Klinefelter Syndrome Associated with Autism Spectrum Disorder: A Forensic Case
Report
OBJECTIVE:
Klinefelter syndrome (47,XXY)(KS) is a chromosomal aneuploidy associated with
physical, cognitive, neurodevelopmental and psychiatric features. The aim of this case
report is to evaluate, from clinical, neurodevelopmental and forensic psychiatric
perspectives, an individual with KS who has symptoms of autism spectrum
disorder(ASD) and to emphasize the importance of genetic etiology in the differential
diagnosis.
Case
A 20-year-old single male was admitted to the forensic psychiatry unit of İzmir City
Hospital under Article 74 of the Turkish Criminal Procedure Code and Article 57/1 of the
Turkish Penal Code(TPC). His background revealed deficits in social-emotional
reciprocity, poorly integrated verbal-nonverbal communication, restricted and unusual
interests, poor academic performance since childhood with no other complaint. Mental
status examination showed deficient and impaired comminication, limited affect,
apathy, poverty of thought content, reduced abstract thinking ability. The Wechsler Adult
Intelligence Scale(WAIS) assessment indicated moderate intellectual disability. The
patient obtained a high score on the Revised Autism Spectrum Quotient, indicating
prominent autistic features. Physical examination revealed phenotypic characteristics
consistent with KS, karyotype analysis confirmed as 47,XXY pattern. No psychotic
symptoms were observed. At the end of the observation period, the case was evaluated
under Article 32/1 of the TPC due to the offense history which is theft of womens
clothes with certain features and throwing them into the garbage in a repetitive,
ritualistic manner. Written informed consent was obtained from the patient for this case
presentation. Discussion
This case highlights the importance of genetic evaluation in individuals who has
symptoms of ASD particularly in the presence of striking phenotypic findings. Early
recognition of neurodevelopmental symptoms of KS may enhance clinical awareness,
support accurate diagnosis and follow-up, contribute to multidisciplinary assessment
and draws attention to evaluation of forensic cases and criminal histories exhibiting
characteristics of ASD.
Keywords: atypical autism, autism spectrum disorder, behavioral disorder, Klinefelter
syndrome.
Zehra Beyza Çelik, Handegül Yıldız, Güneş Devrim Kıcalı
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Somatic Symptom Disorder is characterized by an excessive, disproportionate, and
persistent focus on one or more bodily symptoms, accompanied by intense anxiety,
thoughts, and behaviors related to these symptoms. This case highlights the diagnostic
and therapeutic challenges in a 61-year-old male patient presenting with somatic
complaints and chronic abdominal pain resistant to standard treatment protocols.
CASE: A 61-year-old, single, retired male patient presented with complaints of inner
distress, fatigue, anxiety, and abdominal pain persisting for five years. He reported no
periods of well-being during this time. Due to the severity of the abdominal pain, he was
unable to maintain his social and occupational functioning. Functional impairment and
decreased self-care were evident. His psychiatric history revealed that chronic
abdominal pain and prominent anxiety began after a COVID-19 infection five years
earlier. He had multiple admissions to various medical departments; however, no
organic pathology was identified, and he did not benefit from symptomatic treatments.
Comprehensive evaluations conducted during hospitalization by Neurology,
Gastroenterology, Cardiology, InternalMedicine, and GeneralSurgery revealed no
organic cause. Treatment with duloxetine, venlafaxine, fluoxetine, paroxetine, and
benzodiazepines provided no benefit. In contrast, he reported relief following
intermittent intramuscular haloperidol/biperiden injections. The treatment regimen was
adjusted to fluvoxamine 200 mg/day, olanzapine 20 mg/day, quetiapine 100 mg/day, and
sulpiride titrated to 1200 mg/day. Intramuscular haloperidol was administered for
episodic pain attacks. Under antipsychotic treatment, the patients abdominal pain and
somatic distress symptoms significantly improved. Informed consent was obtained.
DISCUSSION: The patient was evaluated as having Somatic Symptom Disorder and was
followed with a treatment and psychotherapy plan. However, the lack of response to
antidepressants and psychotherapy necessitated therapeutic reconsideration. As
emphasized by Cruz et al. (Cureus2023)antipsychotic strategies should be considered,
particularly in elderly patients with medically unexplained symptoms when standard
treatments fail.
Key Words: Somaticsymptomdisorder, antipsychotic, abdominalpain, sulpiride
(*)Cureus. 2023 Dec 7;15(12):e50116. doi: 10.7759/cureus.50116
Keywords: Somatic symptom disorder, antipsychotics, abdominal pain
Elif Ehliz Tatlıdede, Aslıhan Özdemir Yaşaran, Cansu Bak, Sare Aydın
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Is Catatonia a Risk Factor for Neuroleptic Malignant Syndrome?A Case Report
INTRODUCTION: Catatonia and neuroleptic malignant syndrome(NMS)are severe
neuropsychiatric conditions with overlapping features including altered
consciousness,motor abnormalities,autonomic instability,and hyperthermia(1).NMS
usually emerges shortly after antipsychotic initiation or dose escalation and is
characterized by hyperthermia,muscle rigidity,autonomic instability,altered
consciousness,and elevated CK(2).
Hypodopaminergic activity in catatonia may be exacerbated by dopamine
blockade.Dehydration or inadequate oral intake may further precipitate NMS(3).We
report NMS developing after antipsychotic treatment in a patient with schizophrenia
presenting with prominent catatonic features.
Case
A 30-year-old male with schizophrenia was admitted with standing motionless for
hours,marked psychomotor retardation,unresponsiveness,refusal of oral intake,and
perseverative religious-themed thought content after discontinuing antipsychotics one
month earlier.
Evaluation revealed mutism,negativism,posturing,and decreased responsiveness
consistent with stupor.According to DSM-5,at least four catatonic
symptoms(mutism,negativism,posturing,stupor)were present.He was hospitalized with
a diagnosis of catatonic syndrome.
Due to persecutory delusions,quetiapineXR300mg/day,quetiapineIR50mg/day,and
vortioxetine 20mg/day were initiated.On day two,he developed fever>38°C,sinus
tachycardia,diaphoresis,and CK8,816U/L.With suspected NMS,he was transferred to
intensive care. Antipsychotics were discontinued.Because of absent oral intake,diazepam2×10mgIV
was administered for four days instead of lorazepam.Dantrolene20mgIV and
bromocriptine2×2.5mg were briefly added.Hyperthermia,rigidity,elevated CK,and
autonomic instability gradually resolved.
Catatonic symptoms(mutism,posturing,negativism)persisted,and he returned to the
psychiatry ward.Benzodiazepine treatment and supportive care were continued.
Consent
Written informed consent was obtained from the patients relatives.
Discussion
Catatonia and NMS overlap in motor symptoms,autonomic instability,and altered
consciousness.Beyond symptomatic similarity,a possible pathophysiological
association has been proposed(4).
Dopamine D2 receptor blockade underlies NMS,and dopaminergic dysfunction also
contributes to catatonia.Antipsychotics may exacerbate catatonic
symptoms(5),suggesting that initiating treatment during catatonia may increase
vulnerability to NMS.
Reports describe interaction between antipsychotic-induced catatonia and NMS(6).In
this case,NMS developed shortly after antipsychotic initiation in a patient with catatonic
features,supporting the view that catatonia may represent a potential risk factor for
NMS.Careful assessment before initiating antipsychotics in catatonic patients is
therefore clinically essential.
References
1.WhiteDA,RobinsAH.CNSSpectr.2000;5(7):58-65.doi:10.1017/S1092852900013419
2.WhiteDA,RobinsAH.BrJPsychiatry.1991;158:419-421.doi:10.1192/bjp.158.3.419
3.SatoI,etal.BMJSupportPalliatCare.2020;10(3):265-270.
4.Sienaert P,et,al.FrontPsychiatry.2014;5:181.doi:10.3389/fpsyt.2014.00181
5.HirjakD,et,al.MolPsychiatry.2021;26:6112-6114.
6.VirolleJ,et.al.SchizophrRes.2023.
Keywords: CATATONIA, NEUROLEPTIC MALİGNANT SYNDROME, SCHIZOPHRENIA
Zahid Emre Kösecik, Rahime Gök, Taha Can Tuman, Mehmet Yücel Ağargün
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OBJECTIVE:Catatonia is a neuropsychiatric syndrome characterized by motor,
behavioral and autonomic symptoms and may accompany various psychiatric and
medical conditions. In patients with traumatic brain injury (TBI), disturbances of
consciousness are often attributed to structural brain damage and potentially reversible
syndromes such as catatonia may therefore be overlooked in the differential diagnosis.
This case report aims to present the emergence of catatonia during follow-up after TBI
and the clinical response to lorazepam combined with transcranial direct current
stimulation (tDCS).
CASE:A 20-year-old female patient was monitored in the intensive care unit following TBI
due to a fall from height. Brain magnetic resonance imaging revealed diffuse axonal
injury involving the frontal cortex, thalamus and basal ganglia. Partial improvement in
consciousness was initially observed; however, a marked deterioration developed in
subsequent days. Psychiatric evaluation revealed stupor, rigidity, stereotyped motor
behaviors and autonomic instability. A score of 10 on the BushFrancis Catatonia Rating
Scale supported a preliminary diagnosis of catatonia. Lorazepam treatment was
initiated and concomitant anodal tDCS targeting the left dorsolateral prefrontal cortex
was applied. Significant clinical improvement was observed within the first week, and
the patient achieved full wakefulness by day 19. Written informed consent for
publication of this case report was obtained from the patient and the patients legally
authorized representative. All reasonable efforts have been made to protect the
patients identity.
DISCUSSION:This case emphasizes that catatonia should be considered in the
differential diagnosis of disorders of consciousness following traumatic brain injury.
Despite limited evidence in the literature, the rapid response to lorazepam and the
temporal association between clinical improvement and tDCS suggest a potential
adjuvant role for non-invasive neuromodulation in selected cases. With early
recognition and appropriate treatment, catatonia may represent a reversible condition
even in TBI patients who appear to have severe neurological impairment.
Keywords: Catatonia, Lorazepam, Transcranial Direct Current Stimulation, Traumatic
OBJECTIVE:Even though exanthemas are the most common adverse cutaneous
reactions with psychotropic medications, escitalopram, a selective serotonin reuptake
inhibitor(SSRI), is not typically associated. A rare case of escitalopram induced
maculopapular rash in a patient with anxiety disorder and restless leg syndrome (RLS) is
presented, emphasizing the pharmacological challenges due to concurrent morbidities
and adverse effects.
CASE (The patient consent must be provided and specified with appropriate terms.):A
46-year-old female, who had been receiving treatment for hair loss from the
dermatology clinic for five months, applied to the psychiatry outpatient clinic. She was
married with three children and working in a government office. She complained of
feeling heavy and worried. She was on hydroxychloroquine for hair loss and levothyroxin
because of Hashimoto thyroiditis. Her affect was anxious. She described difficulty
falling asleep, and a detailed anamnesis led to the diagnosis of RLS. International
Restless Legs Study Group Rating Scale(IRLS) score, evaluating the severity of RLS, was
10 out of 40. Her biochemical parameters were unremarkable. She was started on
escitalopram10 mg/d. On the 5th day, eruptions spread from her torso to the extremities
and back. Oral prednisolone and an antihistamine were prescribed. Escitalopram was
stopped. The patient was offered fluoxetine, with recommendations to discontinue if the
rash recurs. After three weeks, the rash didn't recur, nor did the patient's symptoms
improve. Fluoxetine was changed to venlafaxine 75 mg/d, and the patient's symptom
severity decreased. She was advised on regular exercise, which is known to improve RLS
symptoms. Her IRLS score didn't increase. The patient signed the written informed
consent form.
DISCUSSION:SSRIs are the most common prescription for anxiety. The rate of
drug-induced skin reactions due to antidepressants is <0.1%; reactions with
escitalopram are relatively less among these. Serotonergic medication also exacerbates
RLS, which limits treatment options. It's important to use validated instruments, like
IRSL, in cases where management is complex.
Keywords: skin reaction, maculopapular exanthema, escitalopram, RLS
Gamze Burhan, Duçem Selena İşmar, Güneş Devrim Kıcalı
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OBJECTIVE:Major self-mutilation (MSM) in acute psychosis is an extreme phenomenon
characterized by severe tissue damage and high lethality. This report presents a 39-year
old female who inflicted life-threatening cervical lacerations following traumatic
bereavement. We aim to analyze the role of "cyber-phenomenology" and delusions of
infamy in triggering extreme self-harm behavior (SHB).
CASE (The patient consent must be provided and specified with appropriate terms.):A
39-year-old female with no prior psychiatric history was admitted following a violent
SHB attempt involving deep cervical and occipital incisions. Symptoms emerged six
weeks after her husbands suicide, presenting as severe insomnia and persecutory
delusions. The patient exhibited intense ideas of reference via social media, interpreting
random digital stimuli as targeted threats. Initial PANSS score was P8N9G19.
Treatment included Risperidone (titrated to 6 mg/d), Olanzapine (5 mg/d), and
Clonazepam (2 mg/d). Following rapid stabilization, parenteral treatments were
discontinued by day 3. As symptoms remitted, the patient identified her motivation as a
delusional belief regarding an irreversible loss of social status and moral integrity
triggered by digital content. She was discharged on day 7 with outpatient follow-up.
Written informed consent was obtained from the patient.
DISCUSSION:Cervical and occipital injuries are hallmarks of MSM. According to Large et
al. (2021), MSM in psychosis is distinct due to its high medical lethality and the direct
influence of delusional systems. The patients perceived loss of honor aligns with
"delusions of infamy," identified by Nielssen et al. (2022) as a key risk factor for extreme
SHB in first-episode psychosis.
This process was catalyzed by "cyber-paranoia," where digital stimuli crystallize
delusional systems (Garety et al., 2023). Furthermore, Zisook et al. (2022) emphasize
that bereavement-related psychosis can lead to "suicidogenic psychosis" through
identification with the deceased or self-punishment. In conclusion, while rapid
pharmacological intervention is life-saving, long-term management must focus on
processing traumatic grief to prevent relapse.
Keywords: Acute Psychosis, Major Self-Mutilation, Traumatic Bereavement, Cyber
Paranoia.
BACKGROUND AND AIM:Treatment-Resistant Depression (TRD) is defined as failure to
respond to at least two adequate antidepressant trials in the current episode.
Esketamine, a non-competitive NMDA receptor antagonist, promotes synaptogenesis
through mTORC1 activation and BDNF release. This study aims to evaluate esketamines
relapse prevention capacity, long-term safety (up to 6.5 years), and comparative efficacy
by synthesizing data from clinical trials (SUSTAIN, ESCAPE-TRD) and real-world evidence
(REAL-ESK). METHODS (Ethics Committee Approval must be obtained and the number should be
specified.):A comprehensive literature review was conducted using PubMed, Cochrane
Library, and Google Scholar (20192025). Phase studies (SUSTAIN-1, SUSTAIN-2,
SUSTAIN-3), comparative trials (ESCAPE-TRD), and observational real-world data (REAL
ESK) were included. Ethics committee approval is not required for systematic reviews. RESULTS:In SUSTAIN-1 (N=297), esketamine reduced relapse risk by 70% (p<0.001) in
stable responders and 51% (p=0.003) in stable remitters. SUSTAIN-2 reported a 58.2%
remission rate at one year. In ESCAPE-TRD (N=676), esketamine demonstrated
superiority over quetiapine, achieving 27.1% remission at week 8 (p=0.003) and 21.7%
relapse-free remission through week 32. SUSTAIN-3 (N=1148) showed that remission
rates approached 50% and were maintained for up to 6.5 years under intermittent
dosing. REAL-ESK, a multicenter realworld cohort, reported a 40.6% remission rate; in
the subsequent trajectory study (n?78), 55.1% of patients maintained clinical benefit
during continuation treatment. Across studies, 4050% non-response rates reflect the
persistent clinical burden of TRD. CONCLUSIONS:Esketamine represents an important long-term treatment option for
TRD, supported by sustained efficacy and safety data from clinical trials and extension
studies. Nevertheless, reported success rates should be interpreted considering
enriched trial designs, open-label extensions, and potential sponsor relationships. This
poster synthesizes long-term clinical and real-world data to provide a balanced overview
of esketamines role in sustained TRD management
.Keywords: Treatment-Resistant Depression, Intranasal Esketamine, Long-Term
Outcomes, Real-World Evidence
OBJECTIVE
Tirzepatide is a dual glucose-dependent insulinotropic polypeptide (GIP) and glucagon
like peptide-1 (GLP-1) receptor agonist. Beyond appetite regulation, GLP-1based
therapies may modulate dopaminergic signaling within the brains reward circuitry.
While selective GLP-1 receptor agonists primarily suppress appetite, dual GIP/GLP-1
receptor activation may exert broader neurobehavioral effects. We report a case of
marked anhedonia temporally associated with tirzepatide use, followed by increased
alcohol consumption and psychiatric hospitalization.
CASE
A 49-year-old male was initiated on tirzepatide in an endocrinology outpatient clinic for
weight loss. During treatment, he developed prominent anhedonia, decreased
motivation, appetite suppression beyond the expected pharmacological effect, sleep
disturbance, and anxiety symptoms. In an attempt at self-medication, he began
consuming approximately 78 standard alcoholic drinks per day. He subsequently
discontinued tirzepatide on his own and presented to the psychiatry outpatient clinic.
He denied prior alcohol withdrawal symptoms, alcohol-related functional impairment,
psychiatric diagnoses, or family psychiatric history. There was no suicidal ideation.
Although he did not meet DSM-5 criteria for Alcohol Use Disorder, he was hospitalized
due to worsening depressive symptoms, functional decline, and rapidly escalating
alcohol consumption as a maladaptive coping strategy.
Mental status examination revealed dysphoric mood, restricted affect, psychomotor
retardation, and reduced spontaneous speech without psychotic features. Following
detoxification and supportive interventions, sertraline was initiated and titrated to 100
mg/day. Acamprosate 999 mg/day was added to prevent relapse. At discharge, he was
euthymic and abstinent from alcohol.
Written informed consent was obtained. DISCUSSION
Although clinical trials report a low incidence of major psychiatric adverse effects with
tirzepatide, this case highlights possible individual vulnerability. Dual GIP/GLP-1
modulation may enhance inhibitory effects on mesolimbic dopaminergic pathways,
potentially inducing a clinically significant reward deficit. In susceptible individuals,
such pharmacologically induced anhedonia may paradoxically promote compensatory
alcohol use. Further research is warranted to clarify the neuropsychiatric safety profile
of dual incretin agonists
Keywords: Alcohol use, Anhedonia, Case report, GLP-1 receptor agonist, Reward
system, Tirzepatide
Lithium is a mood stabilizer used as a first-line treatment for bipolar disorder and related
conditions, and schizoaffective disorder. The effects of lithium on thyroid function have
been recognized. Clinical and experimental studies show that lithium can impair thyroid
hormone synthesis, release, and the thyroid glands responsiveness to thyroid
stimulating hormone (TSH), leading to dysfunction ranging from subclinical
hypothyroidism to severe myxedema. These endocrine disturbances may adversely
affect mood stability. This case highlights the importance of considering lithium
induced endocrine abnormalities in acute mood exacerbations.
Informed written consent was obtained from the patient.
A 41-year-old male with a 15-year history of bipolar disorder was followed in outpatient
psychiatric care. He had remained euthymic for the preceding three years while
receiving lithium 1200 mg/day and quetiapine 300 mg/day. Over a 10-day period, he
developed insomnia, increased rate and quantity of speech, elevated energy levels,
psychomotor agitation, hostile and aggressive behavior, and paranoid ideation with
suspiciousness and ideas of reference. Due to symptom severity, he was admitted to the
psychiatric inpatient unit with a diagnosis of mania with psychotic features.
Laboratory investigations revealed severe thyroid dysfunction, with a TSH level of 73.7
mIU/mL and free T4 < 0.039 ng/dL, while other parameters were within normal limits.
Hypothyroidism secondary to long-term lithium use was suspected, and an internal
medicine consultation was obtained. Thyroid hormone replacement therapy was
initiated. Given the severity of thyroid dysfunction, lithium was discontinued. The
psychiatric regimen was revised to valproic acid 1000 mg/day, and the quetiapine dose
was increased to 600 mg/day.
During follow-up, TSH levels gradually decreased, indicating improvement in thyroid
function. In parallel, manic and psychotic symptoms resolved, and the patient achieved
a euthymic mood state.
This case emphasizes recognizing lithium-induced hypothyroidism as a reversible
contributor to acute manic episodes and the need for monitoring during long-term
lithium therapy.
Keywords: Bipolar disorder, Hypothyroidism, Lithium
Combined Pharmacological and Cognitive-Behavioral Treatment in Health Anxiety
Focused Obsessive Ruminations: A Case Report
OBJECTIVE: Health anxiety-focused obsessive ruminations involve repetitive,
functionally impairing mental preoccupations from realistic health risk perceptions.
Triggers like medical imaging can intensify these cycles [1]. This report examines
combined pharmacological and psychotherapeutic efficacy in a patient with resistant
ruminations following her child's computed tomography (CT) scan.
CASE: A 42-year-old woman presented with intense anxiety and ruminations regarding
potential radiation-induced cancer in her son after a single CT.SCID-5-CV evaluation
confirmed a DSM-5 diagnosis of Obsessive-Compulsive Disorder (OCD),Health Anxiety
Focused, with Good or Fair Insight. No comorbid depressive or anxiety disorders were
identified; subclinical generalized anxiety symptoms were noted. Initial scores:Y-BOCS
28, BAI 25, BDI 9. The patient frequently searched scientific articles, providing temporary
relief but perpetuating ruminations. Mental status showed ego-dystonic thoughts with
partial insight. Following clinical unresponsiveness to sertraline (200mg/day), fluoxetine
(60mg/day), and aripiprazole (15mg/day), augmentation therapy was initiated. Per
WFSBP guidelines and resistant OCD algorithms [3,4], venlafaxine was titrated to
300mg/day and quetiapine to 600mg/day. Concurrently, a structured 12-session
Cognitive-Behavioral Therapy (CBT) protocol was implemented, including
psychoeducation, cognitive restructuring (addressing catastrophizing and intolerance of
uncertainty), managing reassurance-seeking, Exposure and Response Prevention (ERP),
metacognitive techniques, and uncertainty exposure. At six months, Y-BOCS decreased
to 10 and BAI to 8.However, ruminations flared when her son required a repeat CT for
pneumonia; symptoms remitted after intensified supportive sessions and increased
quetiapine dosage. Written informed consent was obtained.
DISCUSSION: This case demonstrates the efficacy of combined pharmacological and
structured CBT in health anxiety-focused ruminations. CBT addressed cognitive
distortions through ERP and metacognitive techniques [2].SNRI (venlafaxine) and
atypical antipsychotic (quetiapine) augmentation for resistant symptoms aligns with
current guidelines [3,4].Environmental triggers' role in relapse underscores the necessity of treatment continuity and relapse prevention.Combined therapy ensures
sustainable clinical well-being in symptom control and relapse management.
Keywords: combination therapy, health anxiety, obsessive rumination, reassurance
seeking behavior
Muhammet Gündüz, Osman Özdel, Yaşar Enli, Ergin Sağtaş
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BACKGROUND AND AIM:Hippocampal volume reduction is a well-documented
phenomenon in schizophrenia. Multiple studies have shown the hippocampal subfield
volume alterations. The hippocampus is one of the most vulnerable parts of the central
nervous system to oxidative stress. This study investigates hippocampal subfield
volume alterations in schizophrenia and their association with verbal memory
performance, symptom severity, and oxidative stress markers. METHODS :Using Magnetic Resonance Imaging and blood samples, 22 schizophrenia
patients (first episode and chronic) and 22 healthy controls were assessed. The
schizophrenia group was assessed using the Positive and Negative Syndrome Scale, the
Clinical Global Impression Scale, and the Auditory Verbal Learning Test. (Ethics
committee approval 7th April 2022 E-60116787-020-193267.) RESULTS: All participants in schizophrenia group were taking antipsychotic medication
and average duration of disease was 69 months. Bilateral hippocampal body volume
was significantly decreased compared to healthy controls(right f(1-41)=5,306, p,=0,024,
left f(1-41)=5,523, p=0,024). Additionally, a significant decrease seen in several
subfields; bilateral subiculum body (left: f(1-41)=6,451, p=0,015, right:f(1-41)=4,378,
p=0,043)., right presubiculum (head f(1-41)=4,322, p=0,044, body f(1-41)=5,563,
p=0,023), right CA1 head (f(1-41)=4,387, p=0,042), and right posterior molecular layer of
hippocampal plate volumes (f(1-41)=5,326, p=0,026) in schizophrenia group. While the
volumes of several subfields of the hippocampal body were reduced in the
schizophrenia group, only the right CA1 and presubiculum was reduced in hippocampal
head. Hippocampal volumes were negatively correlated with negative symptoms and
positively correlated with memory performance.
In schizophrenia group 8-hydroxy-2-deoxyguanosine levels were negatively correlated
with the volume of right subiculum-head. However, we did not find any further evidence
supporting our hypothesis that proposed oxidative stress as a causal factor in
hippocampal volume loss. Neurotrophin-4 levels showed negative correlations with specific hippocampal subfields in the schizophrenia group. CONCLUSIONS:These findings suggest that hippocampal volume alterations in
schizophrenia are heterogeneous along its longitudinal axis and are associated with
negative symptoms and verbal memory performance.
Keywords: Hippocampal Subfields, Oxidative Stress, Schizophrenia
OBJECTIVE:In Bipolar Disorder (BD), particularly in advanced age, atypical presentations
necessitate excluding organic pathology. Interpreting vegetative symptoms as
depressive can delay recognizing cerebrovascular events, while antidepressant
treatments may destabilize mood. Masking neurological findings with psychiatric
symptoms or medication side effects complicates diagnosis. This study addresses
diagnostic challenges in a patient whose neuropsychiatric symptoms from a left
occipital stroke were initially misidentified as depression, leading to mania after
venlafaxine administration.
CASE (The patient consent must be provided and specified with appropriate terms.):A
56-year-old male with a 35-year BD history presented with confusion and fatigue.
Evaluated as depressive, venlafaxine was added to lithium, triggering a manic switch.
Upon clinic admission, he exhibited disorientation and pressured speech. Initial
neurological evaluation was clear, leading to psychiatric admission. Dysarthria and
shuffling gait developed within a week, initially attributed to risperidone-induced
extrapyramidal side effects. However, visual-motor deficits during self-care prompted
detailed examination, revealing cortical blindness which the patient denied (Anton
Syndrome). Computed tomography confirmed an ischemic lesion in the left occipital
lobe. His expansive mood and grandiosity masked neurological anosognosia as
psychotic denial, creating a diagnostic dilemma.Following manic symptom regression,
he is maintained on olanzapine 30 mg/day. Consent was obtained.
DISCUSSION:The literature reports that venlafaxine carries a higher risk of manic switch
compared to other antidepressants.In this case, the evaluation of the patient's initial
complaints of confusion and lethargy as depressive and the subsequent addition of an
antidepressant to the treatment not only led to a manic presentation but also masked
the findings of Anton Syndrome due to a concurrently developing cerebrovascular event
(CVE).The phenomenological similarity between the grandiose denial resulting from the
expansive/manic mood and neurological anosognosia can lead to the interpretation of
neurological deficits as manic psychosis. Findings such as acute-onset confusion,
dysarthria, and gait disturbances in individuals with psychiatric illness must be
evaluated with contrast-enhanced imaging methods to rule out organic etiology.
Keywords: anosognosia, anton syndrome, bipolar disorder, manic switch
OBJECTIVE:Delusional Infestation (DI), or Ekbom Syndrome, is a rare somatic delusion
involving false beliefs of parasitic infestation. Patients often report itching and
formication. Post-disaster stressors like PTSD, grief, and social isolation can trigger
these delusions. This case discusses an Ekbom Syndrome patient living alone in a tent
city after an earthquake, focusing on clinical characteristics and the significant
challenges encountered in his treatment management.
CASE (The patient consent must be provided and specified with appropriate terms.):A
55-year-old male (Mr. E.), who lost his family in the earthquake and lacks social support,
lives alone in a tent. Believing that insects were gnawing at his body, the patient caused
deep excoriations on his feet by scratching his skin. Multiple dermatology visits revealed
no evidence of parasites. The patient was brought to the psychiatry clinic by a hospital
employee. During the examination, his presentation of dust particles on his glasses as
"evidence" (Matchbox Sign) was notable. In the mental state examination, his self-care
was diminished, affect was restricted, and mood was anxious. Somatic delusions and
tactile hallucinations were prominent. The patient lacked insight, and his judgment was
impaired. Laboratory tests and brain MRI were normal. Olanzapine (5 mg/day) was
initiated. To ensure medication adherence and evaluate treatment response, a follow-up
process has been planned in collaboration with local social services and shelter
officials. To maintain ethical standards, the patient's identity was kept anonymous.
DISCUSSION:This case illustrates how severe psychosocial trauma can manifest as a
somatic delusion. Self-mutilation via scratching reflects the intense anxiety generated
by the delusional belief. The "Matchbox Sign" displayed via eyeglasses underscores the
strength of the delusional system. Social isolation in disaster zones complicates
treatment adherence, highlighting the importance of integrated social service networks
in psychiatric care. In conclusion, our case emphasizes that chronic stress and grief in
disaster settings can trigger rare somatic delusions.
Keywords: delusional infestation, earthquake, somatic delusion, social isolation
OBJECTIVE:Frontotemporal dementia (FTD) is a neurodegenerative disorder
characterized by progressive changes in behavior, personality, and executive
functioning. Behavioral symptoms such as disinhibition, compulsive behaviors,
hyperorality, and hoarding are common and often highly burdensome for patients and
caregivers. Pharmacological interventions for these behavioral disturbances are limited,
and effective treatment options remain under-researched. The aim of this case report is
to evaluate the efficacy and tolerability of brexpiprazole in a patient with FTD presenting
with prominent hoarding behavior.
CASE (The patient consent must be provided and specified with appropriate terms.):A
65-year-old retired woman presented with hoarding behavior, irritability, nervousness,
hyperphagia, reduced self-care, and socially inappropriate behaviors, including
coprolalia. These symptoms had been present for seven years. She persistently
collected discarded items at home and denied awareness of her actions. Two years
prior, she was diagnosed with FTD based on clinical evaluation, neuroimaging findings,
and neuropsychological testing. Psychiatric examination revealed impaired time
orientation, reduced abstract thinking, loss of insight, and deficits in recent memory.
The Mini-Mental State Examination (MMSE) score was 20. Mirtazapine 15 mg/day and
brexpiprazole 1 mg/day were initiated to manage behavioral symptoms and
insomnia.After two months of treatment, the patient demonstrated significant
improvement in hoarding behavior and agitation, with good tolerability and no notable
adverse effects.
Informed consent
Written and verbal informed consent was obtained from the patient for the publication
of this case report.
DISCUSSION:Brexpiprazoles favorable side-effect profile may be particularly
advantageous in elderly patients with dementia-related behavioral disturbances. This
case suggests that brexpiprazole may represent a potential therapeutic option for
managing hoarding behavior and agitation in patients with FTD.
Keywords: brexpiprazole, hoarding behavior, frontotemporal dementia
İldeniz Tolga Uzun, Aslı Aytulun, Eren Yıldızhan, Mustafa Nuray Namlı
Page 239
Presentation preview
OBJECTIVE:Atomoxetine is a non-stimulant approved by the FDA for the treatment of
attention-deficit/hyperactivity disorder in patients aged 6 years and older. Medication
induced akathisia is a rare adverse effect of atomoxetine, and this case report describes
akathisia that developed following atomoxetine use.
CASE (The patient consent must be provided and specified with appropriate terms.):A
49-year-old female patient with a 20-year history of major depressive disorder had been
receiving fluoxetine 60 mg/day. Atomoxetine 60 mg/day was added to the treatment
regimen as an augmentation strategy to improve cognitive symptoms. On the sixth day,
she developed restlessness, inability to remain still, a constant urge to move, and
involuntary motor movements. With worsening symptoms, she admitted to our
emergency department three times; benzodiazepine and propranolol were administered
respectively, and fluoxetine and atomoxetine were discontinued. At her last admission,
persistent akathisia and suicidal ideation were noted, and she was hospitalized for
suicidal risk with preliminary diagnoses of medication-induced akathisia and recurrent
depressive episode. Treatment with mirtazapine 30 mg/day, diazepam 15 mg/day, and
propranolol 60 mg/day was initiated; by day four, the BARNES Akathisia Rating Scale
score decreased from 13 to 0, after which diazepam and propranolol were discontinued,
and mirtazapine dose was increased. (Written informed consent was obtained for the
publication of case)
DISCUSSION:Two cases of atomoxetine-induced akathisia have been reported in the
literature, both in young patients; our case suggests that atomoxetine may also cause
akathisia in adults. Atomoxetine is primarily metabolized by cytochrome CYP2D6, and
fluoxetine is a potent CYP2D6 inhibitor. Their combination may increase atomoxetine
levels, posing a risk for akathisia.Therefore, a lower starting dose and close monitoring
are recommended when atomoxetine and fluoxetine are used in combination. In our
case, the concomitant use of both drugs increased the risk of akathisia.
Keywords: Adverse effects, akathisia, atomoxetine, depression, fluoxetine
OBJECTIVE Long-term substance use has been associated with impairments across
cognitive domains, including memory, attention, executive functions, and orientation. In
middle adulthood, substance-related cognitive impairment may present
heterogeneously, ranging from domain-specific deficits to progressive functional
decline. However, longitudinal case reports describing neurocognitive trajectories in
abstinent polysubstance users remain limited. This case report aims to describe
progressive cognitive and functional deterioration in a middle-aged patient with long
term cannabis and methamphetamine use, emphasizing diagnostic
considerations.CASE A 46-year-old male with a 15-year history of cannabis and
methamphetamine use was brought to the emergency department due to psychomotor
activation and aggression toward family members. Relatives reported several years of
progressive forgetfulness, impaired self-care, and episodic confusion prior to 2023.
Following an intensive care unit admission for bronchopneumonia in 2023, behavioral
and cognitive symptoms accelerated, including frequent disorientation (occasionally
not recognizing his location), impaired daily functioning, episodic urinary incontinence,
and confusion-related misinterpretations such as repeatedly searching rooms and
believing his former spousedespite being divorcedwas present in the home.
Intermittent paranoid themes were observed but did not reach the level of fixed or
systematized delusions. During a one-year abstinence period, supported by negative
urine toxicology, cognitive and functional decline persisted. Cognitive assessment using
the Mini-Mental State Examination (MMSE) demonstrated a decline from 22 to 19 within
one year. Cranial magnetic resonance imaging performed after the 2023 hospitalization
revealed mild cortical atrophy. Neurological consultation did not indicate an alternative
primary neurological disorder. Infectious, metabolic, and routine laboratory evaluations
were unremarkable. Written informed consent was obtained.DISCUSSION This case
illustrates progressive neurocognitive and functional decline in midlife following long
term polysubstance use, persisting despite abstinence. While the clinical presentation
was considered consistent with a substance-induced neurocognitive disorder, alternative diagnosesincluding early-onset dementiasshould be carefully
considered. Potential contributing mechanisms may include cumulative neurotoxicity,
neuroinflammation, and medical stressors such as critical illness.
Keywords: substance-induced neurocognitive disorder, polysubstance use, cognitive
decline
OBJECTIVE
Schizoaffective disorder is associated with recurrent hospitalizations and functional
decline, and a subset of patients remains treatment-resistant despite adequate
antipsychotic trials and electroconvulsive therapy(ECT).When standard strategies fail,
evidence guiding subsequent options is limited.We present a severe case in which
clinical improvement emerged after dual mood stabilizer therapy following insufficient
response to antipsychotic optimization and adequately administered ECT.
CASE
A 43-year-old patient with schizoaffective disorder and multiple prior hospitalizations
was admitted from the emergency setting due to severe psychomotor agitation,
grandiosity, persecutory delusions, and medication refusal.Intramuscular haloperidol
(20 mg/day) with biperiden(10 mg/day) was initiated.Quetiapine extended-release was
started and titrated to 750 mg/day, and clonazepam was added.Despite treatment, the
patient remained verbally aggressive, intermittently refused medication, and required
seclusion. Subsequent optimization with oral risperidone(4 mg/day) followed by
paliperidone long-acting injectable showed no improvement.Cranial magnetic
resonance imaging was normal, and electroencephalography was planned.In a previous
admission, the patient had undergone 12 sessions of ECT with adequate seizure
duration but without sufficient clinical response.Given persistent symptom severity and
significant impairment in self-care and caregiving, valproic acid was titrated to 1500
mg/day; due to insufficient response, lithium was added and titrated to 600 mg/day
based on serum levels.Marked clinical improvement emerged following combined
lithium and valproate therapy, with only mild residual psychotic themes.The patient was
discharged with family collaboration and close outpatient follow-up.Over three months,
functional recovery remained stable, and the family reported high satisfaction with
stability.Written informed consent for publication was obtained.
DISCUSSION
This case suggests that dual mood stabilizer therapy may be associated with meaningful
improvement in selected treatment-resistant schizoaffective presentations where antipsychotic strategies and adequately administered ECT have been insufficient.While
findings from a single case cannot be generalized, this approach may warrant
consideration in refractory cases characterized by severe agitation and functional
deterioration.
Keywords: Schizoaffective disorder, Treatment resistance, Dual mood stabilizer therapy
OBJECTIVE Kleptomania is an impulse-control disorder characterized by recurrent
stealing accompanied by guilt or shame. In patients with recurrent major depressive
disorder (MDD), unrecognized comorbid impulse-control symptoms may worsen
functioning, complicate treatment response, and increase suicidal risk.We present a
case of recurrent MDD with longstanding but undisclosed kleptomania contributing to
depressive exacerbation and a suicide attempt, aiming to highlight diagnostic
awareness.CASEA 39-year-old unemployed, married woman was admitted following a
suicide attempt by ingesting solvent. She had a 13-year history of recurrent non
psychotic major depressive episodes beginning postpartum, with five episodes lasting
approximately six months each.At admission, she exhibited depressed mood,
anhedonia, severe guilt, and marked functional impairment, including reduced self-care
and parenting capacity. During a detailed interview, she disclosed longstanding
kleptomanic behaviors for the first time; the intense guilt associated with these
behaviors had precipitated the suicide attempt.The patient had previously been
hospitalized for treatment-resistant MDD and received eight sessions of
electroconvulsive therapy with partial response and early relapse.She reported partial
benefit from venlafaxine 150 mg/day, accompanied by worsening kleptomanic urges.On
admission, she was already receiving valproate, which was continued given its potential
benefit on impulsive behaviors.Although bipolar-spectrum depression was not
diagnosed, it had been considered externally;therefore, and in the context of severe
suicidality and planned high-dose SSRI treatment, lithium(300 mg/day) was added for
mood stabilization and suicide risk reduction. Fluoxetine(40 mg/day), quetiapine XR(300
mg/day), bupropion, and clonazepam were administered. By week 3, depressive
symptoms and suicidal ideation markedly improved, while kleptomania-related guilt
persisted at reduced intensity.Written informed consent was obtained.
DISCUSSIONThis case underscores the clinical importance of systematically assessing
concealed impulse-control symptoms in recurrent MDD.Continuation of valproate
alongside lithium reflected a pragmatic strategy addressing impulsivity, suicide risk, and
diagnostic uncertainty without reclassifying the primary diagnosis.Careful
antidepressant selection and adjunctive psychotherapy may be crucial in managing
residual guilt and relapserisk.
Keywords: Recurrent depression, Kleptomania, Suicidal behavior
OBJECTIVE:Cotard syndrome is a rare neuropsychiatric condition characterized by
nihilistic delusions, most commonly involving beliefs of being dead or non-existent.
Rarely, patients may present with inverse themes such as delusions of immortality,
considered atypical variants within the Cotard spectrum. This case report describes an
uncommon presentation of psychotic depression dominated by an immortality
delusion, emphasizing diagnostic considerations and treatment challenges in later life.
CASE (The patient consent must be provided and specified with appropriate terms.):A
60-year-old married woman with a two-year history of depressive symptoms was
admitted due to worsening depressed mood, insomnia, social withdrawal, and a fixed
belief that she was immortal. She also reported auditory hallucinations predicting poor
recovery. Her psychiatric history included generalized anxiety disorder and a previous
psychotic episode during pregnancy. Past psychotropic treatments were poorly
tolerated because of sedation and extrapyramidal side effects.
Mental status examination revealed depressed mood, congruent affect, preserved
orientation, and a persistent delusion of immortality accompanied by themes of
nothingness and worthlessness. No active suicidal or homicidal intent was present.
Medical history included hypertension and diabetes mellitus. Neuroimaging was
unremarkable, and cognitive screening showed borderline impairment.
Treatment with sertraline, aripiprazole, and low-dose quetiapine led to gradual
improvement in depressive and psychotic symptoms, with resolution of insomnia and
appetite disturbance. The patient was discharged with outpatient follow-up plans.
Written informed consent was obtained from the patient for publication of this case.
DISCUSSION:Although Cotard syndrome classically involves delusions of death,
atypical presentations such as immortality delusions are recognized within the same psychopathological spectrum. In this case, denial of death and nihilistic themes
emerged in the context of severe depression, supporting a diagnosis of psychotic
depression with a Cotard variant. Advanced age, borderline cognitive functioning, and
chronic medical illness may have increased vulnerability. Awareness of such atypical
presentations is essential to prevent misdiagnosis and guide individualized treatment.
Keywords: Cotard syndrome, Depression, Nihilism, Psychosis.
OBJECTIVE:Selective serotonin reuptake inhibitors (SSRIs) are widely prescribed for
anxiety disorders and are generally regarded as safe. However, rare ocular adverse
effects, including blurred vision, have been reported. This case aims to describe a
reversible visual disturbance associated with sertraline use in the absence of
identifiable ophthalmologic pathology and to emphasize the importance of clinical
awareness of such adverse effects.
CASE (The patient consent must be provided and specified with appropriate terms.):A
51-year-old menopausal woman with no prior psychiatric history presented with anxiety
symptoms, including excessive worry, dyspnea, and hand tremor. Initial treatment with
fluoxetine at an adequate dose and duration resulted in no significant clinical
improvement, prompting a switch to sertraline. Shortly after sertraline initiation, the
patient developed bilateral blurred vision, which she described as viewing objects
through a rain-covered car windshield. The symptom occurred frequently throughout the
day and had not been previously experienced. Comprehensive ophthalmologic
examination and diagnostic investigations revealed no pathological findings. Despite
continued treatment, visual symptoms persisted for over two months. Sertraline was
subsequently discontinued, and vortioxetine was initiated. Following discontinuation of
sertraline, the blurred vision resolved rapidly, with complete symptom remission. After
symptom resolution, written informed consent for the scientific use and publication of
anonymized clinical data was obtained from the patient.
DISCUSSION:Although ocular adverse effects related to SSRIs are considered
uncommon, blurred vision may occur even in the absence of structural ocular
abnormalities. While most SSRI-related visual disturbances are reported during the
early phase of treatment, persistent presentations may also be observed. This case
highlights a probable drug-related, reversible functional visual disturbance associated with sertraline and underscores the need for careful monitoring of visual symptoms
during SSRI treatment, even when ophthalmologic evaluations are normal.
Keywords: Sertraline, selective serotonin reuptake inhibitors, blurred vision, ocular
adverse effects, drug-induced visual disturbance
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.
