The Journal of Neuropsychiatry and Clinical Neurosciences Current Issue

Update on Mild Traumatic Brain Injury: Neuropathology and Structural Imaging

Taber KH, Hurley RA. — Fri, 01 Mar 2013 00:00:00 GMT

In this installment of the Windows to the Brain series, the authors present detailed, graphic representation of neuronal injury for all levels of traumatic brain injury (TBI), including mild. We see representation of the swollen axon profiles characteristic of the “diffuse axonal injury” that produces transient focal deformations resulting from applied forces such as angular acceleration, pressure, and ballistic trauma, and, over time, the localized swelling that can become sufficient to rupture the axon. A challenge for the clinical follow-up of mild TBI is the presence of considerable differences across patients in the anatomic distribution of affected areas.

Hippocampal Volumes in Patients With Chronic Combat-Related Posttraumatic Stress Disorder: A Systematic Review

Childress JE, McDowell EJ, Dalai VK, et al. — Sun, 01 Dec 2013 00:00:00 GMT

The authors and others have recently demonstrated that veterans with chronic combat-related PTSD (CR-PTSD) have a twofold increased risk of dementia. To understand this increased incidence, they performed a systematic review of the literature on neuroanatomical differences between veterans with chronic CR-PTSD and control subjects (22 included studies). The hippocampus was most commonly and consistently reported to differ between groups, thereby suggesting the hypothesis that PTSD is associated with smaller hippocampi, which increases the risk for dementia. However, an alternate hypothesis is that smaller hippocampal volumes are a preexisting risk factor for PTSD and dementia. Studies are clearly needed to differentiate between these important possibilities.

What Neuropsychiatrists Would Like to See in DSM-5

Campbell JJ. — Fri, 01 Mar 2013 00:00:00 GMT

The foundation of neuropsychiatry rests upon the relationship between the brain and behavior. Neuropsychiatrists evaluate patients with neurological disorders and general medical conditions who are experiencing psychiatric symptoms. Knowledge of functional neuroanatomy of the central nervous system is essential to offer accurate diagnoses and treatments.

Decision-Making in Diabetes Mellitus Type 1

Rustad JK, Musselman DL, Skyler JS, et al. — Fri, 01 Mar 2013 00:00:00 GMT

Decreased treatment adherence in patients with diabetes mellitus type 1 (type 1 DM) may reflect impairments in decision-making and underlying associated deficits in working memory and executive functioning. Other factors, including comorbid major depression, may also interfere with decision-making. The authors sought to review the clinically relevant characteristics of decision-making in type 1 DM by surveying the literature on decision-making by patients with type 1 DM. Deficiencies in decision-making in patients with type 1 DM or their caregivers contribute to treatment nonadherence and poorer metabolic control. Animal models of type 1 DM reveal deficits in hippocampal-dependent memory tasks, which are reversible with insulin. Neurocognitive studies of patients with type 1 DM reveal lowered performance on ability to apply knowledge to solve problems in a new situation and acquired scholarly knowledge, psychomotor efficiency, cognitive flexibility, visual perception, speed of information-processing, and sustained attention. Other factors that might contribute to poor decision-making in patients with type 1 DM, include “hypoglycemia unawareness” and comorbid major depression (given its increased prevalence in type 1 DM). Future studies utilizing novel treatment strategies to help patients with type 1 DM make better decisions about their disease may improve their glycemic control and quality of life, while minimizing the impact of end-organ disease.

Man Versus Machine: Comparison of Radiologists’ Interpretations and NeuroQuant ® Volumetric Analyses of Brain MRIs in Patients With Traumatic Brain Injury

Ross DE, Ochs AL, Seabaugh JM, et al. — Fri, 01 Mar 2013 00:00:00 GMT

NeuroQuant® is a recently developed, FDA-approved software program for measuring brain MRI volume in clinical settings. The purpose of this study was to compare NeuroQuant with the radiologist’s traditional approach, based on visual inspection, in 20 outpatients with mild or moderate traumatic brain injury (TBI). Each MRI was analyzed with NeuroQuant, and the resulting volumetric analyses were compared with the attending radiologist’s interpretation. The radiologist’s traditional approach found atrophy in 10.0% of patients; NeuroQuant found atrophy in 50.0% of patients. NeuroQuant was more sensitive for detecting brain atrophy than the traditional radiologist’s approach.

Neuropsychiatric Disease in Patients With Periventricular Heterotopia

Fry AE, Kerr MP, Gibbon F, et al. — Sun, 01 Dec 2013 00:00:00 GMT

Periventricular heterotopia (PH) is a disorder of neuronal migration. Previous clinical reports of PH have largely focused on the seizure-related and neurodevelopmental consequences of this condition. The authors report on four unrelated individuals with PH, with particular emphasis on their behavioral and psychiatric morbidity. A review of the literature suggests that neuropsychiatric presentations are an underrecognized consequence of PH. Clinicians need to be alert to psychiatric complications associated with PH and related disorders of neuronal migration.

The Glucocorticoid Antagonist RU-486 Suppresses HIV Infectivity and Replication

Benton TD, Lynch KG, Dubé B, et al. — Fri, 01 Mar 2013 00:00:00 GMT

The effects of RU-486, a glucocorticoid antagonist, on HIV infection and replication in depressed and nondepressed women were studied using ex vivo models of HIV infection. RU-486 treatment of cells decreased HIV reverse transcriptase activity of monocyte-derived macrophages in a model of acute infectivity. RU-486 also decreased HIV viral replication in the chronically-infected T-cell line ACH-2, but not in the promonocyte cell line U1. No differences were associated with depression status. Thus, glucocorticoid antagonism may suppress HIV infectivity and replication ex vivo. Studies to determine the role of glucocorticoid antagonists in the host defense against HIV should be performed.

Association of Interleukin 2 ( IL-2 ), Interleukin 6 ( IL-6 ), and TNF-alpha ( TNFα ) Gene Polymorphisms With Paranoid Schizophrenia in a Polish Population

Paul-Samojedny M, Owczarek A, Kowalczyk M, et al. — Fri, 01 Mar 2013 00:00:00 GMT

Numerous reports have brought attention to the potential role of cytokines in schizophrenia. The aim of the study was to determine whether polymorphisms of IL-2, IL-6, and TNFα genes are risk factors for development of paranoid schizophrenia in a Polish population. Promoter polymorphisms of IL-6 (rs1800795), TNFα (rs1800629), and IL-2 (rs2069762) genes in patients (N=115) and controls (N=135) were genotyped by PCR-RFLP and AS-PCR methods, respectively. Genotype TT and allele T for IL-2 polymorphism, and genotype AA and allele A for TNFα polymorphism were found to be significantly associated with paranoid schizophrenia. Similarly, haplotypes CTA and GTA increased the risk (4.4 times and 5.9 times, respectively) of schizophrenia. To reveal associations between Positive and Negative Symptom Scale subscales and age at onset of schizophrenia, the authors used a novel method called Grade Correspondence Analysis. This analysis revealed that patients with early age at onset have higher scores on the Negative and General subscales of PANSS, and, in that group of patients, haplotype CTA was the most represented. As far as is known, this analysis was used for the first time with reference to genetic data.

BDNF val66met Polymorphism Is Associated With Age at Onset and Intensity of Symptoms of Paranoid Schizophrenia in a Polish Population

Suchanek R, Owczarek A, Paul-Samojedny M, et al. — Fri, 01 Mar 2013 00:00:00 GMT

The brain-derived neurotrophic factor (BDNF) is one of the candidate genes for schizophrenia. There is evidence that val66met polymorphism may be involved in the pathophysiology of schizophrenia. The authors genotyped val66met (rs6265) polymorphism of the BDNF gene in 208 inpatients with paranoid schizophrenia and 254 control subjects in a Polish population. There was no association between val66met polymorphism and development of paranoid schizophrenia in either men or women. However, an association was found between this polymorphism and age at onset and psychopathology of paranoid schizophrenia. Men with the val/met genotype had an earlier age at onset, and the val/val genotype predisposed to more severe symptoms, particularly on the General Psychopathology Scale of the Positive and Negative Symptoms Scale (PANSS-G). The analysis of PANSS single items has shown that patients with the val/met genotype had higher scores on a hallucinatory behavior item than those with other genotypes.

Does Tardive Dysmentia Really Exist?

Lavania S, Praharaj S, Bains H, et al. — Fri, 01 Mar 2013 00:00:00 GMT

Tardive dysmentia has been described as the behavioral equivalent of tardive dyskinesia in patients with schizophrenia. Its association with tardive dyskinesia and psychopathology has been controversial. The authors assessed 123 inpatients with chronic schizophrenia for presence of tardive dysmentia symptoms/signs. Psychopathology and tardive dyskinesia were also assessed. Of the group, 24 patients (19.5%) had at least one tardive dysmentia symptom/sign, whereas only 1 patient (0.8%) fulfilled the syndromal criteria for tardive dysmentia. Those with tardive dysmentia had higher psychopathology scores, higher Abnormal Involuntary Movement Scale total scores, higher number of women and family psychiatric illness, and higher rates of persistent tardive dyskinesia. Tardive dysmentia symptoms/signs are frequently seen in chronic schizophrenia, but the complete syndrome may be rare.

GABA Predicts Inhibition of Frequency-Specific Oscillations in Schizophrenia

Rowland LM, Edden RE, Kontson K, et al. — Fri, 01 Mar 2013 00:00:00 GMT

This study is the first to show a relationship between in-vivo brain gamma-amino butyric acid (GABA) levels and auditory inhibitory electrophysiological measures in schizophrenia. Results revealed a strong association between GABA levels and gating of the theta-alpha and beta activities in schizophrenia.

Initial Treatment Retention in Psychogenic Non-Epileptic Seizures

Baslet G, Prensky E. — Fri, 01 Mar 2013 00:00:00 GMT

This study investigated whether initial adherence to treatment in psychogenic epileptic seizures differed on the basis of mental health treatment modality and which subject characteristics were predictive of adherence. Initial adherence rates were 54% for combined treatment conducted in the same institution (integrated intervention) and 31% for psychotherapy and psychiatric management offered in different settings (divided intervention). Cognitive complaints and current exposure to antiepileptic drugs (AEDs) were more common among nonadherent patients, and being married (or having a live-in partner) was more common among adherent patients. A predictive model using the mentioned variables (intervention type, marital status, cognitive complaints, and concurrent use of AEDs) showed that this set of variables was predictive of adherence. Marital status and cognitive complaints were the significant contributors to prediction of adherence in the model.

The Clinical Significance of Bilateral Basal Ganglia Calcification Presenting With Mania and Delusions

Johnson JM, Legesse B, Camprodon JA, et al. — Fri, 01 Mar 2013 00:00:00 GMT

The authors present the case of a 37-year-old man who developed a psychotic manic episode and was found to have bilateral basal ganglia calcification (BGC). The authors present this case report along with a discussion of the literature on the neuropsychiatry of BGC.

A Case of Dual Dissociative and Re-Experiencing/Hyperarousal Subtypes in Childhood PTSD: A Neuropsychiatric Formulation

Perez DL, Hunt P, Trieu M. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: Posttraumatic stress disorder (PTSD) is characterized by re-experiencing phenomena, hyperarousal, avoidance, and emotional numbing after experiencing or witnessing life-endangering trauma. Trauma responses exhibit two hypothesized phenotypes: hyperarousal/re-experiencing and dissociative subtypes.^1,2 We present an illustrative case and neuropsychiatric formulation of dual dissociative and nondissociative PTSD symptomatology.

A Case of Early-Onset Obsessive-Compulsive Disorder With Musical Obsessions and Comorbid Tic Disorder

Nath K, Bhattacharya A, Hazarika S, et al. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: Musical obsessions are rarely reported by patients with obsessive-compulsive disorder. We report a case of musical obsessions along with multiple obsessions and compulsions, and a comorbid tic disorder.

A Case of Schizophrenia With Meige Syndrome Induced by Perospirone Successfully Treated With Biperiden

Takahashi S, Suzuki M, Uchiyama M. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: Meige syndrome is a focal dystonia involving symmetrical blepharospasm and oromandibular dystonia. The typical symptom is difficulty in keeping the eyelids open. This syndrome has been reported to be induced by several atypical antipsychotics, including risperidone, olanzapine, quetiapine, and aripiprazole.^1–4 Here, we report a case of Meige syndrome emerging with an atypical antipsychotic, perospirone, which was successfully treated with biperiden. To our knowledge, this is the first report of Meige syndrome induced by perospirone.

A Novel Viewpoint on Parameter Estimation in a Chaotic Neuron Model

Jafari S, Golpayegani S, Jafari A, et al. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: A biological neuron model is a mathematical representation of neurons that describes and predicts biological processes. It is known that neurons show chaotic behavior in some conditions. The characteristic of this chaotic behavior is non-periodic in nature, despite the pseudo-periodic behavior. Although chaotic systems have pseudo-random behavior in time, they are deterministic in phase space (i.e., if we plot the time series as a trajectory in a coordinate of system variables, we will encounter an ordered and specific topology, which is called “strange attractor.”¹

Abulia and Post-Tap Agitation in Normal-Pressure Hydrocephalus

Quinn DK, Hunt J, Diaz S, et al. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: We present a case of a patient with classical symptoms of normal-pressure hydrocephalus (NPH), as well as abulia, that evolved into severe agitation after large-volume lumbar puncture, and we review the literature on neuropsychiatric symptoms in NPH.

Acute Confusion After Minimal Hepatic Encephalopathy

Ioannidis P, Michelaki S, Maiovis P, et al. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: We present the case of a 67-year-old man with a history of portal vein thrombosis due to chronic hepatitis B, presenting at the emergency room with acute confusion. Magnetic resonance imaging of the brain revealed hyperintensities in the basal ganglia bilaterally. Neuropsychological testing and electroencephalography confirmed an encephalopathic process. The patient was treated with lactulose and returned to normal. Minimal hepatic encephalopathy (MHE) is a newly-recognized syndrome that could cause episodes of confusion, with the patient being normal between them. Porto-systemic shunting may be the cause of elevated ammonia levels that affect the brain. Management of MHE includes reduction in the production and absorption of ammonia.

Amisulpride-Induced Macrocytic Anemia

Sarkhel S, Praharaj S, Akhtar S. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: Amisulpride, an atypical antipsychotic used in treatment of both positive and negative symptoms of schizophrenia, has a benign adverse-effect profile.¹ Commonly reported adverse effects include dose-related extrapyramidal syndromes, gastrointestinal, and sexual problems.² A summary of product characteristics³ for amisulpride does not report any hematological toxicity. A PubMed search did not reveal any such association. We report a case of macrocytic anemia induced by amisulpride that reversed after discontinuation of the drug.

Antidepressant Activity of Linezolid

McDaniel W. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: Linezolid is an antibiotic approved for use in cases of infection by highly-resistant bacteria. It has weak activity as an inhibitor of monoamine oxidase.¹ It was reported in 2001 to be associated with a case of serotonin syndrome.² The association of linezolid with serotonin syndrome has been replicated, and it is now accepted practice to discontinue antidepressant medications when linezolid is to be used.³

Auditory Hallucinations Associated With Paget’s Disease

Mohan Chawla J, Viswanathan R, Memon ZI, et al. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: Paget's disease, or osteitis deformans, is a chronic condition of the bone that typically results in enlarged and deformed bones. Neuropsychiatric symptoms have been rarely reported in patients with Paget’s disease. Paget’s disease is characterized by a disorder in the normal bone remodeling process.¹ It occurs in about 3%–4% of the population over the age of 50. Neuropsychiatric symptoms associated with Paget’s disease have rarely been reported in the literature, and, to our knowledge, there have been no reports of auditory hallucinations.^2,3 We report here on a case of auditory hallucinations, anxiety symptoms, and cognitive impairment seen in 56-year-old female patient suffering from Paget’s disease. This patient, with no significant past psychiatric history, presented with auditory hallucinations and panic attacks 2 years after being diagnosed with Paget’s disease.

Autoimmune Thyroiditis-Associated Encephalopathy Without Clinical Steroid-Responsiveness and Recovery After Cyclophosphamide

Agorastos A, Wiedemann K. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: Steroid-responsive encephalopathy associated with autoimmune thyroiditis, also reported as Hashimoto encephalopathy (HE), is a rare autoimmune encephalopathy associated with the presence of serum antithyroid antibodies, normally presenting as an acute or subacute onset of various neurologic and neuropsychiatric syndromes.^1,2 However, in the past, only a few cases were reported with purely psychiatric symptoms.^3–6 We present another case of HE with strictly psychiatric symptoms, additionally, showing no initial clinical steroid responsiveness, but with complete recovery after treatment with cyclophosphamide.

Behavior Disorder After Encephalitis Caused by Dengue

Baldaçara L, Ferreira J, Filho L, et al. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: It has been reported that dengue is known as the most frequent human arboviral infection in the world, with 50 million cases per year and 2.5-to-3 million people at risk of contamination, estimated by OMS.¹ Co-circulation of the four types of dengue viruses and expansion of the dengue epidemic gave rise to infection enhancement and a big expansion of clinical aspects of the disease.² Among these clinical aspects, a small percentage of people who develop dengue develop neuropsychiatric complications (encephalitis, seizures, meningoencephalitis, encephalopathy, personality disorder, and altered level of consciousness) during and after the disease.³ We report on a case of 12-year-old young boy, attending sixth grade, with a history of dengue presenting neuropsychiatric manifestations. The patient was admitted to Palmas General Hospital complaining of severe headache for 10 days, with progressive worsening, fever, vomiting, seizures, and difficulty in walking. The initial medical examination showed temperature of 40°C, heart rate of 88 beats per minute and blood pressure of 100×68 mmHg. Pulmonary and cardiac examination showed no alterations; no signs of meningeal involvement. According to the patient´s parents, there was behavior change in the last 15 days, characterized by emotional lability, dependence, alteration in the rhythm of language and tone voice, anxiety, and change in tastes. Laboratory tests were ordered, including serology for dengue and herpes virus, as well as imaging tests (magnetic resonance imaging and computed tomography). The magnetic resonance and computed tomography showed no changes in the brain, and the studies of cerebrospinal fluid revealed high protein levels and increased lymphocytes. After 5 days of hospitalization, the serology for dengue came back positive for both IgM and IgG immunological markers. The patient received risperidone 1mg per day, and behavioral symptoms improved after 10 days. He was discharged after 21 days of hospitalization, but, 60 days later, behavioral symptoms were still presented. In this case, the neuropsychiatric complication, although rare, can be explain by the knowledge of some isolated or associated events, such as cerebral edema, cerebral hemorrhage, hyponatremia, acute liver failure, or cerebral anoxia, among others.⁴ Infection of the nervous system by dengue virus can be partially understood by knowledge of the three hypotheses of systemic viral infection: the sequential infection theory, developed by Halsted⁵; the hyper-endemicity theory, by Rosen;⁶ and the occurrence of genetic recombination resulting from simultaneous infections by different serotypes.⁶ The rarity of this case, along with the still unknown field of the systemic repercussions of dengue infection, make this report important for further studies.

Brain Activity Preceded Awareness in Libet’s Experiment Is Probably Related to Unconscious Inhibition

Bahmani Z, Gharibzadeh S. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: Free will is a hotly attractive field. Not only do we freely perform actions, but also our conscious decisions initiate our actions. The most dominated method to study the neural basis of free will is Libet’s experiment,¹ in which participants are asked to press a key whenever they want and also to report time of first experience of urge to move. Motor area activity began some 100 milliseconds before conscious intention to move. These findings raise questions about being free or not. Libet’s experiment was repeated using fMRI² and direct recording by electrodes.³

Can Electroconvulsive Therapy Induce Catatonia?

Praharaj S, Sarkhel S, Prasad S, et al. — Sun, 01 Dec 2013 00:00:00 GMT

To the Editor: Catatonia is a psychomotor syndrome in which motor, behavioral, and emotional changes may occur due to various causes.¹ Affective psychoses and schizophrenia happen to be common causes of catatonia. In most cases, catatonia is treated either with benzodiazepines or electroconvulsive therapy (ECT).²

Can the Chaotic Nature of Parkinson’s Disease Be Used to Evaluate the Effect of Medication on Parkinson's Disease Symptoms?

Taherkhani A. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: Parkinson's disease (PD) is the second most common neurodegenerative disorder after Alzheimer’s disease. Patients with PD develop motor symptoms such as muscular rigidity, slowness of movement, and reduced gait speed, as well as non-motor deficits such as disorders of mood and distinctive alteration of speech and voice (hypokinetic dysarthria).¹ The severity of PD can be detected by these symptoms.

Cerebellar Stroke Impairs Executive Functions But Not Theory of Mind

Roca M, Gleichgerrcht E, Ibáñez A, et al. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: Even though cerebellar activation has been described during theory of mind (ToM) tasks in neuroimaging studies, no previous studies have investigated ToM in a group of patients with cerebellar strokes. In the present study, we assessed 11 patients with cerebellar infarction on a variety of executive tests and with the Faux Pas test of ToM. Even if cerebellar patients showed significant deficits on executive tasks relative to a control group, no significant differences were found between the groups on the Faux Pas test. This is the first group study to demonstrate that focal cerebellar lesions do not affect ToM.

Choroid Plexus Papilloma Presenting as Schizophrenia: A Case Report

Arasappa R, Danivas V, Venkatasubramanian G. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: Although the definite etiology of schizophrenia is not known, there have been reports of intracranial tumors presenting with schizophrenia symptoms. In this report, a first such case, we present a patient who had classical symptoms of schizophrenia, who was, on investigation, found to have a choroid plexus papilloma. This case emphasizes the need for imaging in patients having signs of organicity and supports the concept of cognitive dysmetria in patients with schizophrenia.

Complex Visual Hallucinations Associated With Parietal Infarct

Shahani L. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: Complex visual hallucinations (CVH) are a common reason for referral to psychiatrists in consultation–liaison and neuropsychiatric settings. Various organic causes of CVH such as narcolepsy–cataplexy syndrome, peduncular hallucinosis, treated idiopathic Parkinson's disease, Lewy-body dementia without treatment, migraine coma, Charles Bonnet syndrome, schizophrenia, hallucinogen-induced states, and epilepsy have been described in the literature.¹

Dose-Related Reversible Hypotension During Aripiprazole Treatment

Wang Y. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: Aripiprazole, a new second-generation antipsychotic, was approved as an effective antipsychotic that could improve negative symptoms and improved cognition for schizophrenia.¹ Recently, it has become a common alternative treatment for patients who have inadequate responses to antidepressants. Aripiprazole differs from other antipsychotics because of its partial agonist activity at D₂ and 5-HT_1A receptors. The available data indicate that aripiprazole is an effective agent, with minimal sedation, metabolic effects, and cardiac toxicity, such as prolongation of the QT interval. Here, we describe the case of a young schizophrenic man who developed dose-related reversible hypotension after the intake of aripiprazole.

Drug Delivery Using Nano-Pore Zeolites and Ultrasound

Hassanvand A, Hajihassani M, Abdi M, et al. — Fri, 01 Mar 2013 00:00:00 GMT

Dear Editor: Ultrasound is a mechanical wave with frequencies greater than 20 KHz. Biological effects of ultrasound can often be attributed either to temperature rise or to cavitation activity.¹ Ultrasound is adopted in drug delivery such as supplying chemotherapeutic drugs into tumors. Several drugs, such as hydrocortisone, salicylic acid, and lidocaine have been delivered in clinical applications using sonophoresis. Ultrasound is also used to release drugs at the site of interest to perform minimally invasive, localized therapy. A lot of studies show that ultrasound improves drug uptake in cells, tumors, and other solid tissues, such as the brain.²

Effectiveness of a Clozapine–Aripiprazole Combination in Tourette Syndrome and Bipolar Spectrum Disorder

Piccinni A, Veltri A, Marazziti D, et al. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: Antipsychotic combination is a common strategy used in both bipolar disorder and schizophrenia, although just a few trials are available exploring its effectiveness.¹ We report herein the case of a patient suffering from severe Tourette syndrome (TS) and bipolar spectrum disorder who benefited from a combination of clozapine and aripiprazole.

Efficacy of Plasma Exchange in Pharmaco-Resistant Acute Mania in Systemic Lupus Erythematosus

Schwan RR, Tadri MM, Zuily SS, et al. — Sun, 01 Dec 2013 00:00:00 GMT

To the Editor: Systemic lupus erythematosus (SLE) is an autoimmune disease that can affect any part of the body, including the central nervous system. Psychiatric manifestations during SLE are not unusual; their characteristic features are early occurrence and clinical polymorphism.^1,2 This clinical case shows a picture of SLE in which the first manifestations were psychiatric, with, in particular, an episode of mania³ with delirium that was resistant to drug treatment but responded well to plasmapheresis.

Fractal and Statistical Features for the Discrimination Between Patients With Amyotrophic Lateral Sclerosis and Healthy Adults

Falaki A, Almasganj F, Towhidkhah F. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder, by which 2 in 100,000 individuals are affected each year,¹ that affects primary motor neurons in cerebral cortex, brain stem, and spinal cord.² Degeneration of motor neurons will hinder sending cerebrum impulses to the muscle fibers, impairing voluntary movements. Muscle twitching and spasticity, difficulties in speech, swallowing, and breathing are most commonly known symptoms of ALS. One of the most salient features in determining disease severity and appropriate treatment is gait disorder in form of increase in mean stride interval and decrease in mean speed of walking.³ Stride-to-stride fluctuations in healthy adults show alteration in a chaotic manner; these have a fractal (self-similar) structure more than a random one,^4,5 which would approach a stochastic state.⁵

Functional Auditory Hallucinations in a Case of Serotonin Syndrome

Ameen S, Praharaj S. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: Serotonin syndrome is a potentially life-threatening condition that requires heightened clinical awareness for recognition and prompt treatment.¹ It usually results from increased brainstem serotonin activity due to overdose or combinations of medications or drugs of abuse with serotonergic activity.² The clinical features of the serotonin syndrome include alterations in mental status and behavior, hyperthermia, along with signs and symptoms of neurological, gastrointestinal, and autonomic nervous system dysfunction.¹ Auditory and visual hallucinations are common in this condition and are included in Sternbach’s diagnostic criteria.³ However, a PubMed search supplemented with manual search did not reveal any previous reports of functional auditory hallucinations in this condition. This report describes a case of serotonin syndrome that presented with florid functional auditory hallucinations in the absence of any true auditory hallucinations.

Increasing Performance in Children With ADHD By Trapping Lead With a Nano-Zeolite

Delavarian M, Hassanvand A, Gharibzadeh S. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: Attention deficit hyperactivity disorder (ADHD) is one of the most common neurobehavioral disorders.¹ Children with ADHD are inattentive and/or hyperactive/impulsive in more than one setting, such as at home, school, and work.² Some environmental factors, such as maternal smoking during pregnancy, delivery complications, and air pollution increase the rates of ADHD.¹ Among air pollutants, high lead exposure has a significant association with ADHD performance.³

Is Attention a “Period Window” in the Chaotic Brain?

Jafari S, Ansari Z, Golpayegani S, et al. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: Artificial neural networks (ANNs), introduced in the fields of mathematics and engineering, are inspired from biological neural networks. They have abilities like those of the neural network system of the human. Among these abilities, the most important one is ability in learning and generalization. Therefore, the ANNs have become implemented in a variety of fields, such as pattern recognition, classification, and control.¹

Is It Possible to Treat Some Brain Diseases by Drug-Substituted Zeolites?

Hassanvand A, Gharibzadeh S. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: The blood–brain barrier (BBB) contains microvascular endothelial cells (ECs) linked by tight junctions. ECs restrict the diffusion of large molecules into the cerebrospinal fluid (CSF), while allowing the diffusion of small, hydrophobic molecules. The size of materials that can cross the BBB is in the range of 30 nm–280 nm.¹

Neuropsychiatric Symptoms as a Putative Crescendo Warning of a Striatocapsular Infarct?

Rosenzweig I, Bhatia KP, Malhotra T, et al. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: The complex connectivity of basal ganglia with other cortical and thalamic circuits that guide our behavior, cognition, and movement is still a matter of controversy. However, the past decade brought about the increased insight into the synchronized oscillations between basal ganglia-cortical and thalamo-cortical circuits, as well as the awareness about the potential detrimental effect that any interruptions (including brain infarction) of these oscillations may instigate.^1,2 Small infarctions in the subcortical white- and gray-matter areas are sometimes clinically overlooked and only inadvertently reported on post-hoc neuroimaging.^3–8 Furthermore, even those subcortical lesions that appear to be strategically placed are sometimes without overt clinical signs and with symptoms that come and go despite the presence of fixed cavities on the neuroimaging. (as reviewed in⁴). Consequently, a certain incredulity on the part of investigating clinicians, when assessing the retrospective reports by patients and their families about associated symptoms, is common, and their putative impact on cognition and behavior is not always easily argued.^3,4 The converging evidence, however, suggests that such infarcts could affect distant areas/neuronal circuits via a combination of local and remote chemical and electrophysiological effects.^3,4,9–11 We present here the case of intermittent behavioral and cognitive changes associated with the striatocapsular lesion due to infarction. It is hoped that this and similar case reports that detail the plethora of paroxysmal neuropsychiatric symptomatology resulting from lesions in this area will aid improved clinical recognition of subcortical “silent” infarcts.

Paranoid Personality Disorder and Organic Brain Injury: A Case Report

Birkeland S. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: Paranoid personality disorder (PPD) is a mental disorder characterized by, for example, excessive sensitivity, self-reference, suspiciousness, and jealousy, which is included in both DSM-IV-TR and ICD-10 with relatively similar trait-concept definitions.¹ There is a lack of clinical reports describing the presentation of PPD in connection with organic brain involvement. Here below, a retrospective case description is provided in which a patient presented with a history of head trauma, alcoholism, and the full-blown syndrome of PPD.

Planum Parietale Volume in Antipsychotic-Naïve Schizophrenia

Shivakumar V, Kalmady SV, Gautham S, et al. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: “The parietal lobe receives little attention in current neuropathological models of schizophrenia, and there has been little systematic investigation of this area,”¹ despite its recognized importance in processes that are likely disturbed in schizophrenia, such as language,² spatial working memory, and attention. The inferior parietal lobule (IPL), a part of the parietal lobe, also forms the part of the heteromodal association cortex that has been proposed as the site of the key abnormality in schizophrenia.³ It is subdivided into the supramarginal gyrus (area 39) and angular gyrus (area 40). These two structures are a part of the semantic-lexical network that supports “word meanings,” represented by a “grid of connectivity” that constitutes a “final pathway for the chunking of words into thought.”² Further, PET and fMRI studies have confirmed the role of the IPL, particularly the angular gyrus, in language comprehension.⁴ First-rank symptoms (FRS), a group of intriguing experiences characterized by a striking breach of “self versus non-self” boundaries, have had a critical influence on the diagnosis of schizophrenia.⁵ The IPL is also implicated in the pathogenesis of FRS in schizophrenia.³

Quetiapine-Associated Pathological Stealing in An Adolescent Girl

Huang W, Chang L. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editors: “Miss H,” a 17-year-old girl, did not have history of mood disorders, conduct problems, substance misuse, or physical illness. She was diagnosed with schizophrenia at age 16, with initial presentations of persecutory delusion and formal thought disorder. She received comprehensive physical examinations, and organic etiology was excluded. Because of aggravated psychotic symptoms, she was admitted for 1 week. Her psychosis was controlled under quetiapine 600 mg/day. However, 1 month after her discharge, her disorganized speech and referential delusion relapsed. Quetiapine was hence increased to 800 mg/day. The delusions and formal thought disorder subsided gradually; unexpectedly, pathological stealing developed. Miss H stole clothes and stationery in stores and school 3–4 times per week. She alleged that she did not plan before the stealing, but she could not control the impulse of grasping. She did not act under delusion, hallucination, or somatic passivity. Concurrent medication only included estazolam 1–2 mg/day. Because the severity of pathological stealing was not consistent with her psychotic symptoms, quetiapine-associated pathological stealing was suspected. When we tapered quetiapine to 400–600 mg/day, the stealing behavior reduced to once in 2 weeks, but psychosis was aggravated. For better control of the disease, we switched to amisulpiride 400 mg/day. Her psychotic symptoms resolved 2 weeks later, and the stealing behavior appeared no more.

Repeated Adverse Hematologic Reactions Associated With Valproic Acid Use in a Patient With Acquired Renal Insufficiency

Kuo S, Yeh Y, Chen C, et al. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: The oral loading of valproic acid (VPA) is mostly safe and leads to more rapid anti-manic effects than standard titration of offending drugs.¹ Although hematologic toxicities such as thrombocytopenia, neutropenia, and even pancytopenia associated with VPA have been reported, as far as we know, serial acute adverse effects like pancytopenia resulting from oral loading of VPA have rarely been reported.² We present here a case of repeated hematologic adverse effects associated with VPA treatment in a patient with acquired renal insufficiency.

Reversible Dementia in the Young Due to Cobalamin Deficiency

Kumar S, Narasimha A, Holla B, et al. — Sun, 01 Dec 2013 00:00:00 GMT

To the Editor: Vitamin-B₁₂ deficiency (VB12D) has been associated with neuropsychiatric abnormalities like posterolateral myelopathy, peripheral neuropathy, autonomic neuropathy, optic atrophy, mood disorders, psychosis, delirium, and dementia (especially in elderly persons).¹ However, a strong causal relationship between VB12D and dementia has not been established.

Risk of Akathisia Associated With Atypical Antipsychotics

Agarkar SS, Anthony DD, Ferrando SS. — Sun, 01 Dec 2013 00:00:00 GMT

To the Editor: Akathisia is an extrapyramidal symptom (EPS) that is characterized by an objective inability to sit or stand still and by a subjective feeling of inner restlessness.¹ It was first described by Haskovec, who linked symptoms of akathisia to dopamine receptor blockade in nigrostriatal regions of the brain.¹ It can present as a diagnostic and treatment challenge affecting the management of primary conditions. Furthermore, akathisia is associated with significant distress, and has been linked to aggression, violence, suicidality, insomnia, exacerbation of psychotic illness, tardive dyskinesia, and poor adherence to treatment.^2,3

Schizophrenia Presenting With Koro-Like Symptoms

Afonso P, Saraiva S, Gameiro Z. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: Koro is a culture-bound syndrome, first identified in Southeast Asia. It is characterized by the belief that the patient’s penis is shrinking or retracting into the abdomen, and its eventual disappearance will result in the patient’s death.¹

Selective Sound Sensitivity Syndrome (Misophonia) in a Patient With Tourette Syndrome

Neal M, Cavanna AE. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: ”Mr. P” is a 52-year-old man first diagnosed with Tourette syndrome (TS) at the age of 44 after referral to our specialist TS clinic for chronic tic symptoms¹^,². On neuropsychiatric examination, he presented with multiple motor tics (including facial grimacing and shoulder shrugging) and phonic tics (mainly yelping and barking), which were present since the age of 11. All tics were characteristically preceded by premonitory urges, and he was able to voluntarily suppress them at the expense of mounting inner tension. There was no evidence of comorbid psychiatric disorders, with the exception of mild obsessive-compulsive behaviors (counting, lining up newspapers), previous episodes of depression, and sleep problems as a child (somnambulism).

Sodium Benzoate, a D-Amino Acid Oxidase Inhibitor, Increased Volumes of Thalamus, Amygdala, and Brainstem in a Drug-Naïve Patient With Major Depression

Lai C. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: The inhibitor of D-amino acid oxidase (DAAO) can increase D-amino acid (DAA) through the inhibition of DAAO, which might relieve the symptoms of depression and anxiety. The effects of inhibitor of DAAO on subcortical volumes (SCV) are still unknown. Here, we wanted to report that a drug-naïve case with major depressive disorder (MDD) had significant increases of SCV after a 6-week therapy of sodium benzoate (SB), a kind of inhibitor of DAAO.

Successful Use of Add-on Minocycline for Treatment of Persistent Negative Symptoms in Schizophrenia

Jhamnani K, Shivakumar V, Kalmady S, et al. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: Schizophrenia is a chronic neuropsychiatric disorder characterized by diversity of symptoms grouped into positive, negative, and cognitive spheres.¹ Like the symptoms, the etiology of schizophrenia is also diverse. Among the various etiological hypotheses, immune system aberrations have been consistently implicated.² C-reactive protein (CRP), a marker of inflammation, has been found to be high in schizophrenia patients, and its levels linked with the severity of negative symptoms and cognitive deficits in schizophrenia.^3,4 Interestingly, minocycline, an antibiotic with immunomodulatory properties,⁵ has been reported to be useful as an adjunctive agent in acute and early phases of schizophrenia.^6,7 To the best of our knowledge for the first time, herein, we describe two case reports in which minocycline was found to be useful as an add-on agent in treating persistent negative symptoms in schizophrenia with concurrent reduction in levels of CRP.

Tetrabenazine and Suicidal Ideation

Shahani L. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: Huntington's disease (HD) is an inherited progressive neurodegenerative disorder associated with choreiform movements, psychiatric problems, and dementia. Chorea is a key feature and most times the symptom leading to the diagnosis of the disease. Chorea could also be associated with functional impairment and warrants treatment. Most commonly, it can be treated with various pharmacological measures, including typical and atypical neuroleptics, and monoamine-depleting agent such as tetrabenazine.

The Effect of Visual and Cerebellar Exercises on Dyslexia

Delavarian M, Afrooz G, Gharibzadeh S. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: Reading disorder, or dyslexia, affects at least 5% of school-age children.¹ This disorder has a genetic basis. The learning difficulties in these persons are unexpected according to age and cognitive or academic abilities.²

Using Natural Zeolite as a Transporter of Dopamine

Delavarian M, Hassanvand A, Gharibzadeh S. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: Attention deficit-hyperactivity disorder (ADHD) is a developmental disorder that causes problems in attention, monitoring, executive attention, and inhibition responses. Some areas with low activities have been identified in the central nervous system of children with ADHD by SPECT studies.¹ One of them, the cortical-striatal-thalamic-cortical network, is known to be the area of dopamine concentration.¹ Some evidence showed that the function of dopamine and serotonin are altered in ADHD.² It is worth noting that anxiety is one of the symptoms that can exist in ADHD as a secondary feature.¹

Using Paliperidone as a Monotherapeutic Agent on a Schizophrenic Patient With Cirrhosis of the Liver

Chou H, Chen C. — Fri, 01 Mar 2013 00:00:00 GMT

To the Editor: Liver cirrhosis may cause hepatic encephalopathy, which includes a complicated cluster of neurological symptoms. Confusion, irritability, disorganized speech and behavior, and conscious disturbance are not uncommon in this situation.¹ When a schizophrenic patient has comorbidity of liver cirrhosis, some psychotic symptoms may mimic the clinical features of hepatic encephalopathy and it increases difficulties in differentiating the etiology of the patient’s mental condition. We are going to share our experience of treating a schizophrenic patient with liver cirrhosis, using paliperidone as monotherapeutic agent.