BACKGROUND AND AIM:Despite the evolution from second-wave methods to third
wave approaches like Acceptance and Commitment Therapy, psychotherapy continues
to face challenges such as high dropout rates and treatment resistance. A primary
obstacle is the "research-practice gap": while research supports standardized, singular
protocols, clinicians often prefer unstandardized, eclectic methods. This study aims to
propose the "Smart Therapy Hypothesis" as a theoretical foundation for the "Fourth
Wave" of psychotherapy, bridging this gap through an assessment-driven, integrative
model. METHODS (Ethics Committee Approval must be obtained and the number should be
specified.):The Smart Therapy hypothesis is conceptualized as an Integrated Multimodal
Biopsychosocial Intervention. The methodology shifts the focus from standardizing the
treatment protocol to standardizing the assessment process. Interventions are "dosed"
based on a component analysis of their "active ingredients," recognizing therapy as a
neurobiological process. The assessment logic is driven by three primary clinical drivers:
(1) biological prerequisites, (2) "hardware/pattern" issues (trauma/personal history), and
(3) "software/habit" issues (e.g., Cognitive Attentional Syndrome). RESULTS:The resulting Smart Therapy model offers a five-level framework. Level 1
introduces the "Compass" for goal-setting and value alignment. Level 2 addresses
"Biological Prerequisites" such as neuroinflammation or HPA axis dysfunction. Level 3
delivers the core psychological "dose," targeting either "software" (e.g., MCT, ACT) or
"hardware" (e.g., EMDR, Psychodynamic) based on the assessment. Levels 4 and 5
incorporate doses of behavioral activation and systemic interventions. This structure
provides a neurobiologically informed, personalized treatment pathway. CONCLUSIONS:This hypothesis proposes that standardizing assessment rather than
protocols can effectively bridge the research-practice gap. The primary research goal is
to test whether this "Hardware/Software" assessment-to-treatment model yields
superior outcomes compared to monolithic protocols. Future research should move
away from comparing broad protocols and focus on conducting component-based
dismantling studies to refine the selection of therapeutic doses for individual patient
profiles.
Keywords: psychotherapy, integrative psychotherapy, etiology, assessment-driven,
rumination, fourth wave psychotherapy
Ayinzeliha Matsar, Ayse Nur İnci Kenar, Hasan Samed Akkaya, Emine Şeker Ün
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BACKGROUND AND AIM:Optical Coherence Tomography (OCT) is the optical analogue
of ultrasonographic imaging. OCT obtains tomographic cross-sectional images from the
choroid, the vascular layer of the eye. Electroconvulsive therapy (ECT) has been
reported to enhance vascular endothelial growth factors and promote neuroplasticity.
This study aimed to investigate the short- and long-term effects of ECT on the choroid
and to examine the clinical factors that may influence these effects. METHODS :The study included inpatients aged 1865 years with any psychiatric disorder
for which ECT was indicated at a university hospital. Patients with systemic or
neurological diseases affecting the eye were excluded. A minimum of eight effective ECT
sessions were administered three times per week. Choroidal thickness was measured
by OCT before ECT, immediately after ECT, and at the 12th week following ECT. Post-ECT
assessments were completed in 31 patients, and 11 patients were evaluated at the 12
week follow-up. Due to the COVID-19 pandemic, the study lasted one year and the
targeted sample size could not be reached. Ethical approval was obtained from the
Pamukkale University Faculty of Medicine Ethics Committee (10.12.2019, No: 21). RESULTS: Of the patients, 15 (48.4%) were male and 16 (51.6%) were female, with a
mean age of 36.55 ± 13.12 years. Sixteen patients (51.7%) were diagnosed with
schizophrenia and related disorders, forming a heterogeneous diagnostic group overall.
After ECT, a statistically non-significant increase was observed in the right choroid (p =
0.068). At the 12-week follow-up, the change in left choroidal thickness was negatively
correlated with age at illness onset (p = 0.036). CONCLUSIONS: ECT was associated with a non-significant early increase in choroidal
vascularity. Earlier age at onset was associated with left choroidal thinning in the long
term and a reduced response to ECT. Left choroidal thinning in early-onset patients may
represent an endophenotypic marker of neurodevelopmental microvascular pathology.
Keywords: psychiatric disorders, electroconvulsive therapy, optical coherence
tomography, choroid plexus
AuthorToEditor: The study was submitted to the Ethics Committee of Pamukkale
University Faculty of Medicine and was initiated following the approval of the Ethics
Committee dated 10.12.2019 and numbered 21.
BACKGROUND AND AIM: This study investigated the levels of independence in daily
living activities(IL) and social functioning(SFL) in adults diagnosed with autism spectrum
disorder(ASD) in childhood and identified factors predicting these outcomes. METHODS: 87 adults with ASD were evaluated.The Aberrant Behavior Checklist(ABC),
Childhood Autism Rating Scale(CARS), Lawton Brody Instrumental Activities of Daily
Living Scale(IADL), and Social Functioning Scale(SFS) were used.Group comparisons
were performed using parametric and nonparametric tests.Correlations were assessed
using Pearson and Spearman analyses.Predictors of IADL and SFS scores were
examined using multiple linear regression analysis.Approval was obtained from Kocaeli
University(No:2022/333). RESULTS: The majority of participants lived with their families, only 4.6% lived alone.The
IADL and SFS scores were significantly lower in individuals with delays in motor
development(p<0.05), illiteracy(p<0.001), lower IQ(p<0.001), and comorbid psychiatric
disorders(p<0.05).More than half of the participants were dependent on each assessed
daily living activity (laundry, 71.3%; housekeeping, 66.7%; finances, 65.5%;
transportation, 60.9%; food preparation, 60.9%; shopping, 57.5%; managing
medications, 57.5%; telephone use, 51.7%).The IADL and SFS scores increased with
older age, fewer siblings, higher birth order, earlier sentence formation, earlier
acquisition of literacy, and lower CARS and ABC scores(p<0.05).In regression analyses,
the IADL score was significantly predicted by CARS score (? = ?0.25, p = 0.001),
IQ(?=3.12, p=0.001), SFS score(?=0.03, p=0.033), and age at first sentence
formation(?=?0.02, p=0.046).The SFS score was significantly predicted by CARS
score(?=?1.87, p=0.008), IADL score(?=2.67, p=0.018), and age at literacy
acquisition(?=?4.54, p=0.026). CONCLUSIONS: Most adults with ASD are dependent on daily living activities and have
limited social skills.IL was predicted by autism symptom severity, IQ, SFL, and age of
first sentence formation, while SFL was predicted by autism symptom severity, IL, and
age of literacy acquisition.Including individuals with a wide range of autism severity and
IQ, this study provides comprehensive evaluation of adult outcomes using validated
psychometric instruments and contributes valuable data to the literature.
Keywords: autism spectrum disorder, independence, social functioning, adult
BACKGROUND AND AIM: Individuals with autism spectrum disorder(ASD) are at an
increased risk for peer bullying and various forms of abuse. However, adverse life events
in individuals with ASD have predominantly been examined through childhood-based
cross-sectional studies, while lifetime data extending into adulthood remain limited.
This study examined the prevalence of lifelong adverse life events and differences
among ASD subgroups in adults diagnosed with ASD. METHODS: 87 individuals diagnosed with ASD in childhood were evaluated in
adulthood. Based on adult clinical assessment, participants were classified as Autistic
Disorder(AD, 49.4%), Atypical Autism(20.7%), Asperger Syndrome(AS, 24.7%), and loss
of ASD diagnosis(LAD, 5.7%). Lifetime exposure to peer bullying, emotional, physical,
and sexual abuse, and criminal history were retrospectively assessed based on self-
and/or caregiver-reports.Approval was received from Kocaeli University(GOKAEK
2022/20.21). RESULTS: Peer bullying was reported by 49.4% of participants and differed significantly
between diagnostic subgroups(p<0.001), with the highest rates in AS(90.5%), followed
by LAD(80.0%), and the lowest rates in AD(23.3%) group. Sexual abuse was reported by
3.4% of participants, and all individuals with a history of sexual abuse belonged to the
AS group, resulting in a significant group difference(p=0.021).Emotional abuse was
reported by 55.2% of participants and showed significant differences between
subgroups(p=0.001), with the highest prevalence in AS(81%) group.Physical abuse was
reported by 28.7% of participants, and differed significantly between
subgroups(p<0.001), with the highest rates in AS(61.9%) group. 2.3% of participants had
a personal criminal history, with no significant difference between groups(p=0.467). CONCLUSIONS: In this sample, individuals with ASD reported substantial lifetime
exposure to bullying and abuse.Higher rates in AS group may be related to greater social
engagement combined with persistent difficulties in interpreting social cues.In contrast,
lower rates in the AD group may reflect increased parental supervision and limited
social exposure.These findings highlight the need for lifelong, subgroup-specific
preventive and supportive strategies for individuals with ASD.
Keywords: autism spectrum disorder, adult, peer bullying, abuse.
Deniz Doğar, Beyza İlay Tecellioğlu, Mahshid Seıfpour, Sinan Göğüş, Ayşe Beyza Koyun, Ayşe Zülal Tokaç Farımaz
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BACKGROUND AND AIM
Secondary traumatic stress (STS) is caused by indirect exposure to trauma through
witnessing others experiences or repeated occupational exposure to trauma narratives
and is associated with adverse psychological outcomes. This study aimed to assess STS
among emergency physicians and examine its relationship with attitudes toward
seeking psychological help. METHODS
This cross-sectional study was conducted between 2nd and 10th of June 2022, among
physicians in nine emergency departments in Istanbul. Data were collected via an online
questionnaire using convenience sampling and included sociodemographic items; the
Secondary Traumatic Stress Scale (STSS) and the Attitudes Toward Seeking
Psychological Help ScaleShort Form (ATSPH-SF). Ethical approval was obtained from
the Istanbul Medipol University Non-Interventional Clinical Research Ethics Committee
(Decision No: 10840098-772.02-3336). RESULTS
Seventy emergency physicians participated. 54.3% were female, mean age 28.4 ± 4.5
years. Most had 04 years of experience (80.0%). A history of traumatic events was
reported by 55.7%, most commonly emotional or physical abuse (20.0%). Most (74.3%)
had no psychiatric diagnosis; 48.6% had never received psychological support. Based
on STSS scores, 58.6% showed severe STS (4985). Favorable help-seeking attitudes
were present in 51.4%. STSS scores were higher in women (p = 0.029) and differed by
trauma type (p = 0.025), with higher scores measured among those exposed to
traumatic accidents. No correlation was found between STSS and ATSPH-SF (r = 0.144, p
= 0.255).
CONCLUSION
Despite severe STS levels, no association was found between STS and help-seeking
attitudes, suggesting individual and institutional factors influence help-seeking
behavior. Further research is needed to clarify this gap and identify barriers to
physicians psychological help-seeking. As the study was conducted during the COVID
19 pandemic, marked by intense workload and frequent exposure to suffering and
death, findings should be interpreted within this context, underscoring the importance
of context-sensitive preventive interventions.
Keywords: Secondary traumatic stress, trauma exposure, seeking professional
psychological help, emergency physicians
BACKGROUND AND AIM:Parental stress has consistently been associated with child
and adolescent mental health outcomes. However, adolescence represents a distinct
developmental period characterized by increased emotional reactivity and autonomy,
which may alter the nature of parent-child dynamics. The present study aimed to
investigate whether parental perceived stress predicts adolescents internalizing and
externalizing problems after controlling for key demographic factors (child age, child
gender, parental education level, and country of residence). METHODS (Ethics Committee Approval must be obtained and the number should be
specified.):The sample consisted of 223 adolescents aged 12-18 years (52.9% girls) and
their parents. Adolescents problems were assessed using the Strengths and Difficulties
Questionnaire (SDQ), yielding internalizing and externalizing composite scores. Parental
perceived stress was measured using the 4-item Perceived Stress Scale (PSS-4).
Hierarchical regression analyses were conducted separately for internalizing and
externalizing problems. Child age, gender, parental education, and country of residence
were entered in the first step, followed by parental perceived stress. Ethical approval
was obtained from the relevant institutional ethics committee (E-64577500-050.99
79416). RESULTS:Parental perceived stress was significantly correlated with adolescents
internalizing problems (r=.17, p=.013) but not with externalizing problems (r=.12,
p=.064). After controlling for demographic variables, parental perceived stress
significantly predicted higher levels of internalizing problems (?=.14, p=.033),
accounting for an additional 2% of the variance (?R²=.020). In contrast, parental
perceived stress did not significantly predict externalizing problems (?=.09, p=.202). CONCLUSIONS:Findings indicate that parental perceived stress is specifically
associated with adolescents internalizing symptoms rather than externalizing
behaviors. This pattern underscores the importance of considering developmental stage
and symptom profiles when evaluating family-related risk factors, as emotional
difficulties during adolescence may be more sensitive to parental stress. These findings
suggest that interventions aimed at reducing parental stress and improving parental
coping may play a protective role in adolescents emotional well-being.
Keywords: perceived stress, adolescence, internalizing-externalizing problems
Sümeyye Yasemin Çallı, Burak Emmiler, Yağmur Fidan, Arda Kızılsert, İnci Su Taşcan, Recep Ekşi, Yunus Emre Sancak
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BACKGROUND AND AIM:Schizophrenia causes significant functional impairment and
cognitive disturbances that weaken safety judgment (1). Consequently, patients are
highly vulnerable to abuse and unpredictable events, especially during psychotic
exacerbations (2). Although research often emphasizes patient violence, the risk of
criminal victimization in this population is 2 to 100 times higher than the general public,
driven by factors like homelessness and symptomatology (3). Analyzing the complex
interactions of these risk factors requires computational power beyond traditional
statistics. Machine learning excels at detecting hidden patterns and parameter weights
within such datasets (4). Algorithms like Support Vector Machines (SVM) can identify
predictive associations that classical methods may overlook (5). This study evaluates
the utility of machine learning in predicting criminal victimization among patients with
schizophrenia. METHODS (Ethics Committee Approval must be obtained and the number should be
specified.):Approved by the Erenköy Ethics Committee (No: 2025/15), this cross
sectional study collected sociodemographic characteristic, clinical history, and forensic
background data from schizophrenia patients (1865 years) via semi-structured
interviews. During the interview and consent phase, information regarding patients
whose response reliability was clinically doubted was obtained from their relatives
Machine learning models were developed in Python to predict victimization. SVM
outperformed other algorithms and were optimized using 5-fold stratified cross
validation to handle class imbalance. Model performance was assessed via AUC-ROC
metrics and feature importance analysis to identify risk factors. RESULTS:The patient groups were analyzed in two categories: those who were victims of
crime (n=50) and those who were not (n=50). No statistically significant differences were
found between the groups regarding age, gender, educational status, or marital status
(p>0.05).The analysis process was conducted in a local computing environment using the Python
programming language and its libraries. The research population consisted of 100
patients diagnosed with F2029 according to ICD-10 diagnostic criteria. The target
variable of the model was defined as "criminal victimization (Present/Absent)." During
the data preprocessing stage, scaling was applied for feature standardization, and
missing data were addressed using appropriate imputer methods; subsequently, model
objects were saved for future analysis. To predict the risk of criminal victimization,
analyses were performed using SVM algorithms. The RBF (Radial Basis Function) kernel
was preferred in the SVM model to identify complex and non-linear relationships, and
the regularization parameter was set to C=1.0 to prevent overfitting. The probability
estimation feature was activated for the percentage expression of risk scoring. The
relationship between variables and victimization was examined using Point-Biserial
correlation analysis. According to the findings, a history of childhood abuse emerged as
the strongest predictor in the model (r=0.472, p<0.001). Additionally, the use of first
generation depot antipsychotics was identified as a risk-increasing factor (r=0.229). The
discriminative power of the models was evaluated using the AUC-ROC metric. The SVM
model demonstrated an "acceptable/good" level of performance with a mean AUC
score of 0.768 and an overall accuracy rate of 71%. CONCLUSIONS:This study investigated the predictability of criminal victimization risk in
patients diagnosed with schizophrenia using sociodemographic and clinical data
through machine learning algorithms. It has been frequently reported in the literature
that individuals with severe mental disorders are at a higher risk of being victims of
violence rather than perpetrators compared to the general population; this situation is
often associated with substance use, homelessness, and exacerbating psychotic
symptomsspecifically mania and positive symptoms. However, most existing research
relies on traditional regression analyses and remains limited in explaining complex, non
linear relationships.
The SVM model developed in our study, which demonstrated the highest performance
with an AUC score of 0.768, identified a history of childhood abuse as the strongest
predictor of criminal victimization in adulthood, contrasting with the acute clinical
variables emphasized in the literature. This finding is consistent with studies suggesting
that early-life traumas leave individuals vulnerable to revictimization in adulthood.
Furthermore, our analysis identified unemployment and the use of first-generation
depot antipsychotics (AP) as moderately correlated factors, while high educational
attainment was found to be weakly correlated.
In the literature, the impact of pharmacological treatment modalities on violent
victimization presents a complex picture. Although some studies state that the type of
prescribed medication is not directly associated with victimization, treatment non-adherence is known to be a significant risk factor(3). Indeed, it has been shown that
structured processes ensuring treatment continuity reduce the risk of victimization by
decreasing substance use and providing clinical stabilization. In this context, methods
ensuring treatment adherence are expected to serve a protective function. However, the
findings of our study did not support this mechanism and failed to demonstrate that the
use of depot antipsychotics is a protective factor against victimization. In contrast,
polypharmacywhich likely indicates closer follow-up or better symptom controlwas
found to correlate with decreased criminal victimization.
The primary original contribution of this research lies in its association of victimization
risk not only with immediate psychopathology but also with historical trauma burden,
analyzing this relationship through a multivariate, machine learning-based model. Our
findings indicate that in managing the risk of victimization in patients with
schizophrenia, routinely screening for trauma history is as critical as symptom control.
REFERENCES:1-Ross, C. A., Margolis, R. L., Reading, S. A., Pletnikov, M., & Coyle, J. T.
(2006). Neurobiology of schizophrenia. Neuron, 52(1), 139153.
https://doi.org/10.1016/j.neuron.2006.09.015
2-Witt K, van Dorn R, Fazel S. Risk factors for violence in psychosis: systematic review
and meta-regression analysis of 110 studies. PloS One. (2013) 8:e55942. doi:
10.1371/journal.pone.0055942
3-de Vries, B., van Busschbach, J. T., van der Stouwe, E. C. D., Aleman, A., van Dijk, J. J.
M., Lysaker, P. H., Arends, J., Nijman, S. A., & Pijnenborg, G. H. M. (2019). Prevalence
Rate and Risk Factors of Victimization in Adult Patients With a Psychotic Disorder: A
Systematic Review and Meta-analysis. Schizophrenia bulletin, 45(1), 114126.
https://doi.org/10.1093/schbul/sby020
4-Parsaei M, Taghavizanjani F, Cattarinussi G, Moghaddam HS, Di Camillo F,
Akhondzadeh S, et al. Classification of suicidality by training supervised machine
learning models with brain MRI FINDINGS: A systematic review. J Affect Disord. (2023)
340:76691. doi: 10.1016/j.jad.2023.08.034
5-Gou N, Xiang Y, Zhou J, Zhang S, Zhong S, Lu J, et al. Identification of violent patients
with schizophrenia using a hybrid machine learning approach at the individual level.
Psychiatry Res. (2021) 306:114294. doi: 10.1016/j.psychres.2021.114294
Keywords: Artificial intelligence, Crime victimization, Forensic psychiatry, Machine
learning, Schizophrenia
Persistent Genital Arousal Disorder in a Patient with Major Depressive Disorder:
Symptom Improvement Following Antidepressant Dose Optimization
OBJECTIVE: Persistent Genital Arousal Disorder (PGAD) is a rare condition characterized
by persistent physiological genital arousal without accompanying sexual desire. Due to
limited awareness and absence of standardized treatment guidelines, it is frequently
underdiagnosed. We present a case of PGAD comorbid with major depressive disorder
(MDD) that improved following antidepressant dose optimization.
CASE: A 48-year-old woman presented with a two-year history of persistent genital
discomfort, throbbing sensations, pelvic restlessness, and an intrusive urge to touch the
genital area. Symptoms occurred multiple times daily, worsened while sitting, and
caused significant social impairment. She reported no associated sexual pleasure or
increased libido. Gynecological examination and laboratory investigations were
unremarkable. Psychiatric evaluation revealed a five-year history of MDD treated with
paroxetine 20 mg/day. In recent months, depressive symptoms had worsened. After
exclusion of organic pathology, paroxetine was increased to 40 mg/day and olanzapine
2.5 mg/day was added.
Written informed consent was obtained for publication.
At two-month follow-up, depressive symptoms remitted, her mood was euthymic, and
PGAD complaints markedly decreased, occurring only once or twice during the
preceding month.
DISCUSSION: The pathophysiology of PGAD remains unclear, and various
pharmacological and interventional treatments have been reported without consensus.
In this case, symptom improvement may be related to enhanced serotonergic inhibition
following paroxetine dose escalation. Serotonin is known to exert inhibitory effects on
sexual arousal pathways. Additionally, remission of depressive symptoms may have
reduced somatic hypervigilance and distress amplification. Dopaminergic modulation
through low-dose olanzapine may also have contributed.
This case suggests that optimization of antidepressant therapy may represent a rational
initial strategy in PGAD patients with comorbid depression. Increased awareness and
further research are required to establish evidence-based treatment approaches.
191
Keywords: Olanzapine, Paroxetine, Persistent Genital Arousal Disorder
BACKGROUND AND AIM:This study aimed to characterize the demographic, psychiatric,
and medical profiles of children referred to the Outpatient Clinic for the Special Needs
Report for Children (COZGER) and to examine the distribution of special needs levels, as
well as to assess the implications of the COZGER process for child and adolescent
psychiatric practice. METHODS (Ethics Committee Approval must be obtained and the number should be
specified.):This retrospective descriptive study analyzed hospital records of 444
children aged 018 years who applied to the COZGER outpatient clinic of İzmir City
Hospital Child and Adolescent Psychiatry Department between August 15 and
November 15, 2025. Cases with forensic reports, incomplete data, or unfinished
COZGER processes were excluded. Demographic characteristics, psychiatric
diagnoses, and special needs levels were evaluated overall. RESULTS:The median age of the cases was 8 years, and 67.6% were male. At least one
psychiatric diagnosis was identified in 76% of the children, with the most common
diagnoses being Intellectual Disability (29%), Autism Spectrum Disorder (ASD) (19%),
and Specific Learning Disorder (16.9%). Regarding levels of special needs, 75.9% of
cases were classified as having special needs, with 34.5% categorized as Special
Needs (ÖGV) and 13.1% as Severe Special Needs (ÖKGV). Among children with ASD,
48.8% were evaluated at the Moderate Special Needs level and 51.2% at the Severe
Special Needs level. Notably, approximately half of the cases (48.7%) with a special
needs level of at least ÖGV had received their diagnosis for the first time. Ethical
approval was obtained from the İzmir City Hospital Ethics Committee on December 3,
2025, under protocol number 2025/624. CONCLUSIONS:This study shows that the COZGER system effectively differentiates
childrens developmental and psychiatric support needs and provides consistent
classification, particularly for ASD. However, the retrospective single-center design
limits generalizability, indicating the need for multicenter studies to standardize
COZGER practices and strengthen early intervention processes overall future.
Keywords: COZGER, multidisciplinary approach, rehabilitation, special needs
OBJECTIVE:Alcohol Use Disorder (AUD) is common in elderly populations; however, its management becomes more complex in the presence of neurological comorbidities such as Parkinsons disease. Limited data exist regarding safe detoxification and maintenance strategies for AUD in patients receiving dopaminergic treatment. CASE (The patient consent must be provided and specified with appropriate terms.):Written informed consent was obtained from the patient. A 64-year-old male, primary school graduate and retired, presented to the psychiatric outpatient clinic requesting treatment to discontinue alcohol use. He had a long history of alcohol consumption and had met diagnostic criteria for AUD for the past five years. Four years earlier, he was diagnosed with Parkinsons disease by neurology and was treated with levodopa 125 mg/day. The patient had been followed by psychiatry for three years due to insomnia and anxiety and was receiving sertraline 50 mg/day and quetiapine 50 mg/day with partial benefit. Recently, his alcohol consumption had progressively increased, and he reported tolerance and withdrawal symptoms including restlessness, insomnia, and irritability. At admission, the patients CIWA-Ar score was 11, indicating mild to moderate alcohol withdrawal. Detoxification treatment was initiated with thiamine 300 mg/day and lorazepam 3 mg/day. Lorazepam was gradually tapered according to CIWA-Ar scores and discontinued as withdrawal symptoms subsided. The CIWA-Ar score progressively decreased and reached 0 during follow-up. For maintenance treatment, sertraline was increased to 100 mg/day due to persistent anxiety symptoms, and naltrexone 50 mg/day was initiated. At 1-, 3-, and 6-month follow-ups, the patient remained abstinent from alcohol, with a euthymic mood and no worsening of Parkinsonian symptoms. DISCUSSION:This case demonstrates that CIWA-Arguided detoxification and naltrexone maintenance treatment can be safely and effectively applied in elderly patients with Parkinsons disease and AUD. This case supports the clinical feasibility of individualized AUD treatment strategies in neurologically complex elderly patients, emphasizing the importance of careful monitoring, standardized assessment tools, and appropriate pharmacological selection. Keywords: Alcohol Use Disorder, Elderly patients, CIWA-Ar, Naltrexone,
OBJECTIVE[Spinocerebellar ataxia (SCA) is a neurodegenerative disorder characterized
by cerebellar degeneration that may affect individuals cognitive processes, mood
regulation, and motor functions. Psychosis accompanying SCA is rare. This case report
evaluates a patient with spinocerebellar ataxia accompanied by psychotic disorder,
sensorineural hearing loss, and intellectual disability in the context of
neurodevelopmental and structural findings.
CASE(The patient consent must be provided and specified with appropriate terms.):A
28-year-old single male patient was admitted to our forensic psychiatry clinic due to
psychotic symptoms and aggressive behaviors. He had a history of imbalance, speech
difficulties, and hearing loss since early childhood. Neurological examination revealed
dysarthria, dysmetria, ataxic gait, and prominent tremor. Brainstem Auditory Evoked
Response testing demonstrated bilateral severe sensorineural hearing loss, while
cranial MRI revealed cerebellar atrophy, ventriculomegaly, and a cavum septum
pellucidum et vergae variation. Psychiatric evaluation showed erotomanic delusions
and impaired impulse control. Initial treatment with risperidone and valproate was
initiated; however, valproate was discontinued due to worsening ataxia and tremor.
Following the addition of olanzapine, psychotic symptoms markedly improved. Written
informed consent was obtained from the patient for the publication of this case report.
DISCUSSION:Psychiatric manifestationsparticularly depressionmay accompany
SCA, whereas psychotic disorders are rarely reported. The psychotic features and
disinhibited behaviors observed in our patient are consistent with the cognitive
dysmetria model, attributing psychosis to disrupted cerebellar connections with frontal
and limbic circuits. Neurodegenerative involvement affecting judgment and behavioral
inhibition may increase forensic vulnerability in such patients. Impaired impulse control
and aggressive behavior requiring forensic hospitalization highlight the relevance of
cerebellar pathology in forensic psychiatric settings. Exacerbation of ataxia following
valproate underscores the need for individualized pharmacological strategies. This case
emphasizes the importance of recognizing neuropsychiatric symptoms in cerebella disorders and adopting a multidisciplinary approach, particularly in evaluating forensic
risk, criminal responsibility, and long-term institutional care needs.
Keywords: Spinocerebellar ataxia, psychosis, cerebellum, neurodevelopmental
anomaly, cavum septi pellucidi
OBJECTIVE:Factitious disorder is a psychiatric condition characterized by the intentional
production of physical symptoms without external incentives. Diagnosis is challenging,
often resulting in repeated hospitalizations, unnecessary invasive procedures, and high
healthcare utilization. In obstetrics and gynecology, recurrent vaginal bleeding without
an identifiable organic cause represents a critical differential diagnosis. This case report
presents the diagnostic process of a patient with recurrent vaginal bleeding and direct
observation of self-harming behavior.
CASE (The patient consent must be provided and specified with appropriate terms.):A
31-year-old mother of two, with no psychiatric history, presented to multiple facilities
over three years for recurrent vaginal bleeding. She was hospitalized in a gynecology
department following an unplanned pregnancy; however, the bleeding was determined
not to be pregnancy-related. Vaginal examinations revealed various bleeding sites
occurring at different times, leading to repeated surgical interventions.
On the planned discharge day, bleeding recurred, and curettage was performed due to a
hemoglobin level of 6.5g/dL. Post-procedure, the patient failed to respond to verbal
stimuli. Neurological evaluation revealed no organic pathology, and a psychiatric
consultation was requested for suspected conversion disorder. Mental status
examination revealed only a depressed mood.
On the sixthday post-curettage, new bleeding areas appeared at sites inconsistent with
obstetric interventions. Further history revealed long-standing admissions for vaginal
bleeding and repeated presentations of her three-year-old child with unexplained penile
bleeding. During clinical observation, the patient was caught injuring her vaginal area
with a knife. Following gynecological treatment, she was transferred to the psychiatry
ward with a diagnosis of factitious disorder. Paroxetine and diazepam were initiated.
Although no bleeding occurred during the first three days of psychiatric hospitalization,
subsequent self-injury resulted in renewed bleeding, requiring a transfusion of two units
of packed red blood cells. DISCUSSION:This case highlights the importance of considering factitious disorder in
patients presenting with recurrent unexplained vaginal bleeding and repeated invasive
procedures.Written informed consent was obtained from the patient.
Keywords: Factitious disorder, Unexplained vaginal bleeding, Self-injurious behavior,
Recurrent hospital admissions, Hospital shopping
Hatice Öztürk, Barış Kılıç Demir, Selma Çilem Kızılpınar, İbrahim Erdi Gılcık
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OBJECTIVE:Evidence regarding treatment options for neuropsychiatric symptoms
secondary to traumatic brain injury (TBI) is limited.This case discusses the management
of a psychotic disorder that developed following head trauma and in association with
epilepsy in a forensic psychiatry service.
CASE (The patient consent must be provided and specified with appropriate terms.):A
32-year-old male with no prior psychiatric diagnosis suffered a head injury from a fall at
age 24. He underwent decompressive craniotomy and cranioplasty of the left
hemisphere due to an acute subdural hematoma. Neuroimaging revealed
encephalomalacic changes in the left frontal and bilateral temporal regions. The patient
experienced generalized tonicclonic seizures; EEG findings were consistent with left
frontocentrotemporal dysfunction and focal-onset epilepsy, and valproic acid 1000
mg/day was initiated. Subsequently, paranoid, persecutory, mystical, nihilistic, and
grandiose delusions, along with aggression, emerged. The patient committed simple
assault and was admitted to a High-Security Psychiatric Clinic due to lack of criminal
responsibility. He was treated with olanzapine 20 mg/day, haloperidol 20 mg/day, and
paliperidone palmitate 150 mg/month. During observation, delusions persisted (SANS:
62, SAPS: 101), leading to a diagnosis of treatment-resistant psychotic disorder
secondary to traumatic brain injury. Clozapine was initiated, resulting in symptom
reduction at 400 mg/day (SANS: 50, SAPS: 86) without increased seizure activity.
Delusions persisted with reduced dangerousness, and placement in a nursing home
with close psychiatric monitoring was planned. Informed consent was obtained from
the patient and legal guardian.
DISCUSSION:Psychotic cases developing after TBI, accompanied by epilepsy and
frontaltemporal lesions, may exhibit a complex clinical course. Forensic psychiatric
practice requires not only symptom control but also the management of aggression and
the risk of reoffending. Although comorbid epilepsy limits treatment options, the ability
to maintain this treatment without an increase in seizure activity highlights the
importance of individualized assessments rather than rigid exclusion criteria.
Keywords: Post-traumatic psychosis, Traumatic brain injury, Treatment-resistant
psychosis
OBJECTIVE: Neuroleptic malignant syndrome (NMS) is a rare but potentially life
threatening complication of antipsychotic treatment. Although typically characterized
by hyperthermia, severe rigidity, elevated creatine kinase (CK), and autonomic
instability, atypical presentations have been increasingly reported with second
generation antipsychotics. Management is particularly challenging when psychotic
symptoms persist after discontinuation of antipsychotics. We report a patient with first
episode psychosis who developed atypical NMS following short-term antipsychotic
exposure and was successfully treated with aripiprazole.
CASE: Written informed consent was obtained from the patient. A 23-year-old male with
no psychiatric history presented with persecutory delusions, grandiosity, and auditory
hallucinations. Zuclopenthixol acetate 50 mg IM was administered, and olanzapine 10
mg/day was initiated. During follow-up, he developed subfebrile fever, mild rigidity with
cogwheel phenomenon, tachycardia (114/min), blood pressure elevation (142/75
mmHg), and elevated CK (2,348 U/L), AST (138 U/L), and ALT (210 U/L). Based on these
findings and recent antipsychotic exposure, atypical NMS was diagnosed.
Antipsychotics were discontinued, and hydration plus bromocriptine were initiated. As
psychotic symptoms worsened, aripiprazole was cautiously introduced at 2.5 mg/day
and titrated to 20 mg/day. CK levels normalized, and both NMS findings and psychotic
symptoms markedly improved.
DISCUSSION: NMS has been reported with both first- and second-generation
antipsychotics. Reintroduction of antipsychotics after NMS is clinically challenging due
to recurrence risk. Aripiprazole, a D2 partial agonist, may modulate rather than
profoundly block dopaminergic transmission. Although aripiprazole-associated NMS
has been described, reports of its successful use following NMS remain limited. In this
case, aripiprazole was associated with resolution of NMS manifestations and
improvement of persistent psychosis. This case adds to the limited literature suggesting
that aripiprazole may represent a viable therapeutic option in carefully selected patients
when ongoing psychotic symptoms necessitate antipsychotic treatment. Careful
titration and strict clinical monitoring remain essential to minimize recurrence risk. Keywords: Aripiprazole, Dopamine Partial Agonism, First-Episode Psychosis,
Neuroleptic Malignant Syndrome
OBJECTIVE: Catatonia is a neuropsychiatric syndrome characterized by motor
disturbances associated with changes in thought, mood, and consciousness.Studies
suggest that catatonia is more prevalent among patients with mood disorders than
those with schizophrenia.First-line treatments include benzodiazepines or
electroconvulsive therapy (ECT)ECT is especially recommended for malignant catatonia,
neuroleptic malignant syndrome, and benzodiazepine-resistant cases.This case report
aims to contribute to the management of ECT-resistant catatonia.CASE: A 28-year-old
male presented with worsening depressive symptoms, psychomotor retardation,
confusion, and suicidal ideation, leading to hospitalization.The patient had a history of
bipolar disorder with multiple manic and depressive episodes treated with various mood
stabilizers and antipsychotics.In May 2024, catatonic symptoms emerged, and ECT was
initiated.Cognitive side effects, such as confusion and memory impairment, attributed
to the combined use of ECT and lithium, led to a switch from lithium to valproic
acid.Despite initial improvement, symptoms recurred within a month.Lithium was
reintroduced along with further ECT sessions.However, cognitive impairments
worsened, prompting neurological evaluations and brain imaging.Brain CT and MRI
revealed a minimal subdural hematoma and bilateral temporal hyperintensities. Further
investigations were performed.CSF findings were unremarkable; however, PET-CT
revealed bilateral prefrontal and parietal hypometabolism, that may be observed in
patients with catatonia.Based on these neurological findings and clinical features, the
patients condition was considered ECT-resistant catatonia.Due to the unavailability of
lorazepam in Turkey, diazepam was initially administered with partial
improvement.Following the procurement of lorazepam, significant remission was
achieved.Additionally, owing to instability in serum lithium levels, treatment was
switched to extended-release lithium obtained from abroad.The patient was discharged
on lithium, lorazepam, and venlafaxine.Written informed consent was obtained from the
patient for publication of this case report.DISCUSSION: ECT is effective in over 80% of
catatonic cases, yet some factors predict non-response, including comorbid
neurological conditions.Lithium-ECT interactions may contribute to cognitive
deficits.This case highlights the importance of individualized treatment and
benzodiazepine availability in catatonia management.
OBJECTIVE:Tardive dyskinesia (TD) is a syndrome comprising a range of iatrogenic
movement disorders caused by dopamine receptor antagonism, including akathisia,
dystonia, buccolingual stereotypy, chorea, tics, and other involuntary movements. Most
commonly associated with antipsychotic treatment, TD is a persistent and distressing
adverse effect. The geriatric population is particularly vulnerable, as advanced age is a
well-established risk factor due to age-related neurobiological changes and diagnostic
overlap with other movement disorders. Therefore, careful selection and monitoring of
antipsychotic treatment are crucial in elderly patients. We present a geriatric patient
who developed tardive dyskinesia following long-acting antipsychotic treatment.
CASE (The patient consent must be provided and specified with appropriate terms.):A
70-year-old male with a diagnosis of chronic schizophrenia presented with psychomotor
retardation, blunted affect, bruxism, stereotyped pill-rolling hand movements, and
repetitive oropharyngeal dyskinesia. These symptoms developed approximately two
years after receiving a long-acting paliperidone injection. The patient had remained
clinically stable without positive psychotic symptoms for nearly three years prior to
symptom onset. He was hospitalized with a differential diagnosis of secondary
parkinsonism versus tardive dyskinesia. Paliperidone and madopar were discontinued,
with no subsequent clinical worsening suggestive of secondary parkinsonism. Follow-up
evaluations supported a diagnosis of tardive dyskinesia, and antipsychotic treatment
was switched to clozapine. Under clozapine therapy, TD symptoms improved clinically.
The patient continues to be followed on a weekly basis. Consent was obtained from the
patient and his son.
DISCUSSION:The onset, causative agent, and dosage associated with tardive dyskinesia
are unpredictable, making it a treatment-limiting complication in clinical practice.
Advanced age, prior extrapyramidal symptoms, high-dose or long-term antipsychotic
use, psychotic disorders, and comorbid mood disorders are established risk factors.
This case underscores the importance of appropriate antipsychotic selection and risk
management in vulnerable geriatric patients. The observed clinical improvement further
supports the role of clozapine in both reducing TD risk and managing established
symptoms in high-risk populations.Keywords: tardive dyskinesia, geriatric patients, clozapine
OBJECTIVE:Lithium remains a first-line mood stabilizer for the acute and maintenance
treatment of bipolar disorder. However, its narrow therapeutic index and potential for
neurotoxicity warrant close monitoring. Although toxicity is typically associated with
elevated serum lithium levels, neurotoxic effects may also occur within the therapeutic
range, a condition referred to as therapeutic-level lithium neurotoxicity or chronic
lithium neurotoxicity.
CASE (The patient consent must be provided and specified with appropriate terms.):A
61-year-old woman with a 15-year history of bipolar disorder, treated with long-term
lithium, presented with a one-month history of insomnia, speech slowing, depressive
mood, irritability, and cognitive impairment. Mental status examination revealed
confusion, apathy, psychomotor slowing, and reduced speech output. Neurological
examination demonstrated prominent generalized tremor and confusion. Her
medications included lithium 600 mg/day, quetiapine, aripiprazole, and propranolol.
Laboratory investigations showed a serum lithium level of 0.63 mEq/L, within the
therapeutic range, with normal renal and thyroid function tests and unremarkable
routine biochemistry. No alternative medical or neurological etiology was identified.
Lithium-induced neurotoxicity was suspected, and lithium was discontinued.
Antipsychotic treatment was adjusted. Within one week, the patient exhibited complete
resolution of tremor and confusion, with normalization of sleep and cognitive
functioning.
Informed consent:
Written and verbal informed consent was obtained from the patient for publication of
this case.
DISCUSSION: Chronic lithium exposure may result in central nervous system
accumulation, and brain lithium concentrations do not always correlate with serum
levels. Elder age and polypharmacy may increase susceptibility to neurotoxicity.
Previous reports and pharmacokinetic studies have described similar discrepancies,
emphasizing age-related renal decline, bloodbrain barrier alterations, and drugdrug
interactions as contributing factors. This case underscores the importance of prioritizing
clinical assessment over serum lithium concentrations alone. Clinicians should maintain a high index of suspicion for lithium neurotoxicity in elderly patients, even
when serum levels are in therapeutic range.
Keywords: Bipolar disorder, neurotoxicity, lithium, therapeutic-level toxicity
Mahmut Barış Koç, Melike Ceyhan Balcı Sengul, Selim Çiftcioğlu
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Presentation preview
OBJECTIVE
SmithMagenis syndrome (SMS) is a rare genetic disorder characterized by
developmental delay, intellectual disability, distinctive dysmorphic facial features,
behavioral dysregulation, and circadian rhythm disturbances. Due to its clinical overlap
with attention-deficit/hyperactivity disorder, conduct disorder, autism spectrum
disorder, and psychotic disorders, misdiagnosis is common and diagnosis is often
delayed. We present a patient first evaluated at age 7 who received multiple psychiatric
diagnoses throughout childhood and adulthood and was ultimately diagnosed with SMS
at age 27, underscoring the importance of including SMS in psychiatric differential
diagnosis, particularly in cases with longstanding behavioral and cognitive impairment.
CASE
After written informed consent was obtained from the patient and her relatives, history
revealed referral to child and adolescent psychiatry at age 7 for learning difficulties,
lagging behind peers, irritability, self- and hetero-aggression, and attention problems.
She was managed for specific learning disorder, ADHD, and mild intellectual disability.
Over time, anger outbursts, impulsivity, aggression, stereotypies, failure to achieve toilet
training, and marked cognitive impairment became prominent. During childhood,
multiple psychotropic treatments were administered. After age 18, she was followed in
adult psychiatry with a diagnosis of atypical psychosis, and multiple antipsychotic
treatments were administered for persistent behavioral and psychotic symptoms. Due
to clinical worsening, she was hospitalized for reassessment and treatment adjustment.
Despite combined high-dose antipsychotic therapy, response was insufficient, and eight
sessions of electroconvulsive therapy led to marked improvement. Physical examination
revealed dysmorphic features, and phenotype-guided genetic testing confirmed SMS.
DISCUSSION
This case illustrates that SMS may remain unrecognized into adulthood in patients with
chronic behavioral and psychotic symptoms, even after years of continuous psychiatric care. In early-onset behavioral problems accompanied by intellectual disability and
sleep disturbance, careful assessment of dysmorphic features and a multidisciplinary
diagnostic approach are essential for accurate diagnosis.
Keywords: Smith-Magenis Syndrome, Atypical psychosis, Conduct disorder
OBJECTIVE:Neuroleptic malignant syndrome (NMS) is rare but potentially life
threatening condition associated with antipsychotic use and characterized by
hyperthermia, muscle rigidity, altered mental status, autonomic instability.
Electroconvulsive therapy (ECT) is a safe and effective treatment option for severe
psychotic symptoms, catatonia, and treatment-resistant conditions. However; fever,
elevated creatine kinase (CK) levels, transient alterations in consciousness may occur
after ECT, complicating the differential diagnosis between NMS and infectious
etiologies. This case discusses whether clinical deterioration following ECT was
attributable to NMS or secondary to an infectious process.
CASE (The patient consent must be provided and specified with appropriate terms.):61
years old female patient with schizoaffective disorder was hospitalized due to one week
of refusal of oral intake, inability to ambulate, aggressive behavior symptoms. Following
intramuscular haloperidol administration, her CK level was 2229 U/L and emergency
ECT was initiated under olanzapine treatment. After the first ECT session, CK decreased
to 141 U/L, with marked clinical improvement.
After the second ECT session, the patient developed fever (37.8°C), altered mental
status, autonomic instability, elevated CK levels (2778 U/L), raising suspicion for NMS.
Due to clinical deterioration and unstable vital signs, patient was admitted to the ICU,
where Influenza A infection was detected and antiviral therapy was initiated. During
follow-up, CK levels increased to 6340 U/L. Given persistent clinical suspicion of NMS,
bromocriptine treatment was initiated, resulting in a gradual decline in CK levels.
After clinical stabilization, the patient was transferred back to the psychiatric ward;
aripiprazole was initiated, ECT was continued. Vital signs normalized, CK levels
decreased to 485 U/L, oral intake resumed, improvement in psychiatric symptoms was
observed. (Informed consent was obtained.)
DISCUSSION:This case demonstrates that fever, CK elevation following ECT dont
necessarily indicate NMS and that infectious causes must be excluded. It highlights the
dynamic nature of NMS diagnosis and underscores the importance of early treatment
initiation in evolving or atypical presentations.
Keywords: Neuroleptic Malignant Syndrome (NMS), Schizoaffective Disorder,
Electroconvulsive Therapy (ECT), Catatonia, Infection, Bromocriptine
OBJECTIVE
Borderline Personality Disorder (BPD) involves emotional dysregulation, fear of
abandonment, and unstable relationships, often rooted in early attachment trauma.
This poster presents a treatment case of an adopted woman with BPD, showing how
systemic family therapy can address these core wounds.
CASE
A 26-year-old woman with self-harm, unstable relationships, and fear of abandonment
(linked to learning of her adoption at age six) participated with her adoptive parents.
Written consent was obtained. They completed 18 sessions of systemic family therapy
with integrated individual skill-building over six months. The patient was not on
psychotropic medication. The Borderline Symptom List-23 (BSL-23) tracks BPD
symptom severity. Her score dropped from 2.8 (high) at intake to 1.1 (low) post-therapy.
The Experiences in Close Relationships-Revised (ECR-R) assesses attachment anxiety
and avoidance. Her scores moved from 5.2 to 3.4 on anxiety and from 4.8 to 3.1 on
avoidance, indicating a shift towards greater security.
DISCUSSION
Therapy resulted in reduced self-harm, improved emotional control, and a more stable
self-image. This dual approach allowed the family system to heal attachment injuries
while individual skills managed acute symptoms. The BSL-23 and ECR-R provided
objective, data-driven monitoring. Lasting recovery in complex BPD may depend on
repairing the relational matrix while strengthening individual self-regulation.
Keywords: Borderline Personality Disorder, systemic family therapy, attachment
trauma, adoption, BSL-23, ECR-R.
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.
