Cana Aksoy Poyraz

The impact of cognitive impairment, neurological soft signs and subdepressive symptoms on functional outcome in bipolar disorder.

BACKGROUND Cognitive impairments and subsyndromal depressive symptoms are present during euthymic periods of bipolar disorder (BD). Most studies have determined that cognitive impairments and residual depressive symptoms have major impacts on psychosocial functioning. The aim of the present study was to identify the major factor responsible for low psychosocial functioning in a subgroup of patients with BD despite clinical recovery. METHODS Sixty patients with bipolar I disorder and 41 healthy subjects were enrolled in this study. Cognitive performance, neurological soft signs (NSSs), psychosocial functioning, residual mood symptoms and illness characteristics were assessed. Using the median value of the Functioning Assessment Short Test (FAST) as the cut-off point, the patients were divided into two groups, high- (n=29) or low-functioning (n=31), and they were compared based on total NSS, residual depressive symptoms, cognitive performance and clinical variables. RESULTS Performances on the verbal memory tests and social functioning were significantly worse in the euthymic patients with BD. Increased rates of NSS were identified in the patients compared with the normal controls. The low-functioning patients performed significantly worse on verbal memory, and their NSS and residual depressive symptoms were significantly higher compared to high-functioning patients. In the regression analysis, subsyndromal depressive symptoms and verbal learning measures were identified as the best predictors of psychosocial functioning. LIMITATIONS The patients were artificially separated into two groups based on a FAST score cut-off. CONCLUSIONS In this study, residual depressive symptoms and verbal memory impairments were the most prominent factors associated with the level of functioning.

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.

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.

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.

T102C Polymorphism of Serotonin-2A Receptor Gene in Turkish Schizophrenia Patients: Association with Cognitive Impairment and Soft Neurological Signs

Aim: Previous studies have shown an association between the T102C polymorphism of the serotonin-2A receptor gene and schizophrenia. In addition, an association of this polymorphism with clinical phenotypes in schizophrenia such as treatment response and cognitive impairment has been observed. Materials and Methods: In this case-control study conducted in Turkish Caucasians, we compared T102C polymorphism genotype and allele frequencies in 76 schizophrenic patients and 165 healthy controls. We also investigated interaction of this polymorphism with clinical and cognitive variables in patients. Results: No significant difference was observed in the distribution of the three genotypes (T/T, T/C and C/C) and in the allele frequencies in controls and patients with schizophrenia. No evidence of association was detected at various clinical phenotypes including symptom severity, suicidality, treatment response, age of disease onset, number of hospitalizations and history of violence (in co-dominant, dominant, or recessive models). However, as compared to the C/C genotype, patients with 1 or 2 copies of the T allele were characterized by better stroop test performances and less “motor coordination” soft neurological signs. Conclusion: Further research is needed to elucidate the impact of T102C polymorphism on neurocognitive functions in both healthy and patient populations.

Olanzapine-induced atypical neuroleptic malignant syndrome in an adolescent man with anorexia nervosa

Anorexia nervosa (AN) is a serious mental illness that causes significant physical, emotional, cognitive, and social impairments. AN most often develops during adolescence or young adulthood and has high mortality and morbidity rates, in addition to cost burden. Current treatment of AN is multidisciplinary and is typically with a combination of medical, nutritional, and psychological interventions [1] . Antipsychotic medications have been especially used for weight gain and to treat body focused delusional thoughts in adolescent patients with AN [2]. Olanzapine is the most prominent second-generation antipsychotics (SGA) used for the treatment of this condition. However, although it is reported that these drugs are safe to use in adolescents with AN, side effects such as neuroleptic malignant syndrome (NMS) may vary in both the presenting and progressing features in patients with AN. NMS is a rare, idiosyncratic, and potentially fatal complication of antipsychotic medication. Cardinal features of NMS are muscle rigidity, hyperthermia, autonomic instability, and altered mental state. Laboratory findings are non-specific, but leukocytosis is common, and the levels of creatine kinase (CK) are often elevated. Approximately 66 % of NMS cases develop within the first week of initiating of antipsychotic treatment or a change of dose, and almost all cases develop within 30 days [1]. We report a case of an adolescent man with AN, who developed symptoms consistent with NMS after 2 days of treatment with a low dose of olanzapine, and although the symptoms of NMS had been resolved, these symptoms recurred after a month.

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.

Affective temperaments in subjects with female-to-male gender dysphoria

BACKGROUND Males and females have different temperaments. In individuals with gender dysphoria (GD) there is marked incongruence between a person׳s expressed/experienced gender and their biological sex. The present study aimed to investigate the most common affective temperaments in individuals with female-to-male (FtM) GD. METHODS We performed a prospective and comparative study investigating affective temperaments in subjects with FtM GD. Eighty subjects with FtM GD and 68 female controls were enrolled. The Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire (TEMPS-A) was completed by all participants. RESULTS TEMPS-A scores were significantly higher in subjects with FtM GD for hyperthymic temperament (p≤0.001), whereas depressive (p≤0.001), anxious (p≤0.001), and cyclothymic (p=0.028) temperament scores were significantly higher in female controls. LIMITATIONS The study was limited by the lack of male-to-female subjects and male controls. CONCLUSIONS The results of our study indicate that individuals with FtM GD have significantly higher scores of hyperthymic temperament, measured by TEMPS-A. Biological basis underlying the development of gender identity independent from the biological sex might be related with affective temperaments.

The role of affective temperaments and chronotype in pharmacotherapy response in patients with obsessive-compulsive disorder

ABSTRACT BACKGROUND: Comorbid mood disorders affect the prognosis of obsessive-compulsive disorder (OCD) negatively. Affective temperaments are assumed to be subsyndromal symptoms and precursors of mood disorders, but its effects on OCD outcome still remain unclear. There is a body of evidence, which supports the association between circadian rhythm disturbances and mood disorders in the literature. In contrast, there is limited data concerning the effects of chronobiological differences among the patients with OCD and OCD comorbid mood disorders. The main objective of this present study was to examine the clinical effects of affective temperaments and chronotype differences in patients with OCD. METHODS: The study participants were 76 patients with OCD, who have been under treatment at least for 12 weeks, and 55 healthy controls. The participants were administered the Yale-Brown Obsessive Compulsive Scale, Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Auto-questionnaire, Morningness and Eveningness Questionnaire, Hamilton Depression Rating Scale, and Hamilton Anxiety Scale. RESULTS: OCD patients scored higher in depressive, cyclothymic, irritable, and anxious temperament scores compared to the healthy controls. There were significant differences between patients with remission and not remission in depressive, cyclothymic, irritable, and anxious temperaments. Eveningness chronotype was more frequent in OCD patients; however, the difference was not statistically significant. CONCLUSIONS: Understanding the effects of affective temperaments and chronotype differences on the outcome of patients with OCD might provide valuable insights in developing new treatment approaches especially in treatment-resistant OCD cases.