Evan Murray

The Role of Psychotic Disorders in Religious History Considered

The authors have analyzed the religious figures Abraham, Moses, Jesus, and St. Paul from a behavioral, neurologic, and neuropsychiatric perspective to determine whether new insights can be achieved about the nature of their revelations. Analysis reveals that these individuals had experiences that resemble those now defined as psychotic symptoms, suggesting that their experiences may have been manifestations of primary or mood disorder-associated psychotic disorders. The rationale for this proposal is discussed in each case with a differential diagnosis. Limitations inherent to a retrospective diagnostic examination are assessed. Social models of psychopathology and group dynamics are proposed as explanations for how followers were attracted and new belief systems emerged and were perpetuated. The authors suggest a new DSM diagnostic subcategory as a way to distinguish this type of psychiatric presentation. These findings support the possibility that persons with primary and mood disorder-associated psychotic symptoms have had a monumental influence on the shaping of Western civilization. It is hoped that these findings will translate into increased compassion and understanding for persons living with mental illness.

Cold elbow syndrome: Spurious slowing of ulnar nerve conduction velocity†‡

Low temperature decreases nerve conduction velocity (NCV). The across‐elbow segment of the ulnar nerve is superficial and may be particularly susceptible to decreased temperature. We evaluated patients without clinical ulnar neuropathy at the elbow (UNE) but with isolated slowing of the across‐elbow ulnar NCV (normal group), and patients with clinical and electrodiagnostic findings of UNE (UNE group). All subjects had ulnar motor nerve studies completed before and after warming. The mean across‐elbow NCV was 43.4 m/s and 48.6 m/s (P < 0.0001) in the normal group, and 37.4 m/s and 37.7 m/s (P = 0.90) in the UNE group, before and after warming, respectively. There was no change in the forearm segment NCV in either group. Seventeen of 32 subjects in the normal group had completely normal studies after warming. No patients with UNE developed normal across‐elbow NCV with warming. Low temperature slows across‐elbow ulnar NCV in normal subjects without impact on the forearm segment. Warming of the elbow improves across‐elbow ulnar NCV in normals, but does not reverse the abnormalities in patients with UNE. Elbow warming should become a routine part of ulnar nerve conduction studies, especially when there is isolated conduction slowing in the across‐elbow segment. Muscle Nerve, 2005

Mania following vagus nerve stimulation: A case report and review of the literature

Vagus nerve stimulation (VNS) is an increasingly used therapy for patients with treatment-refractory epilepsy and depression. Hypomanic and manic symptoms are a rare but recognized adverse effect of VNS treatment. Here we describe a case in which VNS treatment in a patient with epilepsy and unipolar depression was associated with the rapid development of manic symptoms. The patients manic symptoms resolved with temporary discontinuation of the VNS current, and the patient was eventually able to resume VNS treatment with good effect and without further manic symptoms. Mania is a rare but serious side effect of VNS; however, in this case and in the majority of reported cases of VNS-associated mania, symptoms resolve and VNS can be safely administered.

Neurosyphilis in psychiatric practice: a case-based discussion of clinical evaluation and diagnosis

OBJECTIVE Neurosyphilis can present with a wide range of neuropsychiatric symptoms. Hence, psychiatrists need to be familiar with tests for syphilis screening and how to interpret syphilis serologic tests. METHODS We present four cases of patients with positive syphilis tests encountered in a psychiatric hospital. RESULTS Two cases were treated for neurosyphilis, while the other two cases did not have active syphilis infection despite positive results. CONCLUSION We thus highlight the challenges encountered by psychiatrists in screening for and diagnosing cases of neurosyphilis.

The Clinical Significance of Bilateral Basal Ganglia Calcification Presenting With Mania and Delusions

The authors present the case of a 37-year-old man who developed a psychotic manic episode and was found to have bilateral basal ganglia calcification (BGC). The authors present this case report along with a discussion of the literature on the neuropsychiatry of BGC.

A Case Report of Confusional Psychosis with Abrupt Onset and Rapid Resolution of Symptoms

Psychiatric consultants are frequently asked to evaluate patients with acute confusion. Since confusion is a prominent symptom of delirium, a thorough medical and neurologic evaluation is always warranted. However, primary psychotic disorders should be considered in the differential diagnosis of confusion even though confusion-predominant psychotic disorders with an abrupt onset may not appear to be “psychiatric” in etiology. The Kraepelinian dichotomy of psychotic illnesses into schizophrenia and manic-depressive illness has had an enormous influence on the psychiatric classification. However, because Kraepelin emphasized the deteriorating course of schizophrenia, patients with psychotic illnesses and good outcome can be difficult to categorize. Cycloid psychosis, bouffee delirante, reactive psychosis, and atypical psychosis all describe transient psychotic disorders classifiable as neither schizophrenia nor manic-depressive illness. The existence of non-affective transient psychotic disorders is acknowledged in both ICD-10 and DSM-IV-TR. The ICD-10 classifies these transient psychotic disorders into the category of acute transient psychotic disorders (ATPD), while in DSM-IV-TR, brief psychotic disorder and schizophreniform disorder are designed to capture these remitting psychotic illnesses. We report the case of a young woman who presented with an acute change of behavior and prominent confusion, with rapid resolution of symptoms. We review cycloid psychosis and the ICD-10 classification scheme of transient psychotic syndromes to alert clinicians to rare yet well-described psychiatric syndromes that can mimic deliria or acute confusional states.

New-onset dissociative disorder after electroconvulsive therapy.

Electroconvulsive therapy (ECT) is an exceptionally effective treatment for a number of psychiatric conditions; however, a common adverse effect is temporary cognitive impairment, especially memory loss. The dissociative disorders also involve disturbances of memory, as well as consciousness and personal identity, but are rarely iatrogenic. We report a case in which dissociative symptoms developed after ECT. A 51-year-old woman with hypothyroidism, migraine headaches, bipolar disorder, and anorexia by history was admitted for worsening depression with suicidal ideation. After a course of 7 right-sided ECT treatments, she experienced remarkable personality change, claiming that it was 1976 and behaving as though she was 30 years younger. Neuropsychological tests were normal, and her memory and former personality spontaneously returned 2 weeks later. This case illustrates that such events may be seen in patients with certain psychiatric profiles, and further studies are needed to determine the risk factors for the occurrence of dissociative episodes after ECT.

Effective use of electroconvulsive therapy after craniofacial reconstructive surgery.

The present case report describes a 53-year-old male patient with long-standing, refractory major depressive disorder admitted for electroconvulsive therapy. The patient had a history of head trauma and was status-post craniofacial surgery with mesh and metallic implants. We describe the patients history and the concerns associated with performing electroconvulsive therapy on a patient with metallic skull implants, and we conclude with an account of successful treatment.

Retrospective Analysis of the Short-Term Safety of ECT in Patients With Neurological Comorbidities: A Guide for Pre-ECT Neurological Evaluations

Pre-ECT neurology consultations are often requested to determine the relative risk of the procedure in patients with neurological comorbidities, but there is limited data to guide clinicians. The authors performed a retrospective chart review of all consecutive inpatients at McLean Hospital who underwent a pre-ECT neurological evaluation between January 2012 and June 2014 (N=68). ECT was safe and effective in patients with a wide variety of neurological diseases. Only one minor event was related to a neurological comorbidity, and there were no serious neurological complications. Based on the latest evidence, the authors provide guidance on the pre-ECT evaluation with respect to neurologic status.

Brain and Behavior Relationships

Advances in the natural sciences and medicine have resulted in a shift from exclusively theological or philosophical explanations of human behavior to those that are subject to scientific methods. With this revolution in scientific thought has come the understanding that human behavior is the result of brain activity. Different brain regions are responsible for discrete functions. Emotions, behavior, and cognition are produced and controlled by widely distributed neural systems. The brain and, in turn, behavior are shaped by genetics and a host of environmental factors throughout life. New technologies, such as fMRI and PET, enable scientists to study brain function in vivo and are beginning to yield insights into mental illness and normal cognitive functions such as empathy and wisdom, which have traditionally been left to philosophical speculations. Developments in neuroscience hold great promise for continuing to shape our understanding of ourselves and our relationship with the world around us.