OBJECTIVE:Antidepressant-induced manic shift is a known risk, even in patients without a recent history of mood episodes. In this case report, we will present a case of manic shift triggered by escitalopram use in an 88-year-old woman. CASE :An 88-year-old woman presented with depressive symptoms that emerged following the death of her daughter one year prior. Her symptoms included frequent reminiscing, crying spells, anger outbursts, restlessness, insomnia, fear of death, and self-harm. A review of the patients medical history revealed that she has maintained mood stability without psychiatric
treatment despite a two-month hospitalization over 55 years ago. However, neither the patient nor her family knew the exact diagnosis from her previous hospitalization. Initial treatment with escitalopram 5 mg/day and zopiclone 7.5 mg/night was prescribed for her current complaints but proved ineffective. Consequently, her regimen was adjusted to escitalopram 10 mg/day, mirtazapine 15 mg/day, and medazepam 10 mg/day. Two weeks into the revised treatment, the patient inadvertently took 20 mg of escitalopram instead of the prescribed 10 mg. This resulted in increased talkativeness, excessive energy, irritability, frequent singing, dancing, and psychomotor agitation. She was admitted to the psychiatric clinic with a preliminary diagnosis of mania. During hospitalization, escitalopram was tapered off while medazepam was continued. Olanzapine was introduced at 2.5 mg/day and gradually increased to 2.5 mg three times daily. After eight days of treatment, her symptoms remitted, and she was discharged with follow-up recommendations. Informed consent was obtained from the patient for the case report. DISCUSSION:This case highlights the risk of antidepressant-induced mania in elderly patients, even with prolonged mood stability. Age-related changes in metabolism and neurophysiology may increase this risk, making older patients more sensitive to relatively higher antidepressant doses. Therefore, tailored dosing, regular monitoring, and prompt intervention are essential to prevent psychiatric complications.
BACKGROUND AND AIM:Discrimination experienced by trans and gender diverse (TGD) individuals is closely associated with their mental health, well-being, and life satisfaction. Therefore, there is an increasing amount of research focused on discrimination in TGD. Everyday Discrimination Scale (EDS) is one of the prominent scales to assess individually perceived trans discrimination. This study aimed to investigate the psychometric properties of the Turkish version of the nine-item EDS in a sample of transgender and gender diverse people. METHODS (Ethics Committee Approval must be obtained and the number should be specified.):Ninety-two volunteering TGD respondents (69.7% recruited in a tertiary hospital setting) completed an online battery of questionnaires assessing sociodemographic and gender-affirming information, EDS, Perceived Individual-Based Discrimination Subscale (PIDS),
Depression Anxiety Stress Scale-21 (DASS-21). The Institutional Review Board at Hacettepe University approved the study (22.11.2022). RESULTS:Confirmatory factor analysis indicated a single-factor structure for the nine-item EDS in TGD people (?2 = (25) = 41.31, p <.05) with acceptable fit indices (?2/df = 1.65; RMSEA =.09; CFI =.97; GFI =.92). Moreover, positive and significant correlations were found between EDS and PIDS (r =.77, p <.01) and the subscales of the DASS-21, i.e., depression (r =.50, p <.01), anxiety (r =.55, p <.01), and stress (r =.51, p <.01). These findings respectively supported convergent and concurrent validities. The internal consistency Cronbachs alpha coefficient (.91) and corrected item-total correlations (r =.57 -.79) suggested reliability. The test-retest correlation was investigated in a smaller group (n = 7) within an eight-week interval, and it was significant (r =.95, p <.01). CONCLUSIONS:The current study provides initial findings on the psychometric properties of EDS in TGD populations and provides a valid and reliable research tool for further research on the discrimination and associated features in Turkish-speaking TGD people.
OBJECTIVE:The relationship between pancreatic diseases and psychiatric disorders has been widely studied. Depression rates in pancreatic disease patients range from 33% to 55%, and pancreatic cancer has the highest incidence of major depression among gastrointestinal tumors. This presentation aims to examine a case of anxiety and depression co-occurring with pancreatic disease and explore psychiatric comorbidities in relatives with various pancreatic diseases. CASE (The patient consent must be provided and specified with appropriate terms.):A 57-year-old male patient presented with symptoms of inner distress, restlessness, unhappiness, anhedonia, reluctance to leave the house, and suicidal thoughts. His mental status examination revealed symptoms of major depressive disorder (HAM-D: 31) and severe anxiety (HAM-A: 27). He was receiving mirtazapine 30 mg/day, olanzapine 2.5 mg/day, clonazepam 2 mg/day, and paroxetine 30 mg/day. Due to nausea, loss of appetite, and more than 10% weight loss in the past two months, lab results showed amylase 110 U/L, lipase 102 U/L, glucose 113 mg/dL, and GGT 199 mg/dL. A gastroenterology consultation revealed "Acute Edematous Pancreatitis" and hyperintense contrast in liver segments. Given liver dysfunction, psychiatric treatment was changed to escitalopram 20 mg/day and mianserin 30 mg/day.The patients history included his
mother being treated with ECT for major depressive disorder before being diagnosed with pancreatic cancer, and his maternal uncle experiencing chronic pancreatitis with mild to moderate anxiety. His maternal aunt had depressive episodes related to her pancreatic disease, and his cousin's daughter had died by suicide. Following symptomatic treatment, laboratory findings and clinical symptoms improved. The patients HAM-A and HAM-D scores also decreased, and he was discharged with recommendations for follow-up. Informed consent was obtained for this case report. DISCUSSION:Psychiatric comorbidity in pancreatic diseases is linked to both endocrine and exocrine secretions. Neuropeptide-Y and cholecystokinin-4 and -8 are potential mediators. CCK receptors have been shown to affect panic attacks and depressive symptoms. This family provides supporting evidence for these findings.
BACKGROUND AND AIM:Autism Spectrum Disorder (ASD) research has identified subclinical autistic traits (Broad Autism Phenotype, BAP), which negatively impact quality of life and psychiatric symptoms. Given the avoidance behaviors, sensory processing differences, and social-cognitive deficits in PD, exploring the role of autistic traits in disorder severity is warranted. This retrospective study examines autistic features in PD using the Autism Spectrum Questionnaire (AQ) and their relationship with changes in disorder severity over time. METHODS (Ethics Committee Approval must be obtained and the number should be specified.):This study employed a retrospective design, utilizing medical records from individuals diagnosed with PD at the psychiatry outpatient clinic of Dinar State Hospital. The Panic Disorder Severity Scale (PDSS) was administered at initial consultation (baseline) and at a one-month follow-up, as recorded in patient files. At the six-month visit, among those who continued regular follow-ups, 51 participants (Age: 42.2±10.2; M/F: 19/32) consented to completing the Autism Spectrum Questionnaire (AQ) alongside PDSS reassessment. Exclusion criteria included past or current psychotic disorders, bipolar disorder, alcohol/substance use disorder, and cognitive impairments affecting questionnaire completion. Data were analyzed using repeated-measures ANOVA in IBM SPSS (v25). Ethics approval: AFSU, 13.12.2024, T-2024/11. RESULTS:A significant linear reduction was observed in PDSS total scores across three time points (p <.001). AQ Attention Shifting scores were significantly associated with this reduction
(p=.042). PDSS Agoraphobia sub-scores also showed significant linear reduction (p <.001), correlating with AQ Total Score (p=.037), Communication (p=.041), Social Skills (p=.045), and Attention Switching (p=.010). CONCLUSIONS:The findings of this study suggest that the presence of more severe autistic traits may exert differential effects on the treatment resistance of PD, particularly in the domain of agoraphobia. In conclusion, higher autistic trait levels were associated with a less pronounced decrease in treatment in PD severity, particularly in the domain of agoraphobia.
OBJECTIVE:Frontotemporal lobar degeneration (FTLD) encompasses Frontotemporal Dementia (FTD) and Progressive Supranuclear Palsy (PSP). Of these two clinical conditions that may accompany each other, FTD is characterized by personality changes and executive dysfunction, while PSP is marked by vertical gaze palsy, postural instability, and early falls. Presenting with neuropsychiatric symptoms often leads to misdiagnosis as a psychiatric disorder, especially when early neurological examinations and imaging are unremarkable. This case addresses a patient initially diagnosed with conversion disorder but later identified as having PSP and FTD. CASE (The patient consent must be provided and specified with appropriate terms.):A 59-year-old woman presented with dizziness, imbalance, and frequent falls for two years, along with weight loss, fatigue, low mood, and anhedonia. Neurological and otorhinolaryngological evaluations were unremarkable. Due to persistent symptoms and preceding psychosocial stress, a psychiatric assessment suggested conversion disorder, and antidepressant treatment was initiated. Subsequently, she was hospitalized with ongoing and worsened symptoms to our clinic.Psychiatric examination revealed impaired self-care, reduced facial expression, anxious affect, hypophonic speech with poor rhythm and prosody, and echolalic repetition of the last syllables of her words. Her thoughts were concrete and simplistic, given her background.Her falls were without self-protective behavior or loss of consciousness. Montreal Cognitive Assessment (MoCA) score was 17, and the clock drawing test was poor. Neurological consultation was requested, revealing vertical gaze restriction, left eyelid ptosis, hypophonic speech, echolalia, bilateral bradykinesia, mild rigidity, impaired tandem gait, postural instability, and hyperactive deep tendon reflexes. Neuropsychological testing indicated deficits in visuospatial skills, executive function, and memory. PET/MRI and DAT-SCAN confirmed
frontotemporal lobar degeneration. Informed consent was obtained from the patient and her relative. DISCUSSION:This case highlights the challenge of differentiating neuropsychiatric symptoms of neurodegenerative diseases from primary psychiatric disorders. An interdisciplinary approach is essential for precise diagnosis and effective management.
Dilara Nur Yılmaz, Eren Yıldızhan, Büşra Güney Taşdemir, Mustafa Nuray Namlı
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OBJECTIVE:Subacute Subdural Hematoma (SDH) is characterized by detection of hematoma usually 3 days to 3 weeks after head injury. Burr hole surgery is the main treatment intervention for chronic SDH. We present a case of a subacute SDH in a patient with schizophrenia, and the patient refused surgical interventions for SDH. Our aim is providing clinicians insight about this difficult situation managed with ciritical decisions of the patient, family and treating physicians. CASE (The patient consent must be provided and specified with appropriate terms.):The patient was a 32-year-old female with 8-year history of schizophrenia and she was admitted to the inpatient clinic because of treatment refusal. Her psychiatric examination revealed blunted affect, dysphoric mood, grandiose delusions, auditory and visual hallucinations, and disorganized speech with the absence of insight. Positive and Negative Syndrome Scale (PANSS) score was 91 upon admission. In cranial MRI, subacute SDH with a size of 25 mm in left frontoparietal location; leading to mild shift midline structures was detected. There was no neurological symptoms. Despite neurosurgical consultation recommending surgery, the patient refused any surgical intervention, but she complied with non-surgical treatments. Given that the surgery was not urgent, decision was made for close neurological monitoring. The initial psyhciatric treatment was olanzapine 20 mg/day; later, aripiprazol up to 30 mg/day was added because of treatment resistance regarding positive symptoms. During discharge after 55 days of psychiatric hospitalization, the SDH had regressed to 16 mm, and there was minimal improvement in psychotic symptoms (PANSS score: 81). In the outpatient follow-up examination after a month with regular antipsychotic treatment; there was complete regression of the SDH and her control PANSS score was 77. (The patient's legal representative provided written informed consent for publication of this case.)
DISCUSSION:Treatment refusal in psychotic patients presents ethical challenges. Clinicians must balance respecting patient and caregiver desicions with ensuring appropriate medical interventions.
OBJECTIVE:Lithium is the gold standard for treating bipolar affective disorder. However, its narrow therapeutic range and side effects limit its use. This case report aims to discuss the development of nephrogenic diabetes insipidus (NDI) due to irregular lithium use and a weight loss drug containing borax pentahydrate. CASE (The patient consent must be provided and specified with appropriate terms.):: A 46-year-old female patient, diagnosed with bipolar affective disorder 25 years ago, was admitted with a manic episode. She had been using lithium regularly for two years but began using it irregularly over the last two months. Additionally, she had taken a weight loss drug containing borax pentahydrate, purchased online. During clinical follow-up, laboratory tests revealed hypernatremia, hyperchloremia, and a decreased glomerular filtration rate (GFR). Following a nephrology consultation, NDI was diagnosed, and lithium treatment was discontinued. The patient received intravenous hydration, and both GFR and electrolyte levels normalized within two weeks. However, polyuria and polydipsia persisted for about a month. Written consent was obtained for the case report. DISCUSSION:NDI can occur in patients using lithium and is usually reversible. However, in some cases, recovery may take months or even be permanent, as seen here. The weight loss drug used by the patient contained not only borax pentahydrate but also Epsom salt, magnesium, zinc, mate leaf extract, and potassium sorbate. The effects of these substances and their combinations are poorly understood. Borax pentahydrate, in particular, can be toxic to kidneys, as it is absorbed in the gastrointestinal system and excreted through the kidneys. This case suggests that the weight loss drug exacerbated lithiums nephrotoxic effects. This report emphasizes the risk of unregulated supplements and the importance of monitoring renal function in lithium users.
İldeniz Tolga Uzun, Eren Yıldızhan, Aslı Aytulun, Mustafa Nuray Namlı
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OBJECTIVE:Rabbit syndrome is a movement disorder characterized by involuntary, fine, rhythmic, perioral extrapyramidal movements associated with use of neuroleptics. It is more commonly observed in middle-aged and elderly patients, as well as in women. This case aims to present rabbit syndrome in a female patient with recurrent catatonia who was started on lurasidone due to depressive symptoms. CASE (The patient consent must be provided and specified with appropriate terms.):A 68-year-old female patient presented to our clinic with complaints of anxiety, anhedonia, mutism, and refusal to eat or drink following a knee prothesis surgery. She had experienced similar symptoms after a cholecystectomy surgery in 2018. The patient was admitted to our service with the diagnosis of bipolar disorder; depressive episode with catatonic features. She scored 20 on the Bush-Francis Catatonia Rating Scale. Since oral diazepam treatment was ineffective, 11 sessions of electroconvulsive therapy administered, and the catatonic symptoms improved. Initial medications were olanzapine 10 mg/day and escitalopram 20 mg/day, however, as her depressive symptoms continued, olanzapine and escitalopram were discontinued, and lurasidone 80 mg/day was initiated. Five days after initiating lurasidone, rhythmic tremor-like movement were observed in the perioral muscles and the mandible, consistent with rabbit syndrome. Symptoms resolved four days after discontinuing lurasidone. The abnormal involuntary movement scale score decreased from 18 to 0. Her outpatient treatment was finalized as ketiapin 300 mg/day and duloxetine 60 mg/day. (Written informed consent was obtained for the publication of case). DISCUSSION:In the literature, there is also another case of rabbit syndrome associated with lurasidone (Reichenberg et al. 2017). While rabbit syndrome is often a late-onset side effect of antipsychotics, its appearance on the 5th day is noteworthy. Our case highlights that lurasidone can also cause extrapyramidal side effects (EPS), requiring caution, especially in patients with a prior history of EPS or catatonia.
OBJECTIVE:Trichotillomania (hair-pulling disorder) is a chronic psychiatric condition characterized by recurrent, compulsive hair-pulling resulting in hair loss, significant distress, and impaired functioning. Although selective serotonin reuptake inhibitors (SSRIs) and atypical antipsychotics have been commonly utilized in treatment, their efficacy remains limited. This report presents a case of trichotillomania successfully treated with naltrexone monotherapy, with clinical response objectively evaluated using the Massachusetts General Hospital Hairpulling Scale (MGH-HS). CASE (The patient consent must be provided and specified with appropriate terms.):An 18-year-old single female with a 3-year history of trichotillomania was referred for evaluation. The patient had no comorbid psychiatric or medical disorders. Previous trials with sertraline (100 mg/day), escitalopram (20 mg/day), and risperidone (1 mg/day) failed to yield significant improvement. Naltrexone was initiated at 25 mg/day, with the dose increased to 50 mg/day after one week. Symptom severity was assessed using the MGH-HS, with an initial score of 20, indicating severe hair-pulling behavior. By the second week of treatment, a significant reduction in symptoms was noted, with the MGH-HS score decreasing to 13. At the end of two months, the patient achieved marked improvement, reflected in an MGH-HS score of 5, indicating mild residual symptoms. No adverse effects were reported during the course of treatment. (Informed consent was obtained from the patient.) DISCUSSION:This case highlights the potential utility of naltrexone, an opioid receptor antagonist, in the management of trichotillomania. Naltrexones efficacy may be linked to its modulation of the endogenous opioid system, which plays a critical role in reward-related behaviors. The patients rapid clinical response, objectively supported by a significant reduction in MGH-HS scores, underscores the therapeutic potential of naltrexone in trichotillomania, particularly in treatment-resistant cases. Further controlled trials are warranted to establish its efficacy, optimal dosing, and long-term safety profile in this population.
OBJECTIVE:The prevalence of comorbid bipolar disorder (BD) and eating disorders (ED) ranges from 1.9% to 35.8%. A systematic review found varying BD-ED comorbidity rates across ED subtypes: binge eating disorder (12.5%), bulimia nervosa (7.4%), and anorexia nervosa (3.8%). BD patients are more likely to have binge/purge ED subtypes, linked to impulsivity and emotion dysregulation. This co-occurrence complicates treatment and leads to poorer outcomes, higher suicide risk, and lower quality of life. CASE (The patient consent must be provided and specified with appropriate terms.):A 20-year-old female patient diagnosed with BD is treated with valproic acid 1500 mg/day and aripiprazole 10 mg/day. Due to the seasonal nature of her illness, she experiences depressed mood, anhedonia and anergy during the winter. And sertraline 50 mg/day was added to her treatment. Binge eating episodes occurred during the depressive episodes. The patient didn't show laxative or purgative use, excessive exercise, or self-induced vomiting after binge eating. Therefore, naltrexone 50 mg/day was added to the treatment and the aripiprazole dose was increased to 15 mg/day for impulse control. Cognitive behavioural therapy (CBT) was started to treat depressed mood and binge eating. During follow-up, binge eating symptoms decreased when the depressive episode entered remission. Informed consent was obtained from that patient. DISCUSSION:BD and ED share significant phenomenological similarities in mood, weight maintenance, altered eating behavior, impulses, and activity control. Patients with BD and ED may require specific treatment considerations. At the psychotherapeutic level, as McElroy et al. have argued, CBT or schema-based approaches, which are effective for ED and could be applied for patients with BD as comorbidity. At the pharmacotherapy level, medication selection should consider the metabolic side effects of mood stabilizers and antipsychotics. BD patients should be assessed for comorbid EDs to ensure an optimal treatment program. These findings highlight the need for tailored interventions and comprehensive clinical management for individuals with both disorders.
Güssüm Bakırcı, Rukiye Ay Diker, Hilal Büşra Ardıç Usta
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OBJECTIVE:Restless Genital Syndrome (RGS) is defined as "spontaneous, intrusive and unwanted genital arousal in the absence of sexual interest and desire." RGS is conceptualized as a somatosensory dysfunction resulting from dysfunction in the terminal sensory branches of the pudendal nerve or pelvic vasocongestion. Here, we present a case referred from a gynecology clinic to psychiatry due to RGS symptoms. Written and verbal consent was obtained from the patient. CASE (The patient consent must be provided and specified with appropriate terms.):A 32-year-old female, married for three years, presented to the gynecology clinic with complaints of genital arousal occurring without sexual desire/urge, persisting even after sexual intercourse, causing discomfort, lasting throughout the day, and impairing functionality, which was ongoing for approximately five months. Gynecological examination and ultrasonographic evaluations were deemed normal. She was referred to psychiatry with a diagnosis of RGS. At an external center, the patient was prescribed hyoscine-N-butyl bromide and medazepam at a dose of 1*1. Due to the risk of dependency, the current treatment was discontinued. One week later, following an increase in symptoms, Duloxetine 30 mg at a dosage of 1*1 was initiated. Approximately one month later, the patients symptoms completely resolved, and she remained in remission. DISCUSSION:Neurological, psychological, or vascular theories are suggested in the etiology of RGS. Various treatment options for RGS include local anesthetics, pelvic floor exercises, pharmacotherapy (e.g., dopamine agonists, antidepressants). Duloxetine, which is a serotonin and norepinephrine reuptake inhibitor, is commonly used for depression, anxiety disorders, diabetic neuropathy-related pain, and fibromyalgia. The efficacy of Duloxetine in this case might be attributed to its ability to increase the tone of descending inhibitory pain pathways in the brain and spinal cord through monoamines. Additionally, it may exert an inhibitory effect on sacral and/or thoracolumbar neurons involved in genital sexual arousal and orgasm.
OBJECTIVE Bipolar disorder is a chronic, recurrent affective disorder marked by manic, hypomanic, and depressive episodes. In women, childbirth significantly influences its onset and trajectory. Clinical and genetic evidence suggests postpartum psychosis represents a bipolar manifestation. This case explores the rapid onset of postpartum mania with psychotic features following twin delivery, highlighting the interplay between perinatal factors and bipolar disorder's pathophysiology. CASE A 26-year-old married woman, a university graduate and mother of two, was brought to the emergency department with irritability and excessive talking. Her symptoms began after the cesarean delivery of her monozygotic twins. Within two weeks, she developed persecutory and grandiose delusions, alongside manic symptoms such as irritability, pressured speech, and behavioral changes. She was admitted for further evaluation. Laboratory tests, EEG, and MRI were unremarkable. There was no personal or family psychiatric history. She was diagnosed with manic attack with psychotic features with peripartum onset and treated with Olanzapine (5 mg/day), Biperiden (2 mg/day), Haloperidol (2.5 mg/day), and Quetiapine (12.5 mg/day). Her symptoms improved significantly within six days, allowing discharge with continued outpatient treatment. Informed consent was obtained. DISCUSSION The etiology of postpartum mood disorders and psychotic episodes is multifactorial, with hormonal changes playing a crucial role. During pregnancy, estrogen and progesterone levels rise exponentially and drop sharply after delivery. Estrogen influences the hypothalamic dopaminergic system, and its decline may increase dopamine receptor sensitivity, potentially triggering psychotic symptoms. Animal studies suggest postpartum glucocorticoid secretion is regulated by the dopaminergic system. High oxytocin metabolite levels have been detected in postpartum mania. In this case, the rapid onset of psychotic mania following twin delivery suggests a hormonal trigger. Postpartum psychosis is primarily linked to bipolar disorder, often coinciding with reproductive years. In our case, a manic episode with psychotic features and peripartum onset was the most appropriate diagnosis.
OBJECTIVE:This study presents a case report examining how the subjugation schema can be transformed using Archetypal Processing of Schemas Technique. The client struggled with acting independently against his father's authority, and experiential techniques were used to work with unconscious imagery. Dysfunctional schemas were externalized through Jungian archetypes. CASE (The patient consent must be provided and specified with appropriate terms.):Informed consent was obtained from the 35-year-old male patient. This approach allowed the client to engage with the schema in a less direct yet deeply immersive manner. Session Dialogue: Therapist: Close your eyes and imagine yourself on a journey through nature. You are surrounded by trees, the sound of the wind, and the scent of the earth. As you walk, notice what form the schema you carry within takes. Now, recall one of the difficult moments in your life. Visualize the scene from last week when you were sitting across from your father at work. What did you feel in that moment? Now, What images does nature bring to you? Simply observe the images that your mind naturally creates. What do you see? Client: I see a river. But there is a huge rock in front of it. The river wants to flow, but the rock is blocking its way. The river and rock metaphor represented the clients internal conflict and feelings of being blocked by his fathers authority. Archetypal Processing of Schemas facilitated the externalization and transformation of the clients inner conflicts through metaphors. In the following sessions, the client's resistance was resolved. DISCUSSION:Archetypal Processing of Schemas developed by Serdar Atik in 2021, provided a structured approach for externalizing and transforming the subjugation schema through symbolic imagery. By utilizing Jungian imagery and experiential techniques, this method allowed the client to process their schema in a less confrontational yet deeply impactful manner, leading to a shift in their internal experience and emotional response.
Halil İbrahim Yamaç, Mustafa Onur Zeybek, Mahmut Selçuk
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OBJECTIVE:Insula in various experimental and clinical studies; has been shown to be linked to mood. This case will present a patient diagnosed with who experienced an infarction in the subinsular region during a manic episode and the elevation observed in her mood following the infarction. CASE (The patient consent must be provided and specified with appropriate terms.):A 56-year-old, single female patient was diagnosed with Bipolar Affective Disorder 22 years ago. She was admitted to our service with a manic episode. During the psychiatric evaluation at admission, her mood was elevated and euphoric. On the 26th day of her hospitalization, her euphoria had diminished, her mood and affect were labile, she had no irritability. On the 27th day of her hospitalization, she presented with complaints and findings of inability to articulate, difficulty in finding words, and facial asymmetry, leading to a diffusion MRI. The diffusion MRI reported a focal active stage ischemic focus extending from the right lateral ventricle body to the subinsular region, with diffusion restriction. The patient was referred to neurology, and treatment with acetylsalicylic acid 100 mg and clopidogrel 75 mg was initiated. Follow-up psychiatric evaluations revealed irritability, psychomotor agitation, and excitation in the patient. On the first day of hospitalization, the young mania score was 27, 18 before the infarction, and 27 after the infarction. A significant regression was observed in manic symptoms after infarction treatment. Written informed consent was obtained. DISCUSSION:It has been documented in the literature that subinsular region infarction is rare and occurs in 0.4% of all ischemic brain infarctions. The elevation in mood observed in this patient following an infarction in the subinsular area demonstrates the importance of the insular cortex in emotional functions.
Mustafa Onur Zeybek, Halil İbrahim Yamaç, Mahmut Selçuk
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OBJECTIVE:This case report details presentation of myocarditis occurring on the 12th day of clozapine administration in a patient with treatment-resistant bipolar disorder manifesting as a
psychotic manic episode, subsequently diagnosed as schizoaffective disorder. CASE :32-years-old, single, female patient with no medical history and complaints of grandiosity, diminished sleep requirement, erotomanic and persecutory delusions, admitted to the inpatient service with diagnosis of first attack psychotic manic episode. Patient demonstrated therapeutic unresponsiveness to lithium, olanzapine, risperidone, paliperidone and aripiprazole. On the 53rd day of hospitalization, while maintained on lithium 1200mg/day and olanzapine 20mg/day, it was planned to discontinue olanzapine and initiate clozapine. On day 12 of clozapine treatment, while taking a dose of 175mg/day clozapine, patient developed fever up to 38°c and reported no complaints other than fatigue, there were no findings other than hypotension and fever. Tests revealed CRP: 10,33 mg/L, WBC: 20110 g/L, Neutrophil: 17920 g/L, Eosinophil: 460 g/L. No active infection focus was found, echocardiography was normal. On day 15, hypotension and fever up to 40°c developed. Tests showed CRP: 139,87 mg/L, WBC: 19130 g/L, Neutrophil: 15550 g/L, Eosinophil: 830 g/L, Troponin T: 49,39 mg/mL. Echocardiography revealed a left ventricular ejection fraction of 40%, and clozapine was stopped due to suspected perimyocarditis. On day 18, tests revealed Eosinophil: 2190 g/L, Troponin T: 12,44 mg/mL and the patient's complaints regressed. On day 21, the values were Eosinophil: 4770 g/L, CRP: 11,03 mg/L, Troponin T: 4,68 mg/mL. Myocarditis was confirmed by subsequent cardiac MRI. Written informed consent was obtained from patient. DISCUSSION:In our case, echocardiography and CRP values were normal on the day the fever started. It was observed that eosinophil levels may not serve as a reliable early indicator, with eosinophilia potentially manifesting several days after elevation of troponin levels, and potentially continuing to increase even following the discontinuation of clozapine.
Dilan İrem Zengin, Duçem Selena İşmar, Güneş Devrim Kıcalı
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OBJECTIVE:Manic episodes in bipolar disorder often lead to lack of insight and treatment refusal, complicating management. In HIV-positive patients, this poses additional risks, as adherence to both psychiatric medication and antiretroviral therapy (ART) is crucial. This case report discusses the clinical and ethical challenges of treatment refusal in an HIV-positive patient experiencing a manic episode, emphasizing a multidisciplinary approach. CASE (The patient consent must be provided and specified with appropriate terms.):A 41-year-old, single, university-educated female was diagnosed with HIV in 2014 and bipolar disorder in
2018. She had a history of poor medication adherence and was brought to the emergency department due to manic symptoms. Upon admission, her lithium level was <0.05 mEq/L, and ART adherence was poor. Treatment was initiated with olanzapine 20 mg/day, lithium 600 mg/day, Biktarvy 1x1, and LT4 125 mcg/day, considering potential drug interactions. However, the patient refused all oral medications, including ART, during the first week. She exhibited negativistic behavior and excitability. Due to persistent refusal, IM formulations were initiated. Following IM treatment, the patient showed reduced agitation, decreased negativistic behavior, and improved receptiveness to psychoeducation. Medication adherence improved gradually, and by day 8, she resumed oral treatment. DISCUSSION:Treatment refusal is common in manic episodes, especially in patients lacking insight. In HIV-positive individuals, it also affects immune function and ART adherence. In cases where patients pose a risk to themselves or others, involuntary treatment may be considered under the Turkish Civil Code and Penal Code No. 5237. When choosing antipsychotics and mood stabilizers, drug interactions with ART should be carefully evaluated. Multidisciplinary management is essential for ensuring both psychiatric stability and ART adherence.
Alpaslan Girgin, Dilan Irem Zengin, Güneş Devrim Kıcalı
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OBJECTIVE:DSM-5 defines Somatic Symptom Disorder (SSD) as excessive worry and time spent on symptoms for at least six months. Risk factors include female gender, low education, low socioeconomic status, and health anxiety. This case presents a patient with suspected SSD and delusional disorder having somatic Case Report CASE (The patient consent must be provided and specified with appropriate terms.):Before preparing this poster, Informed written consent was obtained from the patient. A 62-year-old woman presented to the emergency department with a 2-year history of inner restlessness, difficulty staying alone, going outside, abdominal pain, trouble swallowing, and only being able to drink liquids. She believed these symptoms were a punishment related to an argument with
her daughter-in-law. Despite multiple imaging and lab tests for her throat, stomach, and intestines, no organic cause was found. The patient had no psychiatric history in herself or her family. One year ago, she was prescribed Alprazolam and Mirtazapine, but she refused to take them, leading to her admission. She was started on haloperidol drops (3-5mg/day), later switched to Risperidone (2mg/day) and Mirtazapine (7.5mg/day). By the end of the first week, she began solid foods, spent more time alone, and her abdominal pain resolved. A treatment plan was made according to her wishes, and she was discharged with plans for follow-up visits DISCUSSION:The main reason for BBB admission is pain, followed by nausea, vomiting, swallowing difficulty, weakness, shortness of breath, and menstrual issues. Our case, a woman with abdominal pain, nausea, and swallowing difficulty, fits these symptoms. After ruling out physical causes, BBB was diagnosed. The case showed negative attitude, environmental and somatic delusions, initially suggesting psychosis. Improvement with atypical antipsychotics and antidepressants confirmed BBB. This case highlights the need to consider psychosocial stress and somatic symptom disorder in psychosis with refusal to eat.
Duçem Selena İşmar, Alpaslan Girgin, Güneş Devrim Kıcalı
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OBJECTIVE:Bipolar disorder and related conditions are among the most common psychological disorders worldwide, with typical onset during early adulthood. Triggers include stressful life events, obstetric complications, physical illnesses, and substance use. Treatment involves mood stabilizers, benzodiazepines, antipsychotics, antidepressants, and electroconvulsive therapy (ECT). This report presents a case of early-onset bipolar disorder exacerbated by stress caused by the patients mothers chronic illness and multiple suicide attempts. CASE (The patient consent must be provided and specified with appropriate terms.):A 19-year-old woman had attempted suicide multiple times since the age of 15. Despite treatment with various mood stabilizers, antipsychotics, and antidepressants in multiple hospitals, her symptoms persisted. Her mood disorder worsened due to the stress related to her mothers illness. Previous child psychiatry evaluations indicated impulsive suicidal behaviors, unstable relationships, intense anger, and emotional dysregulation, suggesting borderline personality traits. While staying in a nursing home, she impulsively broke a window with the intent of suicide. She
reported auditory hallucinations stating that everything would go wrong. A mental state examination revealed self-harm marks, dysphoric mood, fluctuating emotions, and passive suicidal thoughts. She was using Lithium, Lamotrigine, Aripiprazole, Olanzapine, Haloperidol, Biperiden, and Quetiapine. Due to the persistence of symptoms, depot antipsychotics (Zuclopenthixol, Paliperidone) and ECT were administered. After ECT, her mood stabilized, and suicidal thoughts decreased. Her Young Mania Score decreased from 35 to 10. ECT was performed using the Thymatron device, starting at 35% energy and increasing by 5% each time, completing 12 sessions and finishing at 90% energy. An EEG showed 25 seconds of effective electrophysiological activity. 10 out of 12 sessions were effective. Written consent was obtained from the patient. DISCUSSION:This case emphasizes the interaction between bipolar disorder and borderline personality traits, and how stress caused by the mothers chronic illness exacerbated the condition. ECT provided a dramatic response.
OBJECTIVE:Psychostimulants are widely used for ADHD treatment, but their adverse effects require careful monitoring. Their misuse by individuals without ADHD is a recognized concern, and some populations may be more vulnerable to their neuropsychiatric effects.In this case, methylphenidate misuse in an individual with autism spectrum disorder (ASD) appeared to trigger gambling disorder.This case highlights the potential for psychostimulant misuse to induce gambling disorder, particularly in neurodevelopmental conditions, emphasizing the importance of careful monitoring. CASE (The patient consent must be provided and specified with appropriate terms.):A 21-year-old male patient was diagnosed with autism spectrum disorder at the age of four.Despite not using any psychotropic medication, he had been able to maintain a high level of functioning through various support programs.However, over the past five months, despite having no prior history of gambling, he began engaging in online gambling.He reported that he was unable to discontinue this behavior despite experiencing financial losses and deterioration in his relationship with his family, leading him to seek psychiatric consultation.Based on the history obtained and the psychiatric evaluation, it was learned that the patient had started taking
methylphenidate at a dose of 18 mg/day eight months ago, despite not having a diagnosis of attention-deficit/hyperactivity disorder (ADHD).As the patient had no ADHD diagnosis and gambling disorder emerged after starting methylphenidate, discontinuation was recommended.Behavioral strategies were also provided. During follow-up, he initially experienced gambling urges but managed to resist them and applied the strategies. After three months, he reported a significant decrease in cravings and had abstained from gambling for six months. (Informed consent was obtained from the patient.) DISCUSSION:This case suggests that the misuse of psychostimulant medications may trigger gambling behavior in individuals with autism spectrum disorder. Future studies are necessary to understand the underlying mechanisms of this relationship and to develop risk assessment and prevention strategies.
OBJECTIVE:Bipolar disorder (BD) is a chronic psychiatric illness characterized by recurrent mood episodes, with a global lifetime prevalence of 0.4% to 2.4%. Lithium, a widely used mood stabilizer, is effective in managing mood episodes and reducing suicidal risk. However, its therapeutic mechanisms remain unclear, and its narrow therapeutic range increases the risk of toxicity, particularly in long-term use. This report presents a case of a BD patient who developed delirium due to acute lithium elevation. CASE (The patient consent must be provided and specified with appropriate terms.):A 24-year-old woman with BD was hospitalized with psychotic mania. Her psychiatric history included a seven-year course with periods of remission and relapse, requiring lithium and electroconvulsive therapy. Non-adherence to medication led to another manic episode in 2023, necessitating hospitalization and lithium therapy. On evaluation, she exhibited irritability, pressured speech, grandiosity, persecutory delusions, and impaired insight. Her psychomotor activity was elevated, and neurological and physical exams were unremarkable. Treatment with lithium (900 mg/day), diazepam, and aripiprazole was initiated. During the third week, her psychotic symptoms persisted, and oral intake declined. She developed fluctuating disorientation, hand tremors, balance issues, and slowed speech. Laboratory tests revealed hypoglycemia, elevated uric acid, and a high lithium level (1.23 mEq/L). Lithium dosage was reduced to 600 mg/day, and hydration was initiated, leading to the resolution of symptoms. Patient consent was obtained.
DISCUSSION:Lithium toxicity can arise from overdose, dehydration, or medication interactions. In this case, toxicity was linked to reduced oral intake due to psychotic symptoms. Mild toxicity manifests as tremors and fatigue, whereas severe toxicity may cause irreversible neurotoxicity. Early recognition and dose adjustments are crucial. This case underscores the importance of monitoring not only lithium serum levels but also hydration and oral intake in BD patients to prevent complications.
About this publication
Turkish Journal of Psychiatry
Turkish Journal of Psychiatry (Turk Psikiyatri Derg) is the scientific journal of Turkish Association of Nervous and Mental Health. The journal has been published on a subscription basis four issues annually in March, June, September and December since 1990. Turkish Journal of Psychiatry is indexed in PubMed, Index Medicus, TUBITAK Tıp, Psych-Info, Türkiye Atıf Dizini and has been ranked in Social Science Citation Index (SSCI) since 2005.
27th National Clinical Education Symposium Presentation Abstracts