Alaattin Duran

Case Report: Clozapine use in two women with schizophrenia during pregnancy:

Stabilized patients who receive clozapine may wish to have children; but studies on pregnant women receiving clozapine treatment are limited. In this study, we report on clozapine use during pregnancy in two women. The first woman (Case 1) had two deliveries while she was receiving clozapine treatment for schizophrenia. Both her deliveries were term, uncomplicated vaginal deliveries, and the clozapine dose was reduced throughout pregnancy. The second woman (Case 2) developed schizophrenia after her first child was born. She became pregnant after clozapine initiation. She delivered twins by term, uncomplicated vaginal delivery. In our cases, no specific risks for the mothers and their children can be attributed to the use of clozapine. Physicians must be aware of the changes in fertility induced by prolactin-sparing drugs. Mothers who receive clozapine treatment should not be advised to breastfeed their children.

Factors associated with the duration of untreated illness among patients with obsessive compulsive disorder

BACKGROUND Patients suffering from obsessive compulsive disorder (OCD), despite heightened levels of functional impairment and disability, often wait several years before starting pharmacological treatment. The interval between the onset of a specific psychiatric disorder and administration of the first pharmacological treatment has been conceptualized as the duration of untreated illness (DUI). The DUI has been increasingly investigated as a predictor of long-term outcomes for OCD and other anxiety disorders. The present study investigated DUI, and demographic-clinical factors associated with DUI, among a sample of patients with OCD. The relationships between DUI, insight, and treatment outcomes were also assessed. METHODS We evaluated 96 subjects with a DSM-IV diagnosis of OCD using the Structured Clinical Interview for DSM-IV Axis I disorders, a semistructured interview for sociodemographic and clinical features, the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), and a questionnaire designed by our group to identify reasons for delaying psychiatric admission. Patients with OCD showed a mean DUI of 84 months. However, DUI was not predictive of remission defined by a Y-BOCS total score of 10. Using the median value, a categorical cut-off for DUI of 4 years was calculated. RESULTS For patients with a shorter DUI (≤4 years), the age of OCD onset was significantly older than patients with a longer DUI (>4 years) (p<.001). The following four items related to reasons for delaying treatment were significantly endorsed by patients: the fact that symptoms were spontaneously fluctuating over time (61.5%), believing that OCD symptoms were not associated with an illness (60.4%), believing that one can overcome symptoms by him/herself (55.2%), and not being significantly disturbed by OCD symptoms (33.3%). Delaying treatment because of perceived social stigma was only endorsed by 12.5% of patients. Believing that OCD symptoms were not associated with an illness was significantly associated with a longer DUI (p=.039). CONCLUSIONS Results from the present study suggest that patients with OCD show a significant inclination toward delaying treatment admission. However, DUI was not predictive of remission in terms of symptomatology. Believing that OCD symptoms are not associated with an illness might indicate impairment in insight, a denial of the problem or could be associated with awareness of OCD as a mental illness. Factors related to the nature and course of OCD appear to be important determinants in delaying treatment among patients with OCD.

P wave and QT changes among inpatients with schizophrenia after parenteral ziprasidone administration

OBJECTIVE Although ziprasidone has been reported to cause ventricular arrhythmias, there have been no studies regarding the influence of ziprasidone on atrial conduction. Intraatrial and interatrial conduction time prolongation and inhomogeneous propagation of sinus impulses are indicated by P wave changes on surface electrocardiography. We aimed to evaluate proneness to atrial fibrillation after intramuscular ziprasidone in drug-free inpatients with schizophrenia. METHODS We evaluated 11 eligible inpatients who were drug free for at least 4 weeks with a primary diagnosis of schizophrenia disorder and 11 healthy controls who were hospital staff members. Electrocardiography was performed at baseline and 1.5-2h after ziprasidone injection. A 12-lead surface electrocardiogram was obtained from each subject in the supine position at a paper speed of 50mm/s and 2mV/cm. RESULTS The changes between baseline and the period after parenteral ziprasidone administration in P-wave duration, P-wave dispersion, QTc, QTc(max), QTc(min), and QT dispersion variables were significant (p>0.05). The initial P-wave dispersion was significantly longer in patients than in healthy controls (p<0.05). There were no correlations between electrocardiography parameters and clinical severity scores or demographic variables in either group. CONCLUSION Intramuscular ziprasidone administration does not seem to influence atrial and ventricular electrical conduction in drug-free inpatients with schizophrenia. However, schizophrenia might affect atrial conduction resulting in atrial fibrillation, which may be a cause of some complications in inpatients with this schizophrenia.

Prolonged anorexia nervosa associated with female-to-male gender dysphoria: A case report.

Transsexual (TS) individuals seem to display an increased risk in having eating disorders. Several case reports describe TS individuals with anorexia nervosa (AN). In order to understand better the impact of gender dysphoria (GD) and hormonal/surgical treatments on the occurrence and course of eating disorders in TS patients long term follow-up studies are needed. We present here a 41-year-old female-to-male TS patient suffering from AN. History revealed that pathological eating habits could strongly be associated with her GD. Hormonal and surgical treatments resulted in substantial improvement in the given eating disorder. The impact of GD on the development and treatment of eating disorder is discussed in this report.

Effectiveness of olanzapine in neurosyphilis related organic psychosis: a case report.

The clinicians usually do not consider syphilis in the differential diagnosis for patients with acute and chronic psychiatric symptoms. To familiarize clinicians particularly with neurosyphilis (NS) and to discuss the atypical antipsychotic alternatives, we wish to present a case with agitated, resistant psychotic symptoms related to neurosyphilis. The case was a 55-year-old male who has had anxiety, irritability, auditory hallucinations, ataxia, dysarthric speech, paranoid and persecutory delusions and agitated behaviour. Parenteral ziprasidone 20 mg/bid was initialized at the first day of admission to reduce agitation. Then it was switched to olanzapine velotab 10 mg/bid because of inefficacy. Parenteral cephtriaxon 1 g/daily was administered because of seropositive VDRl and TPHA and positive cerebrospinal fluid VDRl. Olanzapine velotab may be a good alternative antipsychotic and should be considered in reducing agitation and psychotic symptoms in NS.

Clozapine treatment of refractory schizophrenia during essential chemotherapy: a case study and mini review of a clinical dilemma:

Background: Clozapine remains the antipsychotic of choice for refractory schizophrenia. Given the particular side effects of clozapine including neutropenia and myelosuppression, safety and efficacy of add-on chemotherapy for patients who are already under clozapine treatment remain unknown. Objective: We present evidence from a patient with a diagnosis of refractory schizophrenia on clozapine medication, who required essential chemotherapy for chronic lymphocytic leukemia (CLL). We have also reviewed literature regarding this challenging clinical dilemma. Method: We report details about a patient with treatment-resistant schizophrenia who was given chemotherapy (fludarabine, cyclophosphamide and rituximab) for CLL in the course of concomitant treatment with clozapine and granulocyte-colony stimulating factor (G-CSFs). In addition, we have reviewed literature using the PUBMED data base. Results: Current evidence remains insufficient to provide authoritative guide to clinicians regarding the efficacy and safety of the combined use of clozapine and chemotherapy. However, general conclusion from our case and of the published evidence is that a combination of clozapine use and chemotherapeutic agents do not cause additional hematological worsening with no decreasing efficacy concerns raised. Conclusion: Continuing with clozapine in the course of chemotherapy may be relatively safer for patients who responded well to clozapine concomitant with G-CSF treatment.

Neurological soft signs in antisocial men and relation with psychopathy

Neurological soft signs (NSS) were studied in some axis-I disorders like schizophrenia, obsessive compulsive disorder, bipolar disorder, alcohol and substance abuse disorder. Aim of this study is detection of neurological soft signs in antisocial personality disorder and relation of these signs with psychopathy. The study was included 41 antisocial men and 41 healthy control subjects. Sociodemographic form, neurological evaluation scale and Hare psychopathy checklist was applied to the antisocial subjects, whereas sociodemographic form and neurological evaluation scale were applied to the controls. Antisocial men exhibited significiantly more NSS in total score and subgroups scales (p<0.05). It was shown that there was a significant association with psychopathy scores and NSS sequencing complex motor tasks (r=0.309; p=0.049) and NSS other tests subgroup scores (r=0.328; p=0.037). Similar relation was also observed in comparison between psychopathy subgroups. NSS accepted as being endophenotypes in schizophrenia, were also detected in antisocial group significantly more than controls in our study. Significant relationship between psychopathy and NSS may also hint the role of genetic mechanisms in personality development, though new extended studies with larger sample size are needed for clarification of this relationship.

Decreased Expression of α-Synuclein, Nogo-A and UCH-L1 in Patients with Schizophrenia: A Preliminary Serum Study

Objective α-synuclein, Nogo-A and Ubiquitin C-terminal hydrolase L1 (UCH-L1) have neuromodulatory roles for human brain. Therefore, abnormalities of these molecules are associated with neuropsychiatric disorders. Although some serum studies in the other disorders have been made, serum study of α-synuclein, Nogo-A and UCH-L1 is not present in patients with schizophrenia and healthy controls. Therefore, our aim was to compare serum levels of α-synuclein, Nogo-A and UCH-L1 of the patients with schizophrenia and healthy controls. Methods Forty-four patients with schizophrenia who is followed by psychotic disorders unit, and 40 healthy control were included in this study. Socio-demographic form and Positive and Negative Syndrome Scale (PANSS) was applied to patients, and sociodemographic form was applied to control group. Fasting bloods were collected and the serum levels of α-synuclein, Nogo-A and UCH-L1 were measured by ELISA method. Results Serum α-synuclein [patient: 12.73 (5.18–31.84) ng/mL; control: 41.77 (15.12–66.98) ng/mL], Nogo-A [patient: 33.58 (3.09–77.26) ng/mL; control: 286.05 (136.56–346.82) ng/mL] and UCH-L1 [patient: 5.26 (1.64–10.87) ng/mL; control: 20.48 (11.01–20.81) ng/mL] levels of the patients with schizophrenia were significianly lower than healthy controls (p<0.001). Conclusion Our study results added new evidence for explaining the etiopathogenesis of schizophrenia on the basis of neurochemical markers.

Relationship between orthorexia and obsessive-compulsive symptoms in patients with generalised anxiety disorder, panic disorder and obsessive compulsive disorder -

Orthorexia nervosa (ON) refers to an intense desire to consume healthy or biologically pure food that is free of artificial products. ON is not regarded as a separate eating disorder, but its clinical presentation shares common features with obsessive-compulsive disorder (OCD) and eating disorders. The current study examined 136 patients who were diagnosed with OCD (n = 49), panic disorder (n = 44), and generalized anxiety disorder (n = 37). Padua Inventory Washington State University Revision (PI-WSUR), The Eating Attitudes Test-40 (EAT-40), and the ORTO-11 test were given to the participants. There were no significant differences between patient groups in the mean scores of eating attitudes and orthorexia symptom severity. No significant association between ORTO-11 scores and body mass index was noted. Moderate correlations (r > 0.30) were obtained between orthorexia symptom severity and obsessive-compulsive symptom severity, EAT-40 total score, and checking and dressing/grooming compulsions. These findings suggest that ON, a pathological inclination towards an obsession with healthy eating, is not specifically associated with any of the investigated illness groups. However, it has moderate correlations with the ritualistic signs of OCD. Underlying worry may predispose people to develop a compulsion to create the pure diet.

Effectiveness of ultra-rapid dose titration of clozapine for treatment-resistant bipolar mania: case series

Treatment of severe and refractory manic episodes in hospital settings can occasionally be very difficult. In particular, severely excited patients showing aggressive, hostile, impulsive behaviours frequently require physical restraint and seclusion, high doses of antipsychotics and benzodiazepines, and sometimes, electroconvulsive therapy. Hospital stay is generally prolonged and such patients cause great emotional distress for other patients in the ward and clinical staff involved in their care. Here we report on three patients with a diagnosis of bipolar disorder and one patient with a diagnosis of schizoaffective disorder bipolar subtype, all of whom were hospitalized for severe manic episodes with psychotic features. These patients were extremely difficult to manage in the ward as no response could be obtained in the first week of treatment despite high doses of antipsychotics and benzodiazepine administration. The introduction and rapid titration of clozapine proved remarkably effective and was well tolerated in the acute management of these patients. We observed that clozapine had a superior and fast mood stabilization effect with rapid titration and could be extremely helpful in the management of such patients.