Anti-NMDAR Encephalitis: A Multidisciplinary Approach to Identification of the Disorder and Management of Psychiatric Symptoms.

BACKGROUND: The novelty of anti-NMDA receptor encephalitis, for which somatic treatments have only recently been developed, has led to a lack of information on assessment and treatment of its variable behavioral manifestations. METHOD: In this article, we discuss 4 challenging cases of anti-NMDAR encephalitis, focusing on the importance of a multidisciplinary approach to identification and management of the disorder and the necessity of close collaboration in the acute hospital setting for management of the behavioral symptoms. CONCLUSION: The cases we discuss highlight some of the medication and nonpharmacologic treatment strategies that may facilitate management of psychiatric symptoms, both while the medical workup is ongoing and after the diagnosis has been confirmed.

Aspirin misuse: a case report.

Aspirin-use disorder is an underreported condition. Identification of the signs and symptoms of aspirin misuse are important in light of prevalent non-prescribed medicine/over-the-counter medication (NPM/OTC) misuse. We discuss here the case of a patient with a history of chronic aspirin misuse who presented to the emergency department with salicylate intoxication and described elation secondary to deliberate aspirin consumption. This case highlights the importance of screening for NPM/OTC medication misuse in at-risk populations.

Delusional parasitosis on the psychiatric consultation service - a longitudinal perspective: case study.

BACKGROUND: Delusional parasitosis is infrequently seen in hospital-based consultation-liaison psychiatry. AIMS: Although there are many publications on delusional parasitosis, this report reviews a unique case that was diagnosed during a hospital admission and treated over the next 36 months. METHOD: Case report and literature review. RESULTS: This case report describes a 65-year-old man who was diagnosed with delusional parasitosis during a hospital admission for congestive heart failure and acute kidney injury. A longitudinal description of the patient's condition during the hospital stay and in the 36 months following discharge, during which time he was treated by a consultation psychiatrist, is provided. CONCLUSIONS: In discussing the treatment of a challenging presentation, this case demonstrates the opportunity for consultation psychiatrists to initiate care in patients who might not otherwise seek psychiatric services. Patients with somatic delusions represent one group of patients who are unlikely to independently seek psychiatric treatment. DECLARATION OF INTEREST: None. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Medical Students' Perceptions of Electroconvulsive Therapy: The Impact of Direct Exposure.

OBJECTIVES: Although electroconvulsive therapy (ECT) has proven to be an efficacious treatment, the available literature indicates that some medical students have unfavorable perceptions of ECT. To the authors' knowledge, prior studies have not examined the impact of medical student participation in ECT on their perceptions of this modality. To determine if direct participation and observation affect medical students' perceptions of ECT differently, these 2 teaching methods were compared. METHODS: Participants were third year medical students who volunteered to complete 2 questionnaires to examine their perceptions regarding various psychiatric treatment modalities including ECT. The first questionnaire was administered before the start of the clerkship, and the second was given before the conclusion of the clerkship. RESULTS: Most participants expressed a substantially more favorable view of ECT in the second questionnaire compared with the first. This change occurred similarly regardless of whether medical students observed or participated in ECT. Medical students' perceptions of the other treatment modalities did not change substantially during the study period. CONCLUSIONS: The results of the current study do not reflect the superiority of direct participation over observation in improving medical students' perceptions of ECT. This may indicate that both instructional methods are equivalent. Alternatively, these results may reflect a ceiling effect because most participants expressed a very positive view of ECT.

Psy-feld: An Innovative Didactic Using the TV Show Seinfeld to Teach Delusional Disorder Subtypes.

OBJECTIVE: The primary purpose of this article is to introduce Psy-feld, an innovative didactic used to review mental disorders through discussion of the interpersonal relationships of the fictional characters created in Larry David's situational comedy, Seinfeld. To introduce this novel didactic, several peripheral Seinfeld characters were selected, who while not afflicted with a psychotic disorder, demonstrate traits that serve to facilitate discussion to review the different subtypes of Delusional Disorder. METHODS: Psy-feld is a 30-min faculty-facilitated didactic where a selected episode of the sitcom allows for review of multidisciplinary content areas considered germane to the practice of psychiatry. At Rutgers-Robert Wood Johnson Medical School, 104 third-year medical students rotated on the Consultation-Liaison Service from July 2011-March 2014 and participated in Psy-feld. RESULTS: Of the 104 students who participated in Psy-feld, 99 completed surveys on the didactic. Students found the didactic to be of high quality, believed it enhanced their learning, and thought that it prepared them for their final SHELF exam. Students also found it enjoyable and preferred the didactic to more traditional forms of teaching such as large group lectures. CONCLUSIONS: Psy-feld is an example of an innovative teaching method that medical students found informative in reviewing teaching points of Delusional Disorder.

Electroconvulsive therapy performed 6 days after repair of an intracranial aneurysm using a liquid embolic system.

There exists a small, but growing body of literature that describes electroconvulsive therapy (ECT) performed on patients with intracranial aneurysms. These reports include patients with unrepaired aneurysms and others in which aneurysms have been repaired by clipping or coil embolization methods. To date, these cases have described favorable results and minimal complications. We describe the case of a 34-year-old woman, who received ECT 6 days after balloon-assisted embolization, with Onyx HD-500, of a 7-mm aneurysm of the ophthalmic segment of her left internal carotid artery. The patient experienced a significant reduction in depressive symptoms and tolerated a series of 8 treatments with no aneurysm-related complications. To our knowledge, this represents the earliest administration of ECT after repair of an intracranial aneurysm reported in the literature. Also, this is the only report in the literature of ECT performed after an intracranial aneurysm was repaired using the Onyx Liquid Embolic System.

A pilot, open-label safety study of quetiapine for treatment of moderate psychotic agitation in the emergency setting.

OBJECTIVE: The goal of this pilot study was primarily to explore the safety and, secondarily, the efficacy of the use of "prn" quetiapine for treatment of moderate agitation accompanied by psychosis in an emergency department setting. METHODS: This was an open-label study in which 20 patients with psychotic agitation were treated in the emergency department with 100, 150, or 200 mg of quetiapine. Physicians who were unaffiliated with the study established the diagnoses and selected the doses to be used for each patient. A rater who was blinded to the dose performed the assessments. The primary safety measure was the onset of orthostatic hypotension. The primary efficacy measure was a 40% reduction in scores on the Positive and Negative Syndrome Scale-Excited Component (PANSS-EC) over 120 minutes. The secondary efficacy measure was a reduction of 2 points or more on the Behavioral Activity Rating Scale (BARS) at 120 minutes post-dose. All subjects provided written informed consent. RESULTS: With regard to safety outcomes, 40% of subjects exhibited orthostasis by 120 minutes, although only 25% of these patients described clinically significant symptoms. In terms of efficacy, 50% of subjects experienced at least a 40% reduction in PANSS-EC scores at 2 hours, while 68.8% showed reductions of 2 points or more in scores on the BARS over the same time period. CONCLUSION: Quetiapine demonstrated some efficacy as a sedative agent in the emergency setting, although no clear dose-response pattern emerged over the narrow dose range tested. Orthostasis was common and did not correlate with dosing. This small study did not support the use of quetiapine to treat acute agitation in potentially volume-depleted patients.

Innovations: Emergency psychiatry: Relative accuracy of breath and serum alcohol readings in the psychiatric emergency service.

Management of changes in physiologic and mental status due to alcohol is a core skill utilized in the psychiatric emergency service. Blood alcohol concentrations are commonly approximated by measuring breath alcohol at triage. However, the blood-breath ratio is highly variable, and breath tests have produced lower readings than blood tests. The authors assessed the accuracy of breath alcohol readings at triage in a medical emergency department compared with subsequent serum alcohol levels taken in the psychiatric emergency service. The mean breath ethanol concentration was significantly lower than the mean corrected serum ethanol concentration (.15+/-.05 grams per 210 liters and .23+/-.05 grams per 100 milliliters, respectively). The relative accuracy of breath alcohol tests decreased with increasing serum alcohol. Although its low false-positive rate makes the breath test acceptable for legal purposes, the blood alcohol level is more appropriate for clinical use in emergency settings, because breath tests can underestimate the degree of toxicity.

Behavioural manifestations of anabolic steroid use.

The use of anabolic androgenic steroids (AAS) for gains in strength and muscle mass is relatively common among certain subpopulations, including athletes, bodybuilders, adolescents and young adults. Adverse physical effects associated with steroid abuse are well documented, but more recently, increased attention has been given to the adverse psychiatric effects of these compounds. Steroids may be used in oral, 17alpha-alkylated, or intramuscular, 17beta-esterified, preparations. Commonly, steroid users employ these agents at levels 10- to 100-fold in excess of therapeutic doses and use multiple steroids simultaneously, a practice known as 'stacking'. Significant psychiatric symptoms including aggression and violence, mania, and less frequently psychosis and suicide have been associated with steroid abuse. Long-term steroid abusers may develop symptoms of dependence and withdrawal on discontinuation of AAS. Treatment of AAS abusers should address both acute physical and behavioural symptoms as well as long-term abstinence and recovery. To date, limited information is available regarding specific pharmacological treatments for individuals recovering from steroid abuse. This paper reviews the published literature concerning the recognition and treatment of behavioural manifestations of AAS abuse.

Fatalities associated with therapeutic use and overdose of atypical antipsychotics.

Since 1989, several novel antipsychotic drugs have become available for use including clozapine, risperidone, olanzapine, quetiapine and ziprasidone. These agents represent a substantial improvement in the treatment of schizophrenia and related disorders and are considered to have a favourable adverse effect profile relative to traditional antipsychotics. Nonetheless, in rare cases, people have died as a result of taking atypical antipsychotic drugs at therapeutic and supratherapeutic doses. Toxic doses of atypical antipsychotics are highly variable: some patients have died while taking therapeutic doses and others have survived massive overdoses. Toxicity may be increased by coingestion of other agents, particularly drugs with similar metabolic pathways. Atypical antipsychotics are metabolised predominantly by cytochrome p450 (CYP) isoenzymes, particularly CYP1A2 (clozapine and olanzapine), CYP3A4 (clozapine, quetiapine and ziprasidone) and CYP2D6 (olanzapine and risperidone). Concurrent prescription of other drugs that inhibit these isoenzymes may increase the probability of adverse events in patients taking atypical antipsychotics. Deaths due to atypical antipsychotic toxicity are often related to cardiovascular complications, but pulmonary, neurological, endocrine and gastrointestinal complications have also caused fatalities. Prevention and management of atypical antipsychotic overdose are of increased clinical relevance as prescription of these drugs increases.

Pharmacological treatment of psychotic agitation.

The presentation of agitated psychotic patients to psychiatric emergency services is a common occurrence. The traditionally accepted treatment for such patients involves the use of a typical antipsychotic, generally haloperidol. More recently benzodiazepines, such as lorazepam, have been used in combination with antipsychotics due to their sedative properties and relatively benign adverse effect profiles. Standard clinical protocol at many institutions involves the intramuscular administration of 5 to 10mg of haloperidol and 1 to 2mg of lorazepam. Atypical antipsychotics have gained acceptance as first-line treatments for psychotic disorders. These drugs are seen as an improvement over traditional antipsychotics because of their increased efficacy and reduced extrapyramidal effects. The utility of atypical antipsychotics in the emergency setting has been relatively unexplored because slow titration schedules or dose-limiting adverse effects for some members of the class have made this form of treatment impractical. However, the recent availability of oral liquid and rapidly dissolving tablet preparations of some atypical agents has provided useful alternatives in some cases. Nevertheless, for many patients a parenteral drug is the only desirable or feasible treatment option. Intramuscular preparations of the atypical antipsychotics olanzapine and ziprasidone have been developed, and are close to launch in the US. The availability of a rapid-acting intramuscular preparation of an atypical antipsychotic could represent a significant advancement in the treatment of agitation associated with psychosis.

Treatment of Comorbid Tuberculosis and Depression.

Tuberculosis (TB) remains a leading infectious cause of mortality worldwide. While the overall prevalence of TB in the United States has declined in the general population, certain groups remain at high risk, including the homeless, those who are HIV seropositive, individuals with a history of alcohol or drug abuse, and immigrants from a country in which TB is endemic. Many recipients of psychiatric services possess 1 or more of these risk factors, and consequently TB may be overrepresented in this population. Conversely, psychiatric illness may develop subsequent to TB infection. Mood disorders seem to be particularly common in TB patients compared with those with other medical diagnoses. It is important that primary care physicians understand the high prevalence of mental illness in TB patients so that proper treatment provisions can be implemented. Likewise, it is important for psychiatrists to understand the clinical manifestations of TB so that when a patient presents with symptoms of TB proper precautions can be taken and appropriate referrals can be made. This article integrates information concerning mental illness in TB patients with diagnostic and treatment guidelines for TB. Brief suggestions are offered for the treatment of TB patients with comorbid mental illness.