonpharmacologic and pharmacologic factors contribute to obesity development in adults with serious and persistent mental illness. Consequently, similarly targeted nonpharmacologic and pharmacologic interventions have been used to mitigate against body weight gain. Although the results obtained thus far are promising, effect sizes only in the low to medium range have been realized, with nonpharmacologic interventions demonstrating slight superiority. CONCLUSIONS: Improved therapeutic methods are needed to address the effects of obesity on individuals with serious and persistent mental illness. Factors that will likely contribute to such advancement are a better understanding of the mechanisms involved, earlier intervention, and adequately powered, randomized controlled trials of sufficient duration, with baseline body weight as a covariate.

Weight gain, obesity, and psychotropic prescribing.

A majority of psychiatric medications are known to generate weight gain and ultimately obesity in some patients. There is much speculation about the prevalence of weight gain and the degree of weight gain during acute and longitudinal treatment with these agents. There is newer literature looking at the etiology of this weight gain and the potential treatments being used to alleviate this side effect. The authors undertook a comprehensive literature review in order to present epidemiology, etiology, and treatment options of weight gain associated with antipsychotics, mood stabilizers, and antidepressants.

A study of polypharmacy with second generation antipsychotics in patients with severe and persistent mental illness.

BACKGROUND: There is a paucity of empirical support for polypharmacy with second generation (atypical) antipsychotics (SGAs), especially in understudied populations. OBJECTIVE: To investigate the frequency, effectiveness, and safety of this practice in patients with severe and persistent mental illness who are chronically hospitalized. METHODS: A chart review was conducted at a state psychiatric hospital in Syracuse, NY. The study subjects (N=26) were chronically hospitalized individuals with DSM-IV diagnoses of schizophrenia or schizoaffective disorder who were initially prescribed at least one SGA and then received at least one other SGA during the study period. Demographic and clinical data were collected. Baseline and 6-month assessments were compared for statistical significance (p<0.05). RESULTS: Of the 117 chronically hospitalized inpatients at the study center, 22.2% (N=26) received treatment regimens involving polypharmacy with SGAs. These patients as a group achieved statistically significant reductions on their scores on the Brief Psychiatric Rating Scale (34.2 +/- 11.0 compared with 25.3 +/- 11.8; p=0.016) and the Clinical Global Impressions-Improvement Scale (5.5 +/- 0.6 compared with. 5.0 +/- 0.8; p=0.016) at 6 months. There was a significant decrease in the use of prn medications (7.6 +/- 19.6 compared with 1.6 +/- 2.6; p<0.04). However, the number of patients receiving anticholinergic medications increased from 5 to 8 (p<0.04). CONCLUSIONS: Polypharmacy with SGAs is quite frequent among chronic inpatients with severe and persistent mental illness despite a limited empirical database supporting its use. The results of our pilot study do not demonstrate the effectiveness and safety of this practice. However, methodological shortcomings may have contributed to our failure to detect a true, positive effect. Controlled studies are needed to accurately determine the risks and benefits of SGA polypharmacy.

A retrospective study of weight changes and the contributing factors in short term adult psychiatric inpatients.

INTRODUCTION: The authors endeavored to determine if there is significant weight gain during acute psychiatric inpatient hospitalization for adults and, if so, what are the contributing factors. METHODS: A retrospective chart review was conducted of all patients admitted to the psychiatric inpatient unit of a University Hospital in the year 2001. The study was approved by the Institutional Review Board. RESULTS: Out of 535 charts reviewed, 96 patients met the inclusion criteria. The group on average gained 3.9 +/- 13.3 lbs. (P = 0.005; 95% CI = 1.2, 6.6). Lower admission body weight was associated with more weight gain. Patients with diagnoses of bipolar disorder and schizophrenia gained more compared to those diagnosed with major depressive disorder. Patients who were prescribed atypical antipsychotics gained more compared to those who were not prescribed such medications. Smokers gained more weight than nonsmokers, and males gained more than females. Weight at the time of the admission (inverse relationship) and Axis I diagnosis were the strongest predictors of weight gain. CONCLUSIONS: This study demonstrates that significant numbers of patients are at risk of gaining weight when they are admitted to a psychiatric inpatient unit. Patients with lesser degrees of overweight at the time of admission, patients with diagnoses of bipolar disorder and schizophrenia, and those receiving atypical antipsychotics may be more vulnerable to such effects.

Variable effects of psychosocial factors on the clinical course of schizophrenia.

BACKGROUND: Recent work suggests that psychosocial stress factors play a lesser role (qualitatively) in the progression of schizophrenic illness in male patients. The authors endeavored to determine if hospitalization in schizophrenic patients of both sexes is associated with less quantifiable psychosocial stress over time. METHODS: Male and female, schizophrenic inpatients from 2 urban centers in New York State (n = 31) were enrolled in this retrospective and cross-sectional study. Linear regression analysis was performed with illness duration as the independent variable and ln (1 + Paykel Life Events Schedule) score, associated with current hospitalization, as the dependent variable. RESULTS: Linear regression analysis revealed an inverse relationship (slope = -.086) that was statistically significant (p < .01). This result indicates an annual 92% reduction in the psychosocial stress load associated with hospitalization. The inverse relationship remained intact when males and females were analyzed separately. CONCLUSIONS: The data suggest that, over time, male and female patients with schizophrenia experience hospitalization and, likely, relapse as well in response to less of a total significance load of psychosocial stress.

Resolution of risperidone-induced hyperprolactinemia with substitution of quetiapine.

OBJECTIVE: To report a case of risperidone-induced hyperprolactinemia that was successfully managed with quetiapine. CASE SUMMARY: A 30-year-old white woman with schizoaffective disorder, depressive type, and comorbid alcohol and cocaine abuse was treated successfully for her psychotic symptoms with risperidone until she developed adverse effects consistent with hyperprolactinemia. This was confirmed by laboratory blood tests, as her prolactin level was 186.9 ng/mL (normal for nonpregnant women 2.8-29.2). The woman had experienced similar effects in the past, which had led to noncompliance and subsequent psychotic relapse. Normalization of prolactin levels and associated adverse effects were achieved upon switching to quetiapine. No psychotic symptoms reoccurred. DISCUSSION: Dopamine type 2 (D(2)) receptor blockade in the mesolimbic tract is thought to mediate the therapeutic effects of antipsychotics. This action in the tuberoinfundibular system produces prolactin level elevation. Risperidone has a relatively higher affinity for the D(2) receptor in comparison with other atypical antipsychotics, which may explain why it is associated with a higher incidence of hyperprolactinemia. Quetiapine, which has one of the lowest D(2) receptor affinities, is not known to increase prolactin levels to any significant degree. This pharmacologic property allows quetiapine to be a reasonable treatment option for patients who develop risperidone-induced hyperprolactinemia. CONCLUSIONS: Quetiapine may be a suitable substitute when a patient taking risperidone develops hyperprolactinemia.