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Unbearable Affect
In this cohesive, dramatic, and highly readable book, the author establishes a roadmap for the diagnosis and psychotherapeutic treatment of psychotic disorders based on finding, understanding and reordering of unbearable affect. He provides concrete clinical advice, vivid examples, and crisp jargon-free descriptions of theoretical concepts and clinical techniques. Most of all, he demonstrates that it is possible for psychotic patients to take control of their conditions, rebuild family relationships, and establish themselves in the viable productive lives that they have long despaired of achieving.
eBook
Treating the “untreatable”
This book offers compelling stories for the general reader, and teaching tales for students and mental health practitioners who want to work in the realm of madness. These clinical cases demonstrate the efficacy of an intensive psychotherapy of schizophrenia and delusional states, combined with the judicious use of antipsychotics. These tales show that even seemingly “untreatable” and “hopeless” psychotic patients may recover and heal in the course of an inquiring psychodynamic psychotherapy aimed at understanding and working through the symbolic meaning of his or her hallucinations, delusions and bizarre thoughts and actions. Such an approach has led to some maintaining their gains for decades.
eBook
Serotonin syndrome caused by escitalopram in Parkinson’s disease psychosis: a case report
Background
Serotonin syndrome and Parkinson’s disease (PD) are two diseases whose symptoms partially overlap; this poses challenges in distinguishing them in clinical practice. Early manifestations such as tremor, akathisia, diaphoresis, hypertonia and hyperreflexia are common in mild-to-moderate serotonin syndrome and can also occur in PD. Without prompt recognition and treatment, serotonin syndrome can rapidly progress, potentially leading to severe complications such as multiple organ failure within hours. Given their disparate treatment strategies, accurate clinical distinction is crucial for effective treatment. This case study explores a patient with serotonin syndrome triggered by escitalopram in the context of PD psychosis (PDP), providing insights into diagnosis and treatment planning.
Case presentation
A 75-year-old Asian woman with a one-year history of PD, a two-month history of PDP, and a six-year history of depression presented with symptoms including hyperreflexia, tremor, hypertonia, impaired level of consciousness, and inappropriate behavior following a recent one-month adjustment in medication. Initially suspected of being drug-induced parkinsonism or worsening PD, therapeutic drug monitoring revealed warning levels of escitalopram. Subsequent diagnoses confirmed serotonin syndrome. This syndrome may result from increased cortical serotonin activity at the serotonin2A receptor due to dopamine and serotonin imbalances in PDP, compounded by increased dopamine-mediated serotonin release. Additionally, being an intermediate metabolizer of cytochrome P450 enzyme 2C19, the patient experienced excessive escitalopram accumulation, exacerbating her condition.
Conclusions
This case underscores the critical need to differentiate between symptoms of serotonin syndrome and PD, particularly in manifestations like tremor and hypertonia. Careful consideration of receptor profiles in patients with PDP is essential when selecting antidepressants to mitigate the risk of serotonin syndrome.
Journal Article
High-potency cannabis and the risk of psychosis
People who use cannabis have an increased risk of psychosis, an effect attributed to the active ingredient Delta 9-tetrahydrocannabinol (Delta 9-THC). There has recently been concern over an increase in the concentration of Delta 9-THC in the cannabis available in many countries.
To investigate whether people with a first episode of psychosis were particularly likely to use high-potency cannabis.
We collected information on cannabis use from 280 cases presenting with a first episode of psychosis to the South London & Maudsley National Health Service (NHS) Foundation Trust, and from 174 healthy controls recruited from the local population.
There was no significant difference between cases and controls in whether they had ever taken cannabis, or age at first use. However, those in the cases group were more likely to be current daily users (OR = 6.4) and to have smoked cannabis for more than 5 years (OR = 2.1). Among those who used cannabis, 78% of the cases group used high-potency cannabis (sinsemilla, 'skunk') compared with 37% of the control group (OR 6.8).
The finding that people with a first episode of psychosis had smoked higher-potency cannabis, for longer and with greater frequency, than a healthy control group is consistent with the hypothesis that Delta 9-THC is the active ingredient increasing risk of psychosis. This has important public health implications, given the increased availability and use of high-potency cannabis.
Journal Article
Cortical morphological alterations in methamphetamine-induced psychosis: a surface-based morphometry study
Background
Methamphetamine (METH)-induced psychosis (MAP), characterized by transient schizophreniform symptoms, affects approximately 43% of individuals with methamphetamine use disorders (MUD). However, the cortical atrophy pattern associated with MAP remain unclear.
Methods
Ninety-four male patients with MUD (62 without psychotic symptoms [MA] and 32 MAP) and 61 healthy controls (HCs) underwent high-resolution T1-weighted MRI and clinical assessments. Surface-based morphological (SBM) analysis using FreeSurfer 7.1.1 was conducted to explore cortical thickness and volume difference among groups. We also examined the correlation between brain structural changes and clinical variables.
Results
The MAP group showed significant cortical thinning in the left superior temporal gyrus (STG) and the right rostral anterior cingulate cortex (rACC) whether compared to HCs and MA. Additionally, compared to the HCs, the MA group exhibited decreased cortical volume in the left caudal middle frontal gyrus (cMFG) and the superior parietal cortex (SPC). In the MUD cohort, left cMFG volume was positively correlated with craving severity (VAS score,
r
= 0.341,
p
< 0.001).
Conclusions
MAP is associated with distinct region-specific cortical thinning, particularly in temporal and limbic regions, suggesting a structural basis for its psychotic features. These findings provide new insight into the neurobiological mechanisms underlying MAP and may inform future intervention strategies.
Clinical trial number
Not applicable.
Journal Article
Beyond Psychiatric Illness: Paediatric Autoimmune Neuropsychiatric Syndrome Presenting as Psychosis
Aims: Paediatric Autoimmune Neuropsychiatry Syndrome is a rare condition with exact prevalence not known due to dearth of large-scale population studies. Its diagnostic as well as treatment guidelines are not yet validated. There are a few international guidelines but none available in the UK yet. Methods: The referral of a 15-year-girl presenting with symptoms suggestive of PANS to our team prompted us to write this case report. The patient was brought in to the A&E by her parent after an episode of bizarre and chaotic behaviour at school, which included her throwing belongings at the staff while being emotionally labile. On assessment she reported symptoms suggestive of paranoid delusions, delusional perception, auditory and gustatory hallucinations, thought broadcasting and delusional memory. She was also taking more frequent showers, with clothes on. Her sleep was disrupted. Extensive blood and radiological investigations initially didn’t yield any positive findings. Antipsychotic (olanzapine) was initiated and the patient’s mental state quickly improved. Two days later blood investigations showed raised antistreptolysin O titres (200–400 U/Ml). Hence, antibiotic (phenoxymethypenicillin) was initiated. The patient was discharged and followed by our team in the community. The patient continued to present with residual psychotic symptoms which fluctuated in the community setting. But the overall functioning significantly improved. Results: The acute onset of psychosis, characterized by behavioural disturbances, anxiety, sleep disruption, irritability, and emotional lability, along with elevated antistreptolysin O titres, suggested a diagnostic formulation aligning with PANS. Conclusion: The case underscores the importance of considering PANS as a differential diagnosis in school-aged children presenting with symptoms of OCD, first episode of psychoses or unexplained emotional lability.
Journal Article