Bilateral Basal Ganglia Calcifications Manifesting as Psychosis With Manic Features: A Case Report on Fahr's Syndrome.

Fahr's syndrome is a rare neurodegenerative disorder characterized by symmetric bilateral calcifications in the basal ganglia. While this is largely a hereditary disease with autosomal dominant inheritance, a small percentage is sporadic in nature with no metabolic or other underlying causes identified. Fahr's syndrome has both neurological and psychiatric manifestations that include movement abnormalities, seizures, psychosis, and depression. Approximately 40% of patients with basal ganglia calcification present with psychiatric symptoms including mania, apathy, or psychosis. We present a case of a 50-year-old woman with no previous medical or psychiatric history who presented with an altered mental status that progressed to psychosis over three years. On one admission, the patient was found to have elevated liver enzymes and a positive antinuclear antibody panel but was without electrolyte abnormalities or movement disturbances. The patient was subsequently diagnosed with unspecified psychosis in the emergency department, which was later revised to Fahr's syndrome confirmed by neuroimaging. This report discusses her presentation, clinical symptoms, and management of Fahr's syndrome. Above all, it underscores the importance of complete workup and adequate follow-up of middle-aged and elderly patients with cognitive and behavioral disturbances, as Fahr's syndrome can be elusive in the early stages.

Sociodemographic Attributes and Prevalence of Arrest With Possession of Substances in Incarcerated Population in the United States.

Background and objectives In recent years, there has been an increase in the US imprisonment rate. A substantial percentage of those incarcerations are for drug-related offenses. The authors investigated the relationship between the pattern of substance use and drug-related offenses across a broad spectrum of various sociodemographic attributes of the incarcerated population in the United States. Methods Cross-sectional data from the 2016 Survey of Prison Inmates conducted by the Bureau of Judicial Statistics were extracted with inmates who reported possession of a drug at the time of arrest as a primary outcome of interest. Using SAS 9.4 statistical software (SAS Institute Inc., Cary, USA), the authors used multivariate analyses to determine the odds ratios between various sociodemographic attributes of the inmates and possession of substance at the time of the arrest. Logistic regression analysis for age groups in relation to substance possession at the time of arrest is presented in the form of an adjusted odds ratio and their respective confidence interval at p ≤0.5. Results Out of the total 23,798 inmates who reported possession of a drug at the time of arrest, 34.07% were Non-Hispanic Whites, and 31.5% were within the age group of 25-34 years. Only 59.47% of inmates were employed 30 days before the arrest, and 58.02% had less than a high school education. Different patterns of drug use were linked with different types of drugs found in their possession at the time of the arrest. Possession of cannabis at the time of arrest was highest in the age group 18-24 years compared to other age groups (odds ratio: 1.362; 95% CI: 1.159 - 1.602). Inmates with a history of stimulant or hypnotic use were more likely to have another psychoactive substance during a time of the arrest. Only 8.46% of inmates had psychiatric and psychological treatment as part of their sentence. Conclusions A large proportion of incarcerations in the US is because of drug-related offenses, with most of the burden on the younger age group. Inmates should receive psychiatric and psychological treatments for substance use as part of their sentencing while in prison and after release as a form of targeted intervention for this vulnerable group.

Comorbid Substance Use and Mental Health Disorders: Prior Treatment/Admission as a Predictor of Criminal Arrest Among American Youths.

BACKGROUND: There is a dearth of literature with regards to substance use disorder (SUD) treatment outcomes and criminal arrest relationships. AIM: We aimed to examine the association between criminal arrest within a month prior to SUD treatment admissions among 12- to 24-year-old Americans and the role of recurrent or prior SUD treatment. METHODS: The 2017 United States Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Episode Data Set - Admissions (TEDS-A; N = 333,322) was used for this analysis. Prevalence odds ratios from the multivariate logistic regression analyses were used to determine associations between recurrent or prior SUD treatment and criminal arrest one month before admission, adjusting for selected independent variables. RESULTS: Prior history of SUD treatment remained associated with past criminal arrest (adjusted OR = 0.972; 95% CI: 0.954-0.991; P = 0.004) after adjusting for gender, marital status, employment status, and source of income. Comorbid SUD-mental disorder was associated with past criminal arrest (adjusted OR = 1.046; 95% CI: 1.010-1.083; P = 0.012) after adjusting for gender, marital status, employment status, education, and source of income. CONCLUSION: Our study shows that there is a protective association between history of previous substance treatment re-admissions and its relationship with criminal arrest one month before admission.

Posterior Reversible Encephalopathy Syndrome (PRES) in a Patient with Opioid Use Disorder.

Posterior Reversible Encephalopathy Syndrome (PRES) is a characteristic clinical radiographic syndrome with diffuse structural alteration of cerebral white matter secondary to myelin damage with diverse and multifactorial etiologies. It can present with acutely altered mentation, somnolence or occasionally stupor, vision impairment, seizures, and sudden or chronic headaches that are not focal. The pathophysiology remains unclear, but mechanisms involving endothelial injury and dysregulation of cerebral autoregulation have been purported. We report the case of a 36-year-old male with a history of heroin use disorder, who was admitted to our hospital for opioid withdrawal. CT head without contrast and MRI with and without gadolinium showed significant white matter disease in both cerebral hemispheres and cerebellum. He was diagnosed with Posterior Reversible Encephalopathy Syndrome secondary to heroin use and managed on the medical floor in collaboration with the neurology team. His clinical symptoms improved and he was discharged after six weeks. To our knowledge, this case did not present with the risk factors for PRES reported in the literature. For patients with heroin use disorder who present with an altered mental status, PRES should be highly suspected. The diagnosis and management require collaboration between psychiatry and neurology.

Catatonia Presentation as a Rare Alcohol Withdrawal Symptom in a Patient With No Past Psychiatry History: A Case Report.

A complicated alcohol withdrawal syndrome (AWS) includes epileptic seizures and/or delirium tremens (DT). However, there is still a dearth of literature for catatonia as a consequence of AWS especially in terms of clinical reports. Secondly, the few noted reported cases in the literature were mainly of non-American populations. Hence, we present the case of a middle-aged woman with no past psychiatric history admitted for psychosis and altered sensorium with delayed catatonic features in the context of a history of alcohol use disorder. Ms. M., a 44-year-old African American female with no past psychiatric history but a past medical history of gastric bypass surgery, presented to the psychiatric emergency department via emergency medical service due to roaming the street because of acute onset of altered mental status and psychotic features. She had a Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA) score of 33 following last alcohol use a few hours prior to presentation. While on the inpatient unit, the patient had an isolated episode of catatonic stupor despite being administered lorazepam 2mg every four hours as needed. Supportive medical staff should also be aware of catatonia as a rare manifestation of alcohol withdrawal. A persistent, thorough medical workup and evidence-based "investigative" history gathering can help elucidate the source of the presenting symptom in this patient population.

Clozapine Response for Vocal Tics in Schizophrenic Patients: A Case Report With Literature Review.

Antipsychotics have been documented in the literature as the most effective pharmacological treatment for tics thus far. Additionally, evidence in the literature has shown that typical and atypical antipsychotics are effective for the treatment of tic disorders in patients who are diagnosed with schizophrenia and other psychiatric illnesses. This evidence is typified as atypical antipsychotic medications, such as risperidone, aripiprazole, and olanzapine, have been documented as being effective for motor tics, particularly in Tourette's syndrome. Despite the level of evidence with regard to antipsychotics, there is no published literature on the role of clozapine-based treatment for persistent vocal tics in schizophrenia. We present a case of severe adult-onset persistent vocal tics in a schizophrenic patient who was admitted for acute psychotic exacerbation. The patient's vocal tics as well as his comorbid psychotic symptoms were not responsive to risperidone and paliperidone. The combination of risperidone with clozapine for psychosis showed improvements in his symptoms. In addition, the patient's tics showed excellent response to risperidone and clozapine combination therapy. He was subsequently discharged to the community with clozapine 125 mg twice daily and paliperidone palmitate 156 mg every 28 days. The patient was psychiatrically stable without vocalization at the time of discharge. We suggest that clozapine augmentation therapy could be an approach in treatment-resistant vocal tics among schizophrenic patients who are refractory to atypical antipsychotics.

Levetiracetam Induced Behavioral Abnormalities in a Patient with Seizure Disorder: A Diagnostic Challenge.

Levetiracetam is a second-generation antiepileptic drug that is chemically unrelated to other antiepileptic drugs. Levetiracetam is a broad-spectrum antiseizure medication that is approved as an adjunctive therapy in the treatment of partial and generalized tonic-clonic seizures in children and adults with epilepsy. The mechanism by which Levetiracetam induces behavioral changes remains unknown. Its proposed mechanism of action involves binding to synaptic vesicle protein 2A (SV2A) and this leads to neuronal inhibition. Though, the drug has a convenient dosing regimen and is relatively well tolerated, neuropsychiatric side effects can emerge beyond the initial titration period and may be the most common reason for drug discontinuation. Levetiracetam has been reported to cause varying degrees of psychiatric adverse effects including behavioral disturbance such as agitation, hostility and psychosis, and mood symptoms and suicidality. It has been shown to induce psychiatric side effects in 13.3% of adults, with only 0.7% presenting with severe symptoms such as depression, agitation, or hostility. The prevalence rate of development of psychosis in these patients is estimated to be about 1.4%. A review of literature has demonstrated a relative correlation between Levetiracetam use and the development of neurobehavioral symptoms which is increased in predisposed individuals. This research describes the case of a 28-year-old woman with seizure disorder and a psychiatric history of schizoaffective disorder who developed aggressive behavior, paranoia, and severe hostility following administration of Levetiracetam 750 mg orally twice daily. She developed acute behavioral symptoms which were reversed with cessation of Levetiracetam. This report emphasizes the need for developing an appropriately high index of suspicion in promoting surveillance and prompt identification of behavioral adverse effects associated with Levetiracetam especially in high-risk patient population.

Cannabis Use in Inpatients With Schizophrenia Spectrum Disorders at a Community Hospital.

BACKGROUND: Cannabis is the second most used recreational drug in the United States and one of the most used substances in patients with schizophrenia spectrum disorder (SSD). Unfortunately, the increased use is likely to continue as more states legalize recreational use of cannabis. Although the association between cannabis and schizophrenia has been studied extensively, the understanding of the relationship is still evolving. In this study, we sought to determine the prevalence and potential factors associated with cannabis use (CU) among inpatients with SSD at a community teaching hospital. METHODS: We performed a retrospective review of the electronic medical charts of patients discharged from the psychiatric unit of our hospital from July 1, 2017 through October 31, 2017. Patients were included in this study if: 1) They were ≥ 18 years old; 2) They had discharge diagnosis of SSD; and 3) They had urine drug testing performed. Pertinent sociodemographic and clinical variables, including substance use status and hospital length of stay (LOS), were abstracted. Univariate frequencies and summary statistics were performed. Odds ratios (ORs) were determined by logistic regression analysis of bivariate and multivariate analyses. RESULTS: Three hundred sixty-five (52.2%) patients had a discharge diagnosis of SSD, and only 322 had urine toxicology result for cannabinoids and were included in analysis. Of the 322 patients, 41.5% (n = 133) screened positive for cannabinoids. Of the 133 patients, 78% were African American, 15% were Hispanic and 5% were White; 77% were male and the median age was 36 years. Bivariate analyses showed tobacco use (OR: 2.8, 95% confidence interval (CI): 1.7 - 4.6), alcohol use (OR: 3.4, 95% CI: 2.9 - 7.0), younger age (OR: 2.8, 95% CI: 1.8 - 4.5), male gender (OR: 2.9, 95% CI: 2.2 - 3.2), unemployment (OR: 3.91, 95% CI: 3.49 - 7.35), homelessness (OR: 3.18, 95% CI: 2.76 - 3.84) and LOS (OR: 3.46, 95% CI: 2.93 - 4.31) were significantly associated with CU. Result of multivariate analysis was similar to that found in bivariate analysis. CONCLUSIONS: CU appears to be prevalent among patients with SSD. Clinicians and public health professionals are encouraged to understand the health implications of its use in patients with mental illness especially against the backdrop of current marijuana laws.

Two Cases of Persistent Complex Bereavement Disorder Diagnosed in the Acute Inpatient Unit.

Pathological grief has been noted to have considerable adverse effects on affected individuals. In the DSM-5, the diagnosis of complicated grief is included under conditions for further study as Persistent Complex Bereavement Disorder (PCBD). PCBD can be easily missed because it is a relatively new and developing diagnosis. It can also be overlooked when it is comorbid with more common psychiatric disorders. We present 2 patients with PCBD diagnosed in the inpatient unit, while the patients were admitted for comorbid disorders. PCBD contributed immensely to both patients' suffering and decline in functioning. This report highlights the presentation, diagnoses, and management of these patients. We theorize that paying attention to separation distress, reactive distress to loss, and identity disruption in individuals who have been bereaved for over 12 months will enhance treatment specificity and lead to better patient outcomes.

Patterns of Vitamin D Deficiency in a Community Outpatient Psychiatric Practice: a Real-World Evaluation of Treatment Gaps.

Vitamin D is traditionally recognized for its role in bone mineralization but recent observations suggest additional pertinent functions in neuronal biology. The present study examines the rate and pattern of Vitamin D deficiency in the outpatient mental health clinic of a community teaching hospital as well as the vitamin D supplementation practices of outpatient psychiatrists. Participants include 148 consecutive psychiatric outpatients. Individuals with conditions that alter the metabolism of vitamin D were excluded from the study as are those who may be taking medications that influence Vitamin D metabolism. Statistical analysis was performed using the SPSS 25th edition, statistical significance set at p < 0.05. The majority of patients in the study were between 41 and 65 years old (n = 91, 61.5%), African American (n = 120, 81.1%) and female (n = 80, 54.1%). The median level is 23.7 ng/ml. As defined by the Endocrine Society's Clinical Practice Guidelines, 68.2% of the population had insufficient and deficient Vitamin D levels (32.4% and 35.8% respectively), 62.4% of whom were not prescribed any Vitamin D supplementation and of this untreated group, 84% were African Americans. No clinical or demographic characteristics showed any statistical difference in both the "treated" and "not treated groups". Logistic regression did not reveal any significant predictors for Vitamin D deficiency. Vitamin D deficiency remains a significant issue among patients with psychiatric disorders. Our findings show gaps in Vitamin D deficiency treatment and recommend that future studies examine physician prescription practices in light of the racial disparity in Vitamin D deficiency treatment oberved in this study.

Use of Long-Acting Injectable Antipsychotic in an Inpatient Unit of a Community Teaching Hospital.

BACKGROUND: Individuals with Schizophrenia Spectrum Disorders (SSD) often experience significant impairment in educational, occupational, and psychosocial functioning. The clinical benefit of long-acting injectable antipsychotics (LAIs) in the management of patients with SSD is well established. SSD patients who are nonadherent to treatment have lower disease relapse and readmission rates when prescribed a LAI, compared to oral antipsychotics. Despite the reported advantages of LAIs, their prescription rates in clinical settings remain low. This pilot study aimed to determine the pattern of LAI prescription in psychiatric inpatients of a teaching community hospital in Brooklyn, New York. METHODS: A retrospective review of the charts of patients discharged from the psychiatric units of the hospital from September 1, 2017, through September 30, 2017, was conducted. Frequencies and proportions for demographic and disease-related characteristics were calculated. Pertinent continuous variables were recoded into categorical variables. Chi-square-tests or Fisher's exact tests were performed for categorical variables. The one-sample Shapiro-Wilk test (for sample size < 50) was used to check for the normality of distribution of continuous variables. Statistical significance was defined as p ≤ 0.05. RESULTS: Forty-three (70%) of the patients discharged from the inpatient unit during the study period had SSD and were eligible for a LAI. Their ages ranged from 20 to 71 years (mean = 41 years), and more than two-thirds were male. Less than half of the eligible patients (n = 19; 44%) were prescribed a LAI, most of whom were male (n=16; 84%). An association between age group (patients aged 41 years or younger) and LAI use was observed (p < 0.05), while gender, employment status, living arrangement, length of hospital stay, recent hospitalization, and cooccurring substance use disorder were not. CONCLUSION: LAI prescription rate at the inpatient psychiatric unit of the hospital was marginally higher than those reported in most studies. Age appears to influence LAI use during the study period. Initiatives that increase LAI prescription rate for all eligible patients admitted to inpatient psychiatric unit should be encouraged.

Neuropsychiatric Manifestations of Partial Agenesis of the Corpus Callosum: A Case Report and Literature Review.

Agenesis of the corpus callosum is a rare congenital defect that has been linked to psychiatric disorders, cognitive deficits, learning disabilities, and developmental delays. We present the case of a patient with partial agenesis of the corpus callosum who exhibits depressed mood, transient loss of memory, and history of cognitive, social, and behavioral disturbances that developed during his childhood. Recent and pertinent literature was reviewed and the agenesis of the corpus callosum and its associated neuropsychiatric manifestations are discussed.

Olfactory Reference Syndrome with Suicidal Attempt Treated with Pimozide and Fluvoxamine.

The core symptomatology of the Olfactory Reference Syndrome (ORS) is characterized by a preoccupation with the belief that one emits an offensive odor, albeit not perceived by others. The present case is that of a 75-year-old African American woman, with an unclear past psychiatric history, who was brought into our Emergency Room after a suicide attempt. The patient reported a three-year history of a "rotten" smell from her vagina. She adamantly believes that she smells despite being told otherwise by people. The patient reported a trial of several feminine products to get rid of this smell and multiple visits to specialists but her symptoms persisted. Her symptoms involved a significant depressed mood and deterioration in her social functioning, interpersonal relationships, and self-care. She was constantly in the shower and had stopped leaving her apartment due to worries that people might smell her vagina. The culmination of her distress was the suicidal attempt, for which she was brought to the hospital. She was admitted to the inpatient psychiatric unit and started on Pimozide and Fluvoxamine. The patient made remarkable progress within a few days on admission and in the course of her hospitalization. Follow-up in our outpatient clinic shows that the patient remains completely asymptomatic with significant progress in her social functioning.

Tobacco and Substance Use among Psychiatric Inpatients in a Community Hospital: Cessation Counseling, Correlates, and Patterns of Use.

BACKGROUND: Epidemiological and experimental models have been applied to describe the disproportionately high prevalence of tobacco use in patients with mental illness. This observed association has become a dire public health concern. The main objective of the present study was to examine the provision of tobacco treatment strategies in a community teaching hospital serving a predominantly underserved African American population. METHODS: The study was designed as a retrospective review of eight hundred and thirty patients admitted to the inpatient psychiatric units. RESULTS: 52.2% of the entire cohort described themselves as current smokers. Gender, primary psychiatric diagnosis, and urine toxicology showed significant differences in the tobacco smoking and nontobacco smoking groups (P<0.05). Almost all current tobacco smokers (91.9%) had tobacco cessation counseling during the course of their hospitalization, but only 64% were offered treatments for tobacco dependence. More than half (57.9%) of the 680 participants who had urine toxicology reports were positive for any illicit substance with cannabis and cocaine being the most frequently used (32.4% and 23.2%). Direct logistic regression revealed gender, psychiatric diagnosis, and substance use as the only significant predictors of tobacco smoking among our cohort (P= 0.021, 0.001, and 0.001, respectively). CONCLUSIONS: Tobacco screening, cessation counseling, and treatment continue to be a challenge in community psychiatric hospitals and need increased focus in the comprehensive management of patients with psychiatric disorders. The strong association between tobacco smoking and other substance use lends itself to the hypothesis that tobacco smoking debut prevention may be an effective public health strategy for addressing illicit drug use.

Drugs of Abuse.

Drug abuse and its consequences remain a significant public health issue. An increasing number of individuals are present in the emergency room with life-threatening drug intoxication. It is imperative that emergency room physicians are cognizant of the signs, symptoms, and treatment to improve the chances of early recognition and treatment. As a result, the proportion of lives saved will increase significantly. In this article, we present some of the most prevalent life-threatening drugs that lead to emergency room admission. The signs, symptoms, and treatment modalities are discussed.