Anthony Tobia

MELAS with recurrent complex partial seizures, nonconvulsive status epilepticus, psychosis, and behavioral disturbances: Case analysis with literature review

Mitochondrial encephalopathy, lactic acidosis, and strokelike episodes (MELAS) is a progressive neurodegenerative disorder associated with polygenetic, maternally inherited, mitochondrial DNA mutations. MELAS has multisystem presentation including neurological, muscular, endocrine, auditory, visual, cardiac, psychiatric, renal, gastrointestinal and dermatological symptoms. Clinical course and prognosis are variable, often leading to cognitive decline, disability, and premature death. Both convulsive status epilepticus (CSE) and nonconvulsive status epilepticus (NCSE) are reported with MELAS. This report illustrates a case of MELAS with recurrent complex partial seizures, NCSE, confusion, aggressive behaviors, hallucinations, and paranoid delusions. Rapid video/EEG confirmation of diagnosis and aggressive antiepileptic drug intervention are required. Further education of medical professionals regarding this disorder, its appropriate management, and the significance of NCSE is indicated to avoid delay of treatment.

Apparent dose-dependent levetiracetam-induced de novo major depression with suicidal behavior☆☆

Levetiracetam (LEV) is a novel antiepileptic drug (AED) approved for the adjunctive treatment of generalized and partial seizures. LEV has no clinically significant drug interactions and has limited adverse effects. The psychiatric adverse effects of LEV include de novo psychosis, affective disorder, and aggression. LEV-induced suicidal behavior has been reported infrequently with a past history of affective disorders. The authors report an apparent dose/concentration-dependent LEV-induced de novo major depression with near fatal suicide attempt in a patient without prior history of affective disorder. Psychiatric evaluation with emphasis on historic/current affective disorders, impulsive–aggressive behaviors, and assessment of risk factors for suicidal behaviors is indicated in treating patients with epilepsy with LEV. Clinicians should consider therapeutic drug monitoring to optimize therapeutic LEV treatment.

Management of Acute Alcohol Withdrawal Syndrome in Critically Ill Patients.

Approximately 16–31% of patients in the intensive care unit (ICU) have an alcohol use disorder and are at risk for developing alcohol withdrawal syndrome (AWS). Patients admitted to the ICU with AWS have an increased hospital and ICU length of stay, longer duration of mechanical ventilation, higher costs, and increased mortality compared with those admitted without an alcohol‐related disorder. Despite the high prevalence of AWS among ICU patients, no guidelines for the recognition or management of AWS or delirium tremens in the critically ill currently exist, leading to tremendous variability in clinical practice. Goals of care should include immediate management of dehydration, nutritional deficits, and electrolyte derangements; relief of withdrawal symptoms; prevention of progression of symptoms; and treatment of comorbid illnesses. Symptom‐triggered treatment of AWS with γ‐aminobutyric acid receptor agonists is the cornerstone of therapy. Benzodiazepines (BZDs) are most studied and are often the preferred first‐line agents due to their efficacy and safety profile. However, controversy still exists as to who should receive treatment, how to administer BZDs, and which BZD to use. Although most patients with AWS respond to usual doses of BZDs, ICU clinicians are challenged with managing BZD‐resistant patients. Recent literature has shown that using an early multimodal approach to managing BZD‐resistant patients appears beneficial in rapidly improving symptoms. This review highlights the results of recent promising studies published between 2011 and 2015 evaluating adjunctive therapies for BZD‐resistant alcohol withdrawal such as antiepileptics, baclofen, dexmedetomidine, ethanol, ketamine, phenobarbital, propofol, and ketamine. We provide guidance on the places in therapy for select agents for management of critically ill patients in the presence of AWS.

A Case of Sporadic Creutzfeldt-Jakob Disease Presenting as Conversion Disorder

Background. Creutzfeldt-Jakob disease is a rare disorder of the central nervous system. Its initial diagnosis may be obscured by its variable presentation. This case report illustrates the complexity of diagnosing this disease early in the clinical course, especially when the initial symptoms may be psychiatric. It offers a brief review of the literature and reinforces a role for consultation psychiatry services. Methods. PUBMED/MEDLINE was searched using the terms “Creutzfeldt-Jakob disease”, “psychiatric symptoms”, “conversion disorder”, “somatic symptom disorder”, “functional movement disorder”, and “functional neurologic disorder”. Case. The patient was a 64-year-old woman with no prior psychiatric history who was initially diagnosed with conversion disorder and unspecified anxiety disorder but soon thereafter was discovered to have Creutzfeldt-Jakob disease. Discussion. This case highlights the central role of psychiatric symptoms in early presentations of Creutzfeldt-Jakob disease. Still, few other cases in the literature report functional neurological symptoms as an initial sign. The consultation psychiatrist must remain alert to changing clinical symptoms, especially with uncharacteristic disease presentations.

Deconstructing the Film Sinister through the Lens of Psychiatry

Films have long entertained people and affected their attitudes regarding a multitude of issues including mental illness. Over the decades, movies have depicted various aspects of psychiatry ranging from acculturation to the patient-therapist relationship. This paper summarizes a case formulation of the film, Sinister, and demonstrates how introducing a trivial modification to the plot could transform the film into a teaching didactic on the Dissociative Disorders

Corrigendum to “A Case of Sporadic Creutzfeldt-Jakob Disease Presenting as Conversion Disorder”

[This corrects the article DOI: 10.1155/2017/2735329.].

Is the Film Unbreakable Really About PTSD with Dissociation

To the Editor: David Dunn, the protagonist in the filmUnbreakable (2000) by director M. Night Shyamalan, meets The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for posttraumatic stress disorder (PTSD) with dissociative symptoms [1]. Over the course of the film, David is prompted to recover memories and extraordinary physical abilities. We suggest that the emergence of David’s “unbreakable” strength is an exaggeration of psychophysiological phenomena related to dissociation [2].Unbreakable also depicts a potential treatment for PTSD, viz. exposure-based therapy [3]. This film highlights a burgeoning trend of portraying PTSD with dissociation in popular culture. As such, we have found it to be a useful teaching tool for medical students and trainees in psychiatry. David Dunn has had multiple experiences of threatened death, memories he manages via amnestic avoidance. David has restless sleep with nightmares related to the traumatic events in his life. He tells his wife, Audrey, that these nightmares co-occurred with his estrangement from her. David also expresses an inability to feel love and happiness and he appears apathetic for much of the film. In addition, David exhibits hypervigilance at his workplace as a stadium security guard, reacting with exaggerated sensitivity to the behaviors and appearances of various patrons. These symptoms seem to have been present for years and are not attributable to substance use or another medical condition. We hypothesize that David experienced dissociation following each trauma in his life. Following his near-drowning in a swimming pool as a child, David failed to come to terms with the feelings of helplessness and frailty that this event elicited. During those years, the football prodigy David emerged, the opposite of the frail, drowning David: physically powerful, reckless, and unmoored by a sense of vulnerability. But a second event once again induced dissociation inDavid: a near-fatal car accident with Audrey. With his great physical strength, David tore the car door off and saved his future wife. But in doing so, he associated his strength with the car accident, a traumatic memory of near-death. Thus, David’s strength was lost, linked to the sense of vulnerability that he had unknowingly harbored since childhood. Following his second trauma, David emerges as we see him at the start of the film, an apathetic middle-aged man with no great strength, suffering from social and occupational dysfunction related to PTSD. The film depicts prolonged exposure therapy. Following a train explosion in which he was the sole survivor, David meets Mr. Glass, the film’s antagonist. Mr. Glass forces David to face both frailty, illustrated by Mr. Glass’s osteogenesis imperfecta, and strength, represented byDavid’s survival of the train wreck. David also meets his former schoolteacher who cues him to recall thememory of his childhood near-drowning. Finally, near the end of the film, David falls into a pool, the setting of his original childhood trauma, and is pulled out by others. These events transform David and allow him to merge both his strength and vulnerability into his core self. Regarding research findings, evidence indicates that the dissociative subtype of PTSD is more common in those, such as David, who experienced childhood trauma [4]. A psychodynamic view would focus on how early trauma made it difficult for David to incorporate both strength and weakness into his core identity [5]. Thus, David Dunn presents both psychodynamic and criteriological features suggestive of PTSD with dissociative symptoms. The film “Unbreakable” can be viewed as a depiction of exposure and cognitive restructuring therapy for trauma. In our opinion, films like Unbreakable are compelling for multiple reasons. First, it is important that empathetic and reasonably realistic depictions of PTSD are found in the media. The symptoms of PTSD as well as the distress and impairment related to David’s trauma are apparent and welldepicted in Unbreakable. The serious genre of the film enables it to effectively convey the trauma and suffering of * Periel Shapiro ps819@rwjms.rutgers.edu

The Phantom of the Opera: A Case Study of Severe Major Depressive Disorder with Psychotic Features

Objective: Portrayals of psychiatry in the arts have been enjoyed by audiences for almost a century. Courses designed to teach psychopathology have used examples from the arts to emphasize major teaching points. This paper frames Elisabeth Kubler-Ross’s stage theory of grief within selected scenes of Andrew Lloyd Webber’s musical, The Phantom of the Opera, to achieve course objectives such as the etiology, course, and levels of severity of Major Depressive Disorder. Methods: Course content from our Psychopathology course was transformed into a dialogue between an examining psychiatrist and a Broadway performer who was in character. The performance was part of a special Grand Rounds reviewing the Mood Disorders. Results: Goals and objectives were readily achieved with over 450 faculties in attendance. Conclusions: Organizing a curriculum with performing arts is an innovative teaching method that allows for review of mental disorders such as those demonstrated in The Phantom of the Opera.

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

Background Delusional parasitosis is infrequently seen in hospital-based consultation–liaison psychiatry. Aims Although there are many publications on delusional parasitosis, this report reviews a unique case that was diagnosed during a hospital admission and treated over the next 36 months. Method Case report and literature review. Results This case report describes a 65-year-old man who was diagnosed with delusional parasitosis during a hospital admission for congestive heart failure and acute kidney injury. A longitudinal description of the patient’s condition during the hospital stay and in the 36 months following discharge, during which time he was treated by a consultation psychiatrist, is provided. Conclusions In discussing the treatment of a challenging presentation, this case demonstrates the opportunity for consultation psychiatrists to initiate care in patients who might not otherwise seek psychiatric services. Patients with somatic delusions represent one group of patients who are unlikely to independently seek psychiatric treatment. Declaration of interest None. Copyright and usage

Rounds with Dr. Seuss: Formulating a Case of Takotsubo Syndrome through Theodor Seuss Geisel’s How the Grinch Stole Christmas

To the Editor: At our medical school, psychopathology is taught to psychiatry residents in training through creative discussion of examples of mental disorders from film and literature. Our course, REDRUM (Reviewing [Mental] Disorders with a Reverent Understanding of the Macabre), has been previously described [1]. Given its popularity, course directors have implemented a modified version of REDRUM into the core Psychiatry clerkship by condensing the curriculum into a 6week didactics, FilmulationTM, that is broadcasted live over Periscope® for collaborating medical schools and residency training programs. Theodor Seuss Geisel’s first children’s book And to Think That I Saw It on Mulberry Street!was published on December 21, 1937. Twenty years later, Geisel began work on How the Grinch Stole Christmas [2] under the pseudonym of Dr. Seuss. We observe December 21 to commemorate Geisel’s works. This letter describes one example of FilmulationTM from our winter module on Mood Disorders and assimilates information from How the Grinch Stole Christmas, the 2000 film adaptation, and the musical adaptation to formulate what ails one of the most compelling characters of holiday lore.