Tahir Rahman

Antipsychotic Treatment in Breast Cancer Patients

Special consideration is required when prescribing antipsychotic drugs for patients with an existing diagnosis of breast cancer. The package inserts of all approved antipsychotics contain precautions regarding their administration in this patient group. These drugs are well known to elevate serum prolactin levels to varying degrees. Overexpression of the prolactin receptor is seen in more than 95% of human breast cancers. Many genes that are activated by the prolactin receptor are associated with tumorigenesis and cancer cell proliferation. The authors discuss the pathophysiology, clinical implications, and pertinent preclinical data and make specific recommendations regarding the use of antipsychotics in patients with breast cancer.

Infanticide in a Case of Folie à Deux

We report a case of infanticide of a 4-month-old infant boy by starvation and dehydration. The parents were both charged with murder. The mother suffered from schizoaffective disorder, and the father was diagnosedwith shared psychotic disorder (folie a deux) by forensic assessment (T.R.). We describe the couple’s history, including a summary of their delusional beliefs, based on police reports, interrogation videos, an autopsy report, psychological tests, and interviews with several family members.

Capgras syndrome in homocystinuria.

To the Editor: We describe a 42 year-old woman hospitalized for delirium and Capgras delusions secondary to homocystinuria. To our knowledge, this description represents the first example of a delusional misidentification syndrome (DMS) in a patient with homocystinuria and supports the theory that neuronal dysfunction mediated by the N-methyl-D-aspartate (NMDA) receptor may be implicated in DMS (1). Capgras and Reboul-Lachaux first described Capgras syndrome in 1923. The syndrome comprises the delusional belief that family members or friends are imposters or “doubles.” This delusion is commonly seen in the context of an existing psychotic disorder, such as schizophrenia. Homocystinuria is a rare congenital metabolism error, commonly caused by deficiency of the enzyme cystathionine beta-synthase, which is vital in the production of the essential amino acid methionine. Metabolic consequences of homocystinuria include serum accumulation of the amino acid homocysteine (2). Psychiatric manifestations of homocystinuria often occur and include depression, obsessivecompulsive disorder, and psychosis (3). A 42-year-old, right-handed Caucasian woman with a history of pyridoxine-responsive homocystinuria (attributed to cystathionine beta-synthase deficiency) presented with an abrupt onset of delusions about family members and neighbors. These delusions included beliefs that neighbors were spying on her, that animal control officers threatened to harm her dogs, and that her parents had been replaced by imposters. She was taken to an emergency department 2 weeks after the onset of psychotic symptoms but was released when neuroimaging revealed no acute changes. However, her fear of persecution and agitation worsened. The family called emergency services 1 week later, at which point police brought her in for involuntary inpatient psychiatric hospitalization. Her past medical history is remarkable for sequelae typical of homocystinuria, including bilateral ectopia lentis, glaucoma, osteopenia, hypertension, and seizures. The diagnosis was made when the patient was 12 years old following a thromboembolic stroke that left her with residual left-sided spasticity. She was also found to have bilateral carotid artery occlusion, for which she underwent a bilateral carotid bypass graft procedure. She worked as a paraprofessional educator and was independent in terms of daily living activities except for driving because of visual acuity deficits. She denied use of alcohol, tobacco, or illicit substances. Mental status examination revealed a polite woman who was alert and generally cooperative during the interview process. Mild psychomotor slowing was present. Her speech was soft, monotonal, and goal-directed. Her affect was flat. She denied thoughts of self-harm and made no threats toward others. No hallucinations were present. Several bizarre delusions as described previously were present, although her neurologic examination was otherwise unremarkable. Her Mini-Mental State Examination score (4) was 18/30, missing points for memory, orientation, and attention. A comprehensive toxicology screen was negative for alcohol or illicit drugs. The patient was admitted to the inpatient psychiatric unit for assessment and treatment. A genetics consultant recommended immediate reinitiation of pyridoxine, folic acid, and betaine. A quantitative serum homocysteine

Extreme Overvalued Beliefs: How Violent Extremist Beliefs Become “Normalized”

Extreme overvalued beliefs (EOB) are rigidly held, non-deusional beliefs that are the motive behind most acts of terrorism and mass shootings. EOBs are differentiated from delusions and obsessions. The concept of an overvalued idea was first described by Wernicke and later applied to terrorism by McHugh. Our group of forensic psychiatrists (Rahman, Resnick, Harry) refined the definition as an aid in the differential diagnosis seen in acts of violence. The form and content of EOBs is discussed as well as group effects, conformity, and obedience to authority. Religious cults such as The People’s Temple, Heaven’s Gate, Aum Shinrikyo, and Islamic State (ISIS) and conspiracy beliefs such as assassinations, moon-hoax, and vaccine-induced autism beliefs are discussed using this construct. Finally, some concluding thoughts on countering violent extremism, including its online presence is discussed utilizing information learned from online eating disorders and consumer experience.