Introduction. Stroke is a leading cause of mortality and morbidity in the United States. About 20&#37; of the stroke is hemorrhagic and about 50&#37; of these is due to aneurysmal subarachnoid hemorrhage. A troublesome neuropsychiatric complication of subarachnoid hemorrhage is agitation/aggression. Case Presentation. A 45-year-old man with no prior psychiatric history, sustained subarachnoid hemorrhage. After initial stabilization for 2 days, he underwent craniotomy and clipping of anterior cerebral communicating artery aneurysm. Treatment was continued with labetalol, nimodipine, and levetiracetam. Beginning postoperative day 4, patient developed episodes of confusion and agitation/aggression. Switching of Levetiracetam to valproate did not show any improvement. Psychiatry team tried to manage him with intense nursing intervention and different medications like olanzapine, valproate, lorazepam, and haloperidol. However, patient continued to be agitated and aggressive. Switching from labetalol to metoprolol resulted in dramatic improvement within 3 days. Discussion. Antipsychotics and benzodiazepines are often not sufficiently effective in the control of agitation/aggression in patients with traumatic brain injury and similar conditions. Our case report and the literature review including a cochrane review suggests that beta-blockers may be helpful in this situation.

Fayaz Ibrahim

Ramaswamy Viswanathan

Management of Agitation Following Aneurysmal  Subarachnoid Hemorrhage: Is There a Role for Beta-Blockers?

Functional neuroimaging is an innovative but at this stage underutilized method to assess the efficacy of psychotherapy for depression. Functional magnetic resonance imaging (fMRI) was used in this case study to examine changes in brain activity in a depressed breast cancer patient receiving an 8-session Behavioral Activation Treatment for Depression (BATD), based on the work of Hopko and Lejuez (2007). A music listening paradigm was used during fMRI brain scans to assess reward responsiveness at pre- and posttreatment. Following treatment, the patient exhibited attenuated depression and changes in blood oxygenation level dependence (BOLD) response in regions of the prefrontal cortex and the subgenual cingulate cortex. These preliminary findings outline a novel means to assess psychotherapy efficacy and suggest that BATD elicits functional brain changes in areas implicated in the pathophysiology of depression. Further research is necessary to explore neurobiological mechanisms of change in BATD, particularly the potential mediating effects of reward responsiveness and associated brain functioning.

Michael J. Gawrysiak

John P. Carvalho

Baxter P. Rogers

Christopher R. N. Nicholas

John H. Dougherty

Derek R. Hopko

Neural Changes following Behavioral Activation for a Depressed Breast Cancer Patient: A Functional MRI Case Study

Introduction. We present the case of a patient who developed lithium toxicity with normal therapeutic levels, as a result of pharmacokinetic interaction with Valsartan, and probable Neuroleptic Malignant Syndrome from the ensuing lithium toxicity. Case Presentation. A 59-year old black male with bipolar disorder maintained on lithium and fluphenazine therapy presented with a 2 week history of worsening confusion, tremor, and gait abnormality. He recently had his dose of Valsartan increased. At presentation, patient had signs of autonomic instability, he was confused, dehydrated, and had rigidity of upper extremities. Significant labs on admission were lithium level-1.2, elevated CK-6008, leukocytosis WBC-22, and renal impairment; Creatinine-4.1, BUN-35, HCO3-20.1, and blood glucose 145. CT/MRI brain showed old cerebral infarcts, and there was no evidence of an infective process. Lithium and fluphenazine were discontinued, his lithium levels gradually decreased, and he improved with supportive treatment including rehydration and correction of electrolyte imbalance. Conclusions. This case illustrates that lithium toxicity can occur within therapeutic levels, and the neurotoxic effect of lithium can include Neuroleptic Malignant Syndrome. Clinicians should be aware of the risk associated with drug interactions with lithium.

Osamede Edokpolo

Madiha Fyyaz

Lithium Toxicity and Neurologic Effects: Probable Neuroleptic Malignant Syndrome Resulting from Lithium Toxicity

Functional disorders in urology are troubling for both patients and physicians. Moreover, advances in recent research promise to provide biological insights into psycho-neuro-endocrino-immunological pathways that are one important facet of chronic urogenital inflammations. We present a case of a middle-aged woman with long-lasting recurrent cystitis for which especially a psychosomatic approach helped to understand and cure the disorder. Altogether, as practitioners treat subjects, not illnesses, a biopsychosocial understanding of human disease should be taken into account in cases of chronic recurrent cystitis.

Michael Noll-Hussong

Michael Autenrieth

Dan Pokorny

Simone Herberger

Dorothea Huber

The Subject, Its Biology, and the Chronic Recurrent Cystitis

We report the case of a 78-year-old male who developed acute pancreatitis related to quetiapine that was administered for the treatment of delirium. No evidence of hypertriglyceridemia, infection, ischemia, chololithiasis or hypercalcemia could be documented.Clinicians should be alerted when treating critical care patients with antipsychotics, as risks might present and potentially lead to hazardous results.

Evangelos Potolidis

Charalampos Mandros

Dimitrios Karakitsos

P. M. Kountra

Quetiapine-Associated Pancreatitis in a Geriatric Critical Care Patient with Delirium

A 24-year-old pregnant female patient presented with complains of bilateral lower limb swelling and fever for 1 month. On examination, blood pressure was 144/94&#x2009;mmHg along with pitting pedal edema. She had bizarre skin lesions, aligned longitudinally and distributed over the approachable site of the body with tapering ends and in various stages of healing. Lower limbs examination also revealed similar lesions with signs of cellulitis. Her scalp had short and distorted hair suggesting pulling and plucking. These skin lesions and the denial of self-infliction by the patient made us reach the diagnosis of dermatitis artefacta with trichotillomania. Psychotherapy was advocated along with conservative management of skin lesions. The patient improved and is under our follow up.

Neeraj Varyani

Sunny Garg

Garima Gupta

Shivendra Singh

Kamlakar Tripathi

Trichotillomania and Dermatitis Artefacta: A Rare Coexistence

Objective. Glutamate, an excitatory neurotransmitter in the central nervous system (CNS), may play a role in the development of anxiety. Memantine partially blocks N-methyl-D-aspartate (NMDA) receptors' glutamate channels located in the CNS. This paper evaluates memantine as an augmentation therapy for treatment of anxiety. Methods. 15 consecutive partially responding anxious patients were treated with adjunctive memantine for 10 weeks. Memantine was dosed 5&#x2013;20&#x2009;mg/day. Result. Memantine augmentation resulted in clinically relevant reduction in anxiety symptoms when compared to baseline. Forty percent of patients achieved remission (HAM-A &#x2265; 7). Memantine improved sleep quality. Mean dose was 14&#x2009;mg/d (range 5&#x2013;20&#x2009;mg/d). Typical adverse events included nausea and headache. Conclusion. The NMDA receptor antagonist memantine may be an effective augmentation therapy in patients with treatment-resistant anxiety.

Thomas L. Schwartz

Umar A. Siddiqui

Shafi Raza

Memantine as an Augmentation Therapy for Anxiety Disorders

This paper described the application of eye movement desensitization reprocessing (EMDR) for addressing the posttraumatic stress disorder (PTSD) symptoms in a Chinese woman who had experienced multiple traumas in her childhood. EMDR is an integrative therapeutic intervention that uses a standardized eight-phase approach to treatment. It is also a proven, effective, and efficient treatment for trauma. In this client with multiple traumas, the etiological event that lay the foundation of her dysfunctional responses was reprocessed first. The successful resolution of this event allowed the positive treatment effects to transfer to other traumatic events of a similar theme. This case also illustrates the importance of identifying a culturally appropriate positive cognition (PC) in contributing to the success of the treatment.

Maggie Wai-Ling Poon

EMDR in Competition with Fate: A Case Study in a Chinese Woman with Multiple Traumas

Research indicates that contingency management (CM) has potential to improve a number of outcomes (e.g. substance use, treatment attendance, quality of life) among individuals with substance use and cooccurring disorders. However, multiple factors must be considered on a case-by-case basis in order to promote optimal treatment effects. The present study describes an individualized CM protocol for a US Veteran with substance dependence and cooccurring severe mental illness. CM targeted attendance at outpatient appointments and appropriate use of hospital resources. Effects of CM were assessed by comparing the 3-month baseline and CM periods. The CM intervention marginally reduced unnecessary hospital admissions, resulting in cost savings to the medical center of over &#x24;5,000 in three months for this individual. However, CM did not affect outpatient attendance. Several complications arose, highlighting challenges in using CM in populations with substance use and cooccurring disorders. Practical suggestions are offered for maximizing the effects of CM.

Claire E. Adams

Carla J. Rash

Randy S. Burke

Jefferson D. Parker

Contingency Management for Patients with Cooccurring Disorders: Evaluation of a Case Study and Recommendations for Practitioners

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Case Reports in Psychiatry - Table of contents 2012

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Case Reports in Psychiatry publishes case reports and case series in all areas of psychiatry.

Case Reports in Psychiatry