Michele Raja

Transient mania with hypersexuality after surgery for high frequency stimulation of the subthalamic nucleus in Parkinson's disease

Among 30 Parkinsons disease patients who received high frequency stimulation of the subthalamic nucleus, 5 developed remarkable disorders of mood or sexual behavior after the implant. We describe 2 men who developed mania and hypersexuality a few days after the implant that lasted for some months and then gradually disappeared spontaneously.

Suicide risk in depression and bipolar disorder: Do impulsiveness-aggressiveness and pharmacotherapy predict suicidal intent?

The aims of the present study were to examine clinical, personality, and sociodemographic predictors of suicide risk in a sample of inpatients affected by major affective disorders. The participants were 74 inpatients affected by major depressive disorder or bipolar disorder-I. Patients completed a semi-structured interview, the Beck Hopelessness Scale, the Aggression Questionnaire, the Barratt Impulsiveness Scale, and the Hamilton scales for depression and anxiety. Over 52% of the patients were high suicide risks. Those at risk reported more severe depressive-anxious symptomatology, more impulsivity and more hostility. Impulsivity, the use of antidepressants, anxiety/somatization, and the use of mood stabilizers (a negative predictor) resulted in accurate predicting of suicide intent. Impulsivity and antidepressant use were the strongest predictors even after controlling for several sociodemographic and clinical variables.

AUTISM Spectrum Disorders and Suicidality

The paper describes the suicidal ideation and behavior in a series of 26 adult psychiatric patients affected by Autism Spectrum Disorders (ASDs), the clinical features and the psychiatric comorbidity of patients presenting suicidal behavior, and the history of suicide or suicide attempt in their relatives. Two (7,7%) patients committed suicide. One (3.8%) patient attempted suicide twice, and one (3.8%) patient self-harmed by cutting his face and one finger of his hand with a razor. Eight (30.8%) patients presented suicidal ideation. Two (7.7%) patients had one relative who had attempted suicide, and two (7.7%) patients had one or more relatives who had committed suicide. Most patients with suicidal behavior or ideation presented psychotic symptoms. Although it is not clear whether the high suicidal risk is related with ASDs per se or with psychotic symptoms, a high index of suspicion is warranted in evaluating suicidal risk in patients affected by ASDs, whatever is their age, psychiatric comorbidity, and setting of visit.

Clozapine safety, 40 years later.

Clozapine is, and will remain in the coming years, an irreplaceable drug in psychiatry which has elective indication in treatment-resistant schizophrenia, suicide risk in schizophrenia spectrum disorders, aggressiveness or violence in psychiatric patients, psychosis in Parkinsons disease, prevention and treatment of tardive dyskinesia. Unfortunately, the drug is largely underused for many and serious side effects. Only a good knowledge of these side effects and of the main strategies to prevent their occurrence or minimize their impact can allow overcoming the underutilization of this valuable therapy. The article describes the clinical and epidemiological features of the non-motor side effects of clozapine including blood dyscrasias, constipation, diabetes, enuresis, fever, hepatitis, hypersalivation, ileus, myocarditis, nephritis, priapism, seizures, serositis, weight gain and metabolic syndrome. The paper suggests several strategies, supported by scientific evidence, in the management of these side effects. The neuropsychiatric side effects of clozapine are not discussed in this review.

Asperger’s disorder in the emergency psychiatric setting

Abstract Asperger’s syndrome (AS) is a pervasive developmental disorder that may be unrecognized, especially if signs of other psychiatric disorders coexist. The objectives of this paper are: 1) to ascertain the prevalence of AS in the emergency psychiatric setting; and 2) to describe features of AS which may help to differentiate these patients from patients with psychotic disorders. Among 2500 patients admitted to a psychiatric intensive care unit, 5 (0.2%) received a diagnosis of AS, for the first time. Besides impairment of social interaction, common features were the following: male gender, left handedness, obsessive-compulsive symptoms, cognitive hyper-abilities, violent behavior, sense of humor, low WAIS total score, high WAIS verbal/performance score ratio, unusual, restricted interest and clumsiness. Comorbid schizophrenia is difficult to rule out in these patients. Psychotic symptoms should not be overvalued in making the diagnosis when specific features of AS are present.

Impulsive and compulsive behaviors during dopamine replacement treatment in Parkinson's Disease and other disorders

Impulsive and compulsive behaviors, including pathologic gambling, hypersexuality, compulsive shopping, compulsive eating, excessive engagement in hobbies, punding, and Dopamine Dysregulation Syndrome (DDS), are increasingly reported serious side-effects of dopaminergic medication, used in the treatment of Parkinsons Disease (PD) and other disorders. Dopamine Agonists (DA) are strongly related with Impulse Control Disorders (ICDs), while L-dopa is associated with DDS. The present paper focuses on ICDs. The estimated prevalence of ICDs in PD patients treated with DA is as high as 14%. ICDs pathophysiology is complex, due to multiple contributing factors. Dopamine neurotransmission along the meso-cortico-limbic pathway is a modulator of risk behavior and can be altered in PD and in the course of dopaminergic treatment. Psychiatric complications, associated with treatment of PD are still underdiagnosed, although their consequences can be serious, even catastrophic. Physicians treating PD with DA should warn the patients and their relatives of the risk of inducing ICDs. Psychiatrists should be trained to recognize these side effects, that can mimic primary psychiatric conditions. The management of ICDs includes discontinuation of DA or switching from DA to other drugs for the treatment of PD. Cognitive behavior therapy, serotonin selective reuptake inhibitors, nalmefene, zonisamide, low dose of anti-dopaminergic drugs, as quetiapine or clozapine, can be effective. Psychological, spiritual, and ethical support (familial or individual) can help.

Novel antipsychotics and acute dystonic reactions

The growing use of atypical antipsychotics has led to a decrease of acute dystonic reactions (ADR). To evaluate the prevalence of ADR, we recorded all ADR occurring in a population of patients consecutively admitted to a psychiatric intensive care unit. Among 1337 cases treated with antipsychotics, we observed 41 cases (3.1%) affected by ADR. At discharge, mean chlorpromazine-equivalent daily dose was 465.8 (+/-421.5) mg, while 39 cases (3.0%), all treated with typical neuroleptics, received anticholinergics. During hospitalization, 15 cases received quetiapine, 19 sertindole, 95 olanzapine, 142 clozapine, 495 risperidone and 561 typical neuroleptics. Four ADR occurred among the cases treated with risperidone monotherapy, and 4 occurred in risperidone-treated patients after emergency parenteral treatment with typical neuroleptics. In these last 4 cases, temporal relationship suggested that typical neuroleptics had caused ADR. One ADR occurred in a patient treated with olanzapine and 1 ADR in a patient treated with quetiapine. Among cases assuming typical neuroleptics, 32 ADR occurred. The difference between typical and atypical neuroleptics is highly significant (chi2 = 27.756; d.f. = 1; p = 0.000). Atypical antipsychotics carry a minimal risk of ADR.

Neuroleptic malignant syndrome and catatonia. A report of three cases.

SummaryIn a series of 1007 consecutively admitted patients, 3 cases of neuroleptic malignant syndrome (NMS) were identified (0.3%). All three patients were affected by mood disorders with congruent psychotic features, had shown catatonia just before the onset of NMS, and had been treated with low neuroleptic doses. All of them presented low serum iron levels. The relationship between NMS and catatonia and possible therapeutic decisions are discussed.

Improvement or worsening of psychotic symptoms after treatment with low doses of aripiprazole

Aripiprazole, an antipsychotic recently introduced for clinical use, may worsen psychotic symptoms, even at low dose. In other cases, aripiprazole may exercise an antipsychotic action and induce extrapyramidal side-effects, even at low dose. There are no clear-cut criteria to differentiate the patients whose psychotic symptoms will or will not respond to aripiprazole favourably. Conversely, the effectiveness on negative symptoms seem consistent both in patients with or without antipsychotic response. A low dose may be indicated at the beginning of treatment to assess the kind of response.

Oxcarbazepine vs. valproate in the treatment of mood and schizoaffective disorders

To compare the efficacy of oxcarbazepine (OXC) and valproate (VPA) in the treatment of mood and schizoaffective disorders, we retrospectively analysed data regarding 27 in-patients with mood or schizoaffective diagnosis treated with OXC (and other psychoactive drugs except VPA) and 27 matched in-patients treated with VPA (and other psychoactive drugs except OXC), in a psychiatric intensive care unit of a general hospital. In the evaluation of the outcome, we considered the length of hospitalization, the changes in the scores of BPRS, SAPS, SANS, MMSE, CGI, GAF, UPDRS, BAS, and Morrisons scale. The assessment of global psychopathology and functioning, of positive and mood symptoms suggested similar efficacy of OXC and VPA. Unexpectedly, OXC appeared more efficacious in the treatment of negative symptoms.