The Journal of Neuropsychiatry and Clinical Neurosciences Current Issue

Neuroanatomy of Dopamine: Reward and Addiction

Sun, 01 Jan 2012 00:00:00 GMT

Abnormalities of the physiological reward system are believed to play a major part in many serious psychiatric disorders, such as substance abuse, pathological gambling, and major depression. Motivation that involves liking, wanting, craving, and learning about pleasurable events and behavior is heavily influenced by the circuitry of the dopamine reward system, which plays a major role in both normal reward behavior and pathological behavior and addiction. In this Windows to the Brain article, the authors elucidate the mechanisms of this system.

The Neuropsychiatry of Vitamin B 12 Deficiency in Elderly Patients

Sun, 01 Jan 2012 00:00:00 GMT

Vitamin B12 deficiency is a common cause of neuropsychiatric symptoms in elderly persons. Malabsorption accounts for the majority of cases. Vitamin B12 deficiency has been associated with neurologic, cognitive, psychotic, and mood symptoms, as well as treatment-resistance. Clinician awareness should be raised to accurately diagnose and treat early deficiencies to prevent irreversible structural brain damage, because current practice can be ineffective at identifying cases leading to neuropsychiatric sequelae. This clinical review focuses on important aspects of the recognition and treatment of vitamin B12 deficiency and neuropsychiatric manifestations of this preventable illness in elderly patients.

Impulse-Control Disorders in Gilles de la Tourette Syndrome

Sun, 01 Jan 2012 00:00:00 GMT

Impulse-control disorders (ICDs) are more common in clinic populations with Gilles de la Tourette syndrome (GTS) than in the general population. The clinical phenomenology of ICDs differ between men with GTS (who tend to be externally impulsive) and women with GTS (who tend to be internally impulsive). This article reviews the relevant literature to-date on impulsivity in GTS, with special focus on intermittent, explosive disorder, self-injurious behavior, trichotillomania, and impulsive-compulsive sexual behavior. The medical and legal community should be aware of the full spectrum of organically-based behaviors that may predispose patients with GTS to unwanted legal disciplinary action.

Mood Response to Deep Brain Stimulation of the Subthalamic Nucleus in Parkinson's Disease

Sun, 01 Jan 2012 00:00:00 GMT

Deep brain stimulation of the subthalamic nucleus, as used to treat Parkinson's disease, often brings about improvement in motor function, but can have variable effects on mood. The authors give a detailed process description of the effects of variable electrode placement, as it relates to unilateral and bilateral approaches and exact positioning of stimulation.

Getting Past “g”: Testing a New Model of Dementing Processes in Persons Without Dementia

Sun, 01 Jan 2012 00:00:00 GMT

The cognitive correlates of functional status are essential to dementia case-finding. The authors have used structural-equation models to explicitly distinguish dementia-relevant variance in cognitive task performance (i.e., δ) from the variance that is unrelated to a dementing process (i.e., g′). Together, g′ and δ comprise Spearman's “g.” Although δ represents only a small fraction of the total variance in cognitive task performance, it is more strongly associated with dementia severity than is g′. In this analysis, the authors test whether δ can predict future cognitive decline in persons clinically without dementia at baseline. These results have implications for the clinical assessment of dementia and suggest that functional status should assume a more important role.

Comparison of Personality Characteristics on the Bear-Fedio Inventory Between Patients With Epilepsy and Those With Non-Epileptic Seizures

Sun, 01 Jan 2012 00:00:00 GMT

This study used the Bear-Fedio Personality Inventory (BFI) to compare 41 individuals with temporal lobe epilepsy (TLE) and 37 with psychogenic non-epileptic seizures (NES). Both groups exhibited similar elevations on the BFI, although TLE individuals show greater endorsement of at least one hypergraphia symptom, as compared with those with NES. The correlates of the BFI with demographic and seizure characteristics differed between the groups. These results argue against a specific TLE personality syndrome and suggest that personality characteristics may be related to the experience of having repeated seizures, rather than the specific underlying pathophysiology of temporal lobe epilepsy.

Longitudinal Evaluation of Neuropsychiatric Symptoms in Huntington's Disease

Sun, 01 Jan 2012 00:00:00 GMT

A group of 111 patients with Huntington's disease (HD) underwent a minimum of three annual neuropsychiatric assessments, using the Problem Behaviors Assessment for Huntington's Disease (PBA-HD). Longitudinal prevalence of neuropsychiatric symptoms was notably higher than baseline prevalence, suggesting that previous studies may have underestimated the extent of this clinical problem. Moreover, apathy, irritability, and depression were each associated with distinct longitudinal profiles. Apathy progressed over time and across disease stages. Irritability also increased significantly, but only in early stages of HD. Depression did not increase significantly at any stage of disease. The neuropsychiatric syndrome of apathy appears to be intrinsic to the evolution and progression of HD.

Sustained Attention Deficits Among HIV-Positive Individuals With Comorbid Bipolar Disorder

Sun, 01 Jan 2012 00:00:00 GMT

Difficulties with sustained attention have been found among both persons with HIV infection (HIV+) and bipolar disorder (BD). The authors examined sustained attention among 39 HIV+ individuals with BD (HIV+/BD+) and 33 HIV-infected individuals without BD (HIV+/BD–), using the Conners' Continuous Performance Test–II (CPT–II). A Global Assessment of Functioning (GAF) score was also assigned to each participant as an overall indicator of daily functioning abilities. HIV+/BD+ participants had significantly worse performance on CPT–II omission errors, hit reaction time SE (Hit RT SE), variability of SE, and perseverations than HIV+/BD– participants. When examining CPT–II performance over the six study blocks, both HIV+/BD+ and HIV+/BD– participants evidenced worse performance on scores of commission errors and reaction times as the test progressed. The authors also examined the effect of current mood state (i.e., manic, depressive, euthymic) on CPT–II performance, but no significant differences were observed across the various mood states. HIV+/BD+ participants had significantly worse GAF scores than HIV+/BD– participants, which indicates poorer overall functioning in the dually-affected group; among HIV+/BD+ persons, significant negative correlations were found between GAF scores and CPT–II omission and commission errors, detectability, and perseverations, indicating a possible relationship between decrements in sustained attention and worse daily-functioning outcomes.

Cognitive Performance Related to HIV-1-Infected Monocytes

Sun, 01 Jan 2012 00:00:00 GMT

The effect that HIV type 1 (HIV) has on neurocognition is a dynamic process whereby peripheral events are likely involved in setting the stage for clinical findings. In spite of antiretroviral therapy (ART), patients continue to be at risk for HIV-associated neurocognitive disorders (HAND), which might be related to persistence of inflammation. In a yearly assessment of HIV DNA levels in activated monocytes, increased HIV DNA copies were found in patients with persistent HAND. Furthermore, activated monocytes from patients with high HIV DNA copies secreted more inflammatory cytokines. Since these activated monocytes traffic to the CNS and enter the brain, they may contribute to an inflammatory environment in the CNS that leads to HAND.

Obsessive-Compulsive-Spectrum Symptoms in Patients With Focal Dystonia, Hemifacial Spasm, and Healthy Subjects

Sun, 01 Jan 2012 00:00:00 GMT

This study is aimed at investigating obsessive-compulsive disorder (OCD) in three groups of patients matched for age and gender; namely, focal dystonia (FD), hemifacial spasm (HFS), and healthy-control subjects (HC). All subjects were investigated with the Structured Clinical Interview for DSM–I, the Hospital Anxiety and Depression Scale, the Symptom Checklist–90, the Yale-Brown Obsessive-Compulsive Scale, and the Structured Clinical Interview for Obsessive-Compulsive Spectrum Self-Report, Lifetime Version (SCI-OBS-SR-LT). The prevalence of OCD was significantly higher in both FD and HFS than in HC participants. On the SCI-OBS, HFS patients showed higher scores than FD or HC for “contamination” and “aggressiveness.” Despite the different pathophysiology, OCD is highly represented in both FD and HFS, with different thematic content characterizing the two conditions.

Motor Functioning in Autistic Spectrum Disorders: A Preliminary Analysis

Sun, 01 Jan 2012 00:00:00 GMT

The study sought to identify differences in motor functioning between autism and Asperger syndrome while also assessing the diagnostic contribution of such assessment. A sample of 16 individuals with autism and 10 with Asperger syndrome completed the Dean-Woodcock Sensory-Motor Battery, and outcomes were compared. Significant differences were found in measures of cerebellar functioning, favoring Asperger subjects. Deficits in coordination, ambulation, and the Romberg test were associated with both disorders. On the basis of motor outcomes alone, 100% were accurately differentiated. Findings support the idea that motor dysfunction is a core feature of these presentations and demonstrated the utility of motor assessment in diagnostic practice.

Symptom Profile and Etiology of Delirium in a Referral Population in Northern India: Factor Analysis of the DRS–R98

Sun, 01 Jan 2012 00:00:00 GMT

Delirium is understudied in developing countries, where there tends to be a lower proportion of older persons and comorbid dementia. The authors assessed 100 consecutive cases of DSM-IV delirium (patients' mean age: 44.4 [standard deviation: 19.4] years; mean DRS–R98 score: 25.6 [3.6]) referred to an adult Consultation–Liaison Psychiatry service in Northern India. Disturbances of attention, orientation, visuospatial ability, and sleep disturbance were the most frequent symptoms, followed by language, thought-process abnormality, and motor agitation. A three-factor solution was identified, representing domains for cognition, higher-order thinking, and circadian rhythm/psychosis. These domains can guide studies addressing the relationship between symptom profile, therapeutic needs, and outcomes and are consistent with core domains previously identified in other countries.

Underlying Neurobiology and Clinical Correlates of Mania Status After Subthalamic Nucleus Deep Brain Stimulation in Parkinson's Disease: A Review of the Literature

Sun, 01 Jan 2012 00:00:00 GMT

Deep brain stimulation (DBS) is a novel and effective surgical intervention for refractory Parkinson's disease (PD). The authors review the current literature to identify the clinical correlates associated with subthalamic nucleus (STN) DBS-induced hypomania/mania in PD patients. Ventromedial electrode placement has been most consistently implicated in the induction of STN DBS-induced mania. There is some evidence of symptom amelioration when electrode placement is switched to a more dorsolateral contact. Additional clinical correlates may include unipolar stimulation, higher voltage (>3 V), male sex, and/or early-onset PD. STN DBS-induced psychiatric adverse events emphasize the need for comprehensive psychiatric presurgical evaluation and follow-up in PD patients. Animal studies and prospective clinical research, combined with advanced neuroimaging techniques, are needed to identify clinical correlates and underlying neurobiological mechanisms of STN DBS-induced mania. Such working models would serve to further our understanding of the neurobiological underpinnings of mania and contribute valuable new insight toward development of future DBS mood-stabilization therapies.

Can Computerized Cognitive Tests Assist in the Clinical Diagnosis of Attention-Deficit Hyperactivity Disorder?

Sun, 01 Jan 2012 00:00:00 GMT

A group of 34 children and adolescents suspected of having attention-deficit hyperactivity disorder were referred for a computerized evaluation that included sustained attention, working memory, planning, and set-shifting. Although only sustained attention had reasonable specificity, all tests had questionable contribution to the diagnostic evaluation.

The Johns Hopkins Atlas of Digital EEG: An Interactive Training Guide, 2nd Edition

Sun, 01 Jan 2012 00:00:00 GMT

With this second edition of a work already considered the standard textbook in digital EEG (d/EEG), these three noted epileptologists, Krauss, Fisher, and now Kaplan, have created a work that will become a classic in its field.

Letters

Sun, 01 Jan 2012 00:00:00 GMT

Full text of all letters listed below are posted online as part of the Winter 2012 issue at http://neuro.psychiatryonline.org/content/vol24/issue1/index.dtl#LETTERS.

Errata

Sun, 01 Jan 2012 00:00:00 GMT

In the Letter to the Editor “Charles Bonnet Syndrome-Induced Psychosis? Visual Hallucinations With Paranoid Delusions in a Visually-Impaired Man” (J Neuropsychiatry Clin Neurosci 2011; 23(4):http://ajp.psychiatryonline.org/Article.aspx?10.1176/appi.neuropsych.23.4.e6), by Chris Makarewich and Donald A. West, M.D., author Chris Makarewich's degree status should have been listed as B.A. He is a fourth-year student at Dartmouth Medical School. The Journal regrets this error.

Cerebral Amyloid Angiopathy-Related Inflammation: A Treatable Cause of Rapidly-Progressive Dementia

Sun, 01 Jan 2012 00:00:00 GMT

To the Editor: The first priority of diagnostic evaluation of dementia syndrome is the identification of potentially treatable causes. Cerebral amyloid angiopathy-related inflammation is a recently described diagnostic entity that is characterized by a treatment-responsive, rapidly-progressive dementia syndrome. It has been suggested that it can be noninvasively diagnosed on the basis of a characteristic combination of clinical and radiological features. We present a representative case and discuss typical findings.

Combined Delusional Misidentification Syndrome in a Patient With Parkinson's Disease

Sun, 01 Jan 2012 00:00:00 GMT

To the Editor: Delusional misidentification syndromes (DMS) are unusual in Parkinson's disease (PD). We describe a patient with advanced PD and combined Capgras and intermetamorphosis syndromes for whom known predisposing factors appear to be insufficient to explain DMS in PD. Rather, delayed habituation induced by abnormalities of dopaminergic or cholinergic systems may represent a novel mechanism to account for DMS. Moreover, this may represent a unifying feature of DMS across neuropsychiatric disorders.

Effectiveness of Clozapine in Treating Severe Tardive Dystonia and Associated Pyosis

Sun, 01 Jan 2012 00:00:00 GMT

To the Editor: A 58-year-old African American woman with long-standing schizophrenia, paranoid type, and severe tardive dystonia had history of repeated nonadherence and hospitalization. Multiple medication trials were unsuccessful. She was then treated with clozapine in a dose of 250 mg/day, and dystonia was measured using Burke-Fahn and Marsden Rating Scale. She had near-total resolution of tardive dystonia after initiation of clozapine, and the improvement was sustained over a 3-year follow-up period.

Impairment of Affective Theory of Mind in Corticobasal Degeneration

Sun, 01 Jan 2012 00:00:00 GMT

To the Editor: The term Theory of Mind (ToM) refers to the ability to attribute mental states to others and to predict, describe, and explain behavior on the basis of such mental states.⁺¹ Usually assessed in subjects with various psychiatric disorders such as schizophrenia, autism, depression, and personality disorders, in recent years researchers have also started to assess ToM ability in patients with neurodegenerative diseases.^+2,+3 These studies showed that ToM processes may be differently affected by neurodegenerative processes: for example, patients with Alzheimer's disease and patients with Parkinson's disease may present difficulties related to the cognitive ToM component Inference About Others' Beliefs more than to the affective ToM component Inference About Others' Feelings, whereas patients with frontotemporal dementia may present impairments of both ToM components. To our knowledge, ToM has never been investigated in patients with corticobasal degeneration (CBD), a progressive neurodegenerative disease that typically presents with asymmetrical parkinsonism and cognitive dysfunction.⁺⁴ We report on the case of an affective ToM impairment in a case of clinically diagnosed CBD. “Ms. TD,” a 62-year-old, right-handed, married, retired woman, came to our attention in September 2010 because of the appearance of difficulties of memory, mental calculation, and praxis in everyday life, associated with mild depression. Ms. TD underwent a neurological examination, showing a clinical picture of upper-limb tremor, more marked on the left side, and limb apraxia. She also underwent electroencephalography, which showed bilateral temporo-parietal alterations; a computed tomography, showing cortical atrophy; and an 18-FDG positron emission tomography, showing a bilateral hypometabolism in the frontal-temporal-parietal cortices, more marked in the right hemisphere. The patient did not undergo a magnetic resonance imaging scan because of the presence of a metallic implant. The global cognitive status evaluation showed mild impairment (Mini-Mental State Exam raw score: 23/30). Her Movement Imitation Test yielded scores suggestive of a bilateral limb ideomotor apraxia, mildly left-lateralized. At the neuropsychological evaluation, she also presented preserved memory functioning and a mild impairment of executive and visuospatial functions. This clinical picture was suggestive of a clinically diagnosed corticobasal degeneration.⁺⁴ In this patient, we assessed affective ToM with the Reading the Mind in the Eyes (RME) test,⁺⁵ consisting of the presentation of photographs of the eye region of human faces; participants are required to choose which word best describes what the individual in the photograph is thinking or feeling. For the control of possible visual difficulties interfering with the task, participants are also asked to decide the gender of each individual represented only by the eye region. TD had a score of 17/36 in the RME task and a score of 30/36 in the gender control task. We deemed that the presence of mild visuospatial difficulties could not totally explain impaired performance in the RME, considering the better performance in the gender control task. This finding suggests, as previously reported for behavioral-variant frontotemporal dementia,,⁺² that when the neuropathology affects orbital and ventromedial portions of the prefrontal cortex (as shown by the 18-FDG PET), performances in tasks of affective ToM may be impaired.

Intubation in a Case of Psychogenic, Non-Epileptic Status Epilepticus

Sun, 01 Jan 2012 00:00:00 GMT

To The Editor: Psychogenic nonepileptic seizures (PNES) constitute an important differential diagnosis for atypical and refractory seizures. We present a case of “psychogenic non-epileptic status epilepticus” in which the patient was intubated.

Progressive Non-Fluent Aphasia in a Bilingual Subject: Relative Preservation of “Mother Tongue”

Sun, 01 Jan 2012 00:00:00 GMT

To the Editor: Although bilingualism is common globally, cases of progressive aphasia due to frontotemporal lobar degeneration have rarely been reported. These cases are of potential interest for understanding the neuropsychological substrates of language.

Bipolar Disorder Co-Occurring With Periodic Paralysis: A Case Report

Sun, 01 Jan 2012 00:00:00 GMT

To the Editor: Primary periodic paralyzes (PP) are autosomal dominant disorders of ion-channel dysfunction characterized by episodic flaccid weakness secondary to abnormal sarcolemmal excitability. Membrane destabilization due to involvement of Na,K-ATPase has been one of the hypothesis for bipolar disorders, and the therapeutic effect of lithium has been linked to it. We report a case of bipolar disorder (BD) co-occurring with periodic paralysis and response to lithium treatment.

Demonstration of Uniparental-Isodisomy on Chromosome 22q11.2 in a Patient With Childhood Schizophrenia and Facial Dysmorphology by Whole-Genome Analysis

Sun, 01 Jan 2012 00:00:00 GMT

To the Editor: Chromosome 22q11 and the gene/genes in this region that may be responsible for susceptibility to schizophrenia have been previously studied.⁺¹ We present a novel finding in schizophrenia that is a maternally-inherited uniparental disomy (UPD) on chromosome 22 cent-q11.2 in a female patient with disorganized behavior and psychotic symptoms.

Dystonia as a Presenting Feature of Alcohol Withdrawal

Sun, 01 Jan 2012 00:00:00 GMT

To the Editor: Dystonias are movement disorders in which sustained muscle contractions cause twisting and repetitive movements or abnormal postures.⁺¹ We present three interesting cases where dystonia and extrapyramidal symptoms were the presenting features of alcohol withdrawal.

Good Response to Clonidine in Tourette Syndrome Associated With Chromosomal Translocation Involving the IMMP2L Gene

Sun, 01 Jan 2012 00:00:00 GMT

To the Editor: Tourette syndrome (TS) is a neuropsychiatric condition characterized by childhood-onset multiple motor tics and at least one phonic tic, plus frequent comorbid behavioral problems.⁺¹ Despite the failure of genetic linkage studies to converge on specific candidate genes, a small number of chromosomal abnormalities have been found to co-occur with TS.^+(2,+3) Little is known about the clinical course and response to treatment of patients with TS associated with chromosomal abnormalities. We report the clinical outcome of a rare patient diagnosed with TS in association with loss of the IMMP2L gene by de-novo unbalanced chromosomal translocation.

Levocarnitine-Induced Hypophosphatemia in a Hemodialysis Patient With Acute Valproic Acid Toxicity

Sun, 01 Jan 2012 00:00:00 GMT

To the Editor: Levocarnitine is utilized for valproic acid overdose to prevent the formation of hepatotoxic metabolites. Levocarnitine has been shown to reduce phosphorus levels. We present a case where levocarnitine was administered for valproic acid toxicity and may have contributed to hypophosphatemia.

Psychosis in a Patient With Silent Vascular Brain Lesions

Sun, 01 Jan 2012 00:00:00 GMT

To the Editor: A plethora of information is available on psychiatric disorders after vascular brain lesions presenting clinically as stroke, but there is scant literature on silent vascular brain lesions or infarcts without any overt neurological signs or symptoms presenting with psychiatric disorders. The extant literature on silent brain infarctions has focused mainly on depression and, to some extent, on mania, while psychosis in this context has only been rarely described.^+1,+2 We describe a case of psychosis in a patient with silent vascular lesions in the right frontal lobe and discuss the interplay of cognitive deficits and psychiatric presentation in such cases.

Delusional Misidentification Syndrome: Right-Hemisphere Findings on SPECT

Sun, 01 Jan 2012 00:00:00 GMT

To the Editor: Delusional misidentification syndromes (DMS) are conditions in which affected individuals falsely believe that the identity of a person, object, or place has been altered. The most common DMS is the Capgras delusion, which is the belief that a person or persons have been replaced by imposters; 25%–40% of DMS cases have an identifiable neurological etiology.⁺¹ One specific type of misidentification, the “phantom boarder symptom” (PBS), in which affected individuals imagine that there are people in the home, has been identified in >20% of dementia patients.⁺² We report on a case of DMS associated with right-hemisphere dysfunction that most closely resembles PBS.

Successful Treatment of Olfactory Reference Syndrome With Paroxetine

Sun, 01 Jan 2012 00:00:00 GMT

To the Editor: Olfactory reference syndrome (ORS) is characterized by the erroneous belief that one emits an offensive body odor (which is not perceived by others) and that the odor displeases others.⁺¹ ORS is classified as a delusional disorder, somatoform disorder, obsessive-compulsive spectrum disorder, or social anxiety disorder in DSM-IV.^+2,+3 ORS also appears to share symptomatological similarities with jiko-shu-kyofu, which is a severe subtype of taijin kyofusho, described in DSM-IV as a culture-bound syndrome.⁺⁴ There is no consensus on diagnostic classification of ORS in the current diagnostic systems. Description of ORS cases can contribute to modifying its nosological status and promoting its recognition by physicians. Herein, we report a case of an ORS patient who had undergone polysurgery and showed good response to paroxetine monotherapy.

Mental Practice: A Psychotherapy to Improve Action-Selection in Obsessive-Compulsive Disorder

Sun, 01 Jan 2012 00:00:00 GMT

To the Editor: Action selection is the task by which an agent characterizes what to do next.⁺¹ In goal-directed behavior, deciding which action to take is biased by the prediction of the outcome. Differences between predicted and actual outcome (error signal) can be used to optimize the behavior.⁺² Obsessive-compulsive disorder (OCD) is an anxiety disorder that is related to inappropriate behavioral optimization, characterized by repetitive, interfering thoughts and compulsive behaviors. OCD patients tend to feel that something is wrong even when they perform correctly. This produces severe anxiety, which causes recurrent behaviors in order to decrease the emotional pressure.⁺³ The “hyperactive error-monitoring” hypothesis of OCD suggests that patients receive faulty error signals when they don't reach their goals, urging them to repeat their compulsive behaviors.⁺⁴ In machine-learning, “reinforcement learning theory” studies the way that artificial systems/agents can learn to predict the outcomes of their behaviors and optimize them in the environment to maximize some notion of cumulative reward.⁺⁵ In other words, reinforcement learning (RL) is learning how to map situations or states to actions in order to maximize a reward or minimize a punishment. Two of RL model components are the “policy function” and the “model of the environment.” Policy function maps the agent states to best actions, and model is described as anything that an agent can use to predict the environmental responses to its actions.⁺⁶ We hypothesize that the high error signals produced in the brain of OCD patients contribute to an inappropriate mapping of the state of the environment to a proper action (inappropriate action-selection). In RL language, we suggest that OCD patients suffer from an improper policy function. Hence, what these patients need as a therapy is a suitable way to improve their policy. One of the ways to improve policy in the RL domain is composed of two steps: 1) learning the model of “how the environment works;” and, 2) choosing “the best action,” given the current knowledge of the environment. Traditionally, cognitive-behavioral therapy (CBT) has been used as the most effective type of psychotherapy for this disorder. The patient is exposed many times to a situation that triggers the obsessive thoughts, and learns gradually to cope with the anxiety and resist the urge to perform the compulsion. Here, we propose a therapy that combines CBT and RL. This method, like above-mentioned RL method, consists of two steps, and, unlike CBT, this method does not need exposure to real situations. In this method, for the first step, the patient, with the help of the therapist, learns a model of the environment. In other words, the patient learns how the environment will respond to his or her actions. A model produces a prediction of the next state of the environment. In fact, the model is used to simulate the environment and produce simulated experience. With a learned model, the patient no longer needs real experiences and can use a model to produce simulated experience in the mind; so the patient can expose herself/himself to a simulated situation in his or her mind that triggers the obsessive thoughts, and, with the help of the learned model, predict the environmental response and then choose the best action mentally. So, this method is a mental practice that reduces the anxiety encountered by the patient in the real situation. We think that behavioral studies on several groups of OCD patients, comparing the results of our method with traditional methods, may be a good beginning for testing our hypothesis.

Asterixis (Flapping Tremors) As an Outcome of Complex Psychotropic Drug Interaction

Sun, 01 Jan 2012 00:00:00 GMT

To the Editor: Asterixis (flapping tremors) is an important clinical sign. It is not pathognomonic of any condition, but gives a clue to serious underlying disease processes. A few psychotropic drugs are also known to cause asterixis, especially when used in combination. Here, we report on a patient who developed asterixis on a combination of psychotropic agents: clozapine, sodium valproate, and risperidone. Asterixis (flapping tremors) is a motor disturbance marked by intermittent lapses of an assumed posture, as a result of intermittency of sustained contraction of groups of muscles. It was first described by Adams and Foley in 1949; it usually manifests as a bilateral flapping tremor at the wrist, metacarpo-phalangeal, and hip joints. It may also be seen in tongue, foot, and any skeletal muscle. Except for the facial muscles, the tremors occur in an asynchronous fashion on either side of the body.⁺¹ The exact mechanism by which asterixis occurs remains unknown. A leading theory suggests interruption of the posture pathway in the rostral reticular formation and abnormal joint proprioception. The lapse of posture has been termed “negative clonus” because, during tonic muscle contraction (i.e., posture), a short EMG silent period precedes the tremor. In essence, the patient struggles to maintain posture while posture-control repetitively vanishes.⁺² It is best demonstrated by extending the hand and dorsiflexing the hand. Common causes of asterixis are hepatic encephalopathy, renal failure, metabolic encephalopathy, CO2 toxicity, and Wilson's disease. A few psychotropic drugs are also associated with asterixis, and, most of the time, it is the combination of psychotropic drugs that can lead to asterixis. Here, we report on a patient who developed asterixis on a combination of psychotropic agents: clozapine, sodium valproate, and risperidone.

Auditory Hallucinations as the Only Presenting Symptom of Right-Parietal Spontaneous Hemorrhage: FDG-PET Evidence of Corpus Callosum Hyperactivity

Sun, 01 Jan 2012 00:00:00 GMT

To the Editor: Auditory hallucinations are very rare in stroke patients. We report FDG-PET findings in a case of hemorrhagic stroke presenting with auditory hallucinations.

Eating Disorder in Type 1 Diabetes Can Be Unmasked by Information Technology

Sun, 01 Jan 2012 00:00:00 GMT

To the Editor: In patients affected by type 1 diabetes mellitus (T1DM), the use of continuous subcutaneous insulin infusion (CSII) therapy has markedly increased in the last few years. In the medical literature, many studies demonstrated the efficacy of this therapeutic approach.⁺¹ However, some disadvantages must be mentioned, such as weight gain and increased risk of ketoacidosis.⁺²

Levomepromazine-Induced Retrograde Ejaculation

Sun, 01 Jan 2012 00:00:00 GMT

To the Editor: Levomepromazine, one of phenothiazines, has sedative properties and is used for the treatment of schizophrenia and schizoaffective disorder.⁺¹ Male patients with schizophrenia treated with antipsychotics can suffer from a variety of sexually disabling side effects,⁺² including retrograde ejaculation. Retrograde ejaculation has been reported in association with the use of risperidone.⁺³ Presented here is the case of a patient with schizophrenia who developed retrograde ejaculation in association with levomepromazine.

NeuroQuant® Revealed Hippocampal Atrophy in a Patient With Traumatic Brain Injury

Sun, 01 Jan 2012 00:00:00 GMT

To the Editor: This report describes the case of a 57-year-old man who was in an accident in which his vehicle was rear-ended by a tractor-trailer, leading to traumatic brain injury (TBI) and other injuries. His MRI brain data were analyzed with NeuroQuant®,⁺¹ an FDA-approved method for measuring brain volume.

Open-Lip Schizencephaly Associated With Bipolar Disorder in a Young Man Exposed in Utero to the Chernobyl Disaster

Sun, 01 Jan 2012 00:00:00 GMT

To the Editor: Schizencephaly, a rare neurodevelopmental disorder, consists of a cleft in the cerebral mantle, extending from the subarachnoid space to the ventricular system. Clefts are classified as closed- or open-lip. They may result from abnormal neuronal migration, alcohol abuse-related vascular insults, cytomegalovirus infection, abdominal trauma, or EMX2 mutation. Clinical features may include motor deficits, partial or generalized seizures, and mild-to-severe mental retardation.⁺¹ Associated psychiatric disorders were described only seldom.

Serotonin Toxicity in Aripiprazole Augmentation

Sun, 01 Jan 2012 00:00:00 GMT

To the Editor: Aripiprazole is approved for treatment of schizophrenia, bipolar disorder, irritability with autistic disorder, and as adjunctive treatment of major depressive disorder.⁺¹ Although atypical antypsychotics have lower potential for extrapyramidal symptoms, they are not completely without risk.⁺¹ We describe a patient who developed serotonin toxicity (ST) after a single dose of aripiprazole.

Successful Use of Quetiapine in Two Successive Pregnancies

Sun, 01 Jan 2012 00:00:00 GMT

To the Editor: Ethically, it is not possible to conduct randomized, controlled trials in pregnant women; hence, most of the data with respect to use of quetiapine in pregnancy is in the form of case reports, case series, and only few studies have reported its effect on pregnancy.⁺¹ However, there are no data with respect to use of quetiapine in successive pregnancies. We report on a patient who received quetiapine throughout two successive pregnancies.

17 Years of Treatment-Resistant Mutism in Non-Catatonic, Childhood-Onset Schizophrenia: A Rare Case Report

Sun, 01 Jan 2012 00:00:00 GMT

To the Editor: Mutism is one of the commonest psychopathological symptom manifestations seen especially in catatonic schizophrenia and may appear in several different clinical settings. Important organic causes of mutism include head injury; posterior fossa surgery; encephalitis; frontal lobe lesions; the post-ictal phase of epilepsy; laryngeal tumors; and endocrine disorders, including hyperparathyroidism, myxoedema, diabetic ketoacidosis, and Addison's disease. Medications capable of inducing mutism include tacrolimus and cyclosporine.^+1,+2 There are reports of mutism lasting for years in catatonic schizophrenia. The largest report on mutism associated with non-catatonic schizophrenia is from the Kosraean population, where it is described as a specific cultural variant of psychopathology. Mutism has lasted from a few days to 20 years in this community and is noted in the initial part of the illness, predicting relapse.⁺³ To our knowledge, only two cases of longstanding mutism associated with paranoid schizophrenia had been reported in the literature, but not in the pediatric age-group as yet.^+4,+5 We report the first case of longstanding, treatment-resistant mutism in childhood-onset, non-catatonic schizophrenia, which was repeatedly suspected to be of neurological nature and lasted for about 17 years from its onset without remission, observed and treated in a rural, tertiary-care psychiatric hospital in Central India.

Comorbid Multiple Sclerosis and TDP-43 Proteinopathy in a Gulf War Sea Captain

Sun, 01 Jan 2012 00:00:00 GMT

To the Editor: Multiple sclerosis (MS) is a complex trait inflammatory demyelinating disease, considered the most common cause of neurological disability in young adults.⁺¹ The disorder results from an interplay between as-yet unidentified environmental factors and susceptibility genes.⁺¹ Apart from infectious agents, an association with MS has been shown for various toxins, dietary factors, low sunlight exposure, and trauma. Cognitive dysfunction can begin during the early stages of disease, even in the absence of physical disability.⁺² The authors report on a patient with a history of MS and cognitive dysfunction encompassing progressive anomia and impaired word-comprehension, whose initial symptoms were putatively linked to being onboard a ship that caught fire during the Gulf War.

Late Onset of Psychotic Symptoms in a Patient With Cavum Septum Pellucidum and Cavum Vergae

Sun, 01 Jan 2012 00:00:00 GMT

To the Editor: Enlarged cavum septum pellucidi (CSP) and cavum vergae (CV) are associated with susceptibility to psychosis, unstable gait, and decreased mental status. One such rare case is presented along with discussion on psychiatrc symptomatology and its treatment.

Psychotic Episode During Steroid Therapy in Hashimoto Encephalopathy

Sun, 01 Jan 2012 00:00:00 GMT

To the Editor: Hashimoto encephalopathy (HE) is a rare, relapsing, steroid-responsive disease, associated with elevated blood concentrations of antithyroid antibodies. Clinical manifestations include a large variety of neuropsychiatric symptoms, such as cognitive deterioration, confusion, stupor, stroke-like episodes, seizures, tremor, myoclonus, behavioral changes, agitation, hallucinations, and psychosis.⁺¹

Sertraline-Induced Hyponatremia and Seizures in Old Age

Sun, 01 Jan 2012 00:00:00 GMT

To the Editor: Numerous case reports and observational studies have reported hyponatremia associated with selective serotonin reuptake inhibitor (SSRI) use.⁺¹ Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is postulated to be the cause of hyponatremia with SSRIs.⁺² Here, we present the case of an elderly gentleman developing hyponatremia and generalized convulsions immediately after initiation of sertraline treatment.

Successful Treatment of Benzodiazepine-Resistant Malignant Catatonia With Electroconvulsive Therapy

Sun, 01 Jan 2012 00:00:00 GMT

To the Editor: This report describes the case of a patient who presented with malignant catatonia (MC) that did not respond to benzodiazepine treatment but was treated successfully with ECT.

A Case of Auditory Hallucinations Due to Cerumen-Induced Transient Hearing Loss, Successfully Treated With Cerumenolysis, in a Patient With a Major Depressive Episode

Sun, 01 Jan 2012 00:00:00 GMT

To the Editor: We present, with interest, a case of a depressed gentleman, who suffered temporary hearing loss with subsequent auditory hallucinations:

Dandy Walker Variant With Treatment-Resistant Bipolar Disorder

Sun, 01 Jan 2012 00:00:00 GMT

To the Editor: Dandy Walker Variant is part of a continuum of developmental brain anomalies termed Dandy Walker Complex. The Variant is characterized by hypoplastic cerebella vermis, cystic dilatation of the fourth ventricle, and a normal posterior fossa. A literature search shows it has been reported in association with bipolar disorder I.^+1,+2