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Case Report Abstracts
Case Report Abstracts
ADDICTION
[Abstract:0109] Addiction
Dangers of synthetic cannabinoids: a case report
Mehmet Karadag1, Ihsan Aksoy2, Osman Virit2, Abdurrahman Altindag2, Haluk A. Savas2
Department of Child and Adolescent Psychiatry, Gaziantep University, Gaziantep-Turkey
1
Department of Psychiatry, Gaziantep University, Gaziantep-Turkey
2
e-mail address: [email protected]
Cannabis has become the most widely consumed illicit substance worldwide since discovery of cannabinoid receptors in the 1980s.
Then the effects of cannabinoids have been started to be studied in diseases such as pain syndromes and neoplasms where their antineoplastic effects were claimed. Synthetic cannabinoids (SCs), known mostly as JWH agents, were first identified in 1990s and they were
found to have 2-100 times more potent than THC. These psychoactive compounds are obtained with very minor modifications on the
original cannabinoid compound and their amount and types tend to show regional differences with varying chances to be detected in
routine toxicological screens. Recently the use of SCs known as Bonsai (“K2” for USA and “Spice” for Europe) has increased considerably and
SC-related deaths have increased a lot. SC side effects may include nausea and vomiting, shortness of breath or respiratory suppression,
hypertension, tachycardia, chest pain, muscle twitches, acute renal failure, anxiety, agitation, psychosis, suicidal thoughts, cognitive
impairment and generalized epileptic seizures.
Divorced, a37-year-old male was hospitalized with the history of SC (bonsai) abuse for 3 months. He reported to have irritability; sweating
and generalized pain whenever he did not used 1.5 gr SC per day. He started to have convulsions after using SC and prescribed with
carbamazepine 400 mg/day before. He was brought to emergency department with chest pain and loosing consciousness immediately
after using SC 1 month ago. He had psychomotor agitation but he had not clear psychosis including hallucinations. His toxicological
analysis revealed no sign of illicit drugs. Bradycardia (52 beats/min) was detected in the ECG without arrhythmia. He had slightly elevated
CK-MB levels (48 U/L). Echocardiogram examination was normal. Cranial MRI results were unremarkable. EEG showed paroxysmal slow
waves with sharp characteristics in both hemispheres. Diazepam 40 mg/day and mirtazapine 30 mg/day treatment was started and
carbamazepine was stopped after the consultation with neurology because his convulsions ceased after he stopped using SC. His
withdrawal symptoms decreased gradually within 4 days and patient was discharged on his will at 15th day.
In the literature, the most common expressed side effect of SCs is tachycardia, although bradycardia was present in our case probably
because he was not using SC for one day. So tachycardia may be considered as an acute phase side effect of SCs. History of chest
pain and loss of consciousness a month ago suggests a prior MI and he had slightly elevated CK-MB levels. Mortality due to SCs may
be related to sudden cardiac death. Cardiac side effects in the acute phase are thought to result from the stimulation of sympathetic
nervous system and epileptic abnormalities may be due to the impact of SCs on CB1 receptors or inhibition of γ-aminobutyric acid
(GABA) neurotransmission. Novel generalized seizures and chest pain especially in young people should be warning for neurologists and
cardiologists in terms of potential SC abuse.
Keywords: bonsai, generalized epileptic seizures, synthetic cannabinoids
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Case Report Abstracts
[Abstract:0190] Addiction
Lipid infusion therapy in sinus tachycardia induced with synthetic cannabinoid (SC) intoxication:
two cases report
Filiz Izci1, Vedat Izci2, Servet Izci3, Merve Setenay Iris Koc1, Rabia Bilici1, Engin Emrem Bestepe1
Department of Psychiatry, Erenkoy Training and Research Hospital, Istanbul-Turkey
1
Department of Emergency, Kartal Lutfi Kirdar Training and Research Hospital, Istanbul-Turkey
2
Department of Cardiology, Kartal Kosuyolu High Specialized Education and Research Hospital, Istanbul-Turkey
3
e-mail address: [email protected]
Prevalence of synthetic cannabinoid (SC) use is gradually increasing. Unlike cannabis, intoxication symptoms of SC are similar to those
seen in more stimulating and sympathomimetic drug use. Varying side effects include sweating, nausea, vomiting, hypertension /
hypotension, tachycardia / bradycardia, respiratory depression, confusion, psychomotor agitation and sedation. The most common
physical side effect is tachycardia. Here, we discuss two cases with sinus tachycardia induced with SC intoxication which were treated
with lipid infusion therapy.
Case 1: A 24-year-old male patient was admitted to emergency room with nausea, flushing, restlessness, burning eyes, palpitations,
anxiety. According to the history,the patient was using cannabinoids and SC for 4 years. He had taken a huge amount of SC 3 hours ago
and his complaints had started afterwards. The patient’s consciousness was clear. Vital signs; temperature: 380C, blood pressure: 100/75
mm Hg, pulse:160/min. Blood biochemistry and total blood count results were normal. Sinus tachycardia was present in ECG. Because SC
metabolites can not be detected in urine the urine test results were clear. The patient was referred to a general emergency department
with a preliminary diagnosis of SC intoxication. Symptomatic treatment was started and iv bolus with 100 ml of a 20% lipid solution and
0.5 ml/kg/min iv infusion was administered. Patient’s pulse and blood pressure were stabilized within 3 minutes. The patient’s tachycardia
was resolved 30 min. after the administration of 500 ml of lipid infusion. After the 24-hour observation period the patiet was referred to
our psychiatry department for the treatment of substance use disorder.
Case-2: A 28-year-old male patient admitted to emergency room with aggression, nausea, vomiting, flushing, palpitations, hearing voices.
He had a history of mixed substance use for 10 years. He had increased the SC use in recent days and he had used SC with his friends 6
hour before admission. The patient’s consciousness was clear but orientation was partial. Anxiety, agitation, aggression, depersonalization,
auditory hallucinations, irritability, mood elevation was present in the mental status examination. Vital signs; temperature: 370C, blood
pressure: 110/60 mm Hg, pulse:155/min. Blood biochemistry and total blood count results were normal. Sinus tachycardia was present
in ECG. Because SC metabolites can not be detected in urine the urine test results were clear. The patient was referred to a general
emergency department with a preliminary diagnosis of SC intoxication. Symptomatic treatment was started and 0.5ml/kg/min iv infusion
with a 20% lipid solution was administered. After the 24-hour observation period the patient was stabilized and discharged.
Generally, decreased psychomotor activity, sedation and lethargy are seen in patients with cannabinoid intoxication whereas agitation
and irritability are more common in synthetic cannabinoid intoxication. The most common physical side effect is tachycardia. Here we
report two cases with SC intoxication symptoms at whom sinus tachycardia was present. Lipid emulsions are known to use in Haloperidol,
verapamil, sertraline, quetiapine, bupropion and lamotrigine toxicity. The two cases in our report were benefited from lipid infusion
therapy for sinus tachycardia induced with synthetic cannabinoid intoxication.
Keywords: synthetic cannabinoids, sinus tachycardia, lipid infusion
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[Abstract:0198] Addiction
Is carbamazepine abused or misused?
Leman Inanc1, Sema Inanir1, Merih Altintas2, Ece Yazla3
Department of Psychiatry, Tokat Mental Health Hospital, Tokat-Turkey
1
Department of Psychiatry, Erenkoy Training and Research Hospital for Psychiatry, Istanbul-Turkey
2
Department of Psychiatry, Corum Training and Research Hospital, Corum-Turkey
3
e-mail address: [email protected]
Mood stabilizers has been established as clinically useful, safe and effective in substance abusers. Carbamazepine (5H-dibenzazepine5-carboxamide) is an iminostilbene derivative with a tricyclic structure. The potential of misuse of carbamazepine was not typically
mentioned in the prescriber’s aids. Because carbamazepine is not recognized as a drug with high-abuse potential, data on carbamazepine
abuse and addiction are lacking. Here, we report a case regarding to potential abuse of carbamazepine for euphoria.
The patient is a 28-year-old man, primary school graduate, working irregularly. He has a previous psychiatric history of psychosis. His
illness started 6 years ago with abusing substances. The first episode occurred 6 years back and was characterized by irritability, excitation,
agitation, aggressive behavior, delusions, decreased sleep and psychosocial dysfunction. Three years ago he presented to mental health
service for the second time with agitation, irritability, aggressive behavior and somatic delusions diagnosed with substance/medicationinduced psychotic disorder. The patient was treated by quetiapine. The dosage was adjusted and a mood stabilizer carbamazepine was
added. The patient received carbamazepine for several weeks with quetiapine. Carbamazepine was conducted at 400mg/ day for several
weeks. As a result, his behavioral disorders symptoms improved.
He was admitted to our ward presenting irritability, agitation symptoms. This was the third relapse for the patient. His relatives brought
him to hospital due to taking overdose carbamazepine and uncontrollable behavior. He stopped abusing substance 3 years ago and was
taking overdose carbamazepine for 3 years. At the emergency department carbamazepine blood level was 15,4. The patient admitted
that he had consumed approximately 10 (equivalent to 4000 mg) of carbamazepine pills daily. He reported that a psychiatrist prescribed
carbamazepine 3 years ago to relieve his aggressive behavior and due to anticraving efficacy. Initially carbamazepine provided relief for
both conditions, however later he started taking it irregularly 1-2 times a week to get high. He increased the dose of carbamazepine to
3200-4000 mg/day. He said he felt euphoria while on high doses of carbamazepine and have a little dizziness and nausea afterwards. He
took this medication with six-hour intervals mostly two times per day and experienced euphoria and relief.
He was close monitored of vital signs, cardiac rhythm and serial carbamazepine levels. Physical examinations were unremarkable. He
has no comorbid medical illness and his family history was also unremarkable. There was no neurological signs and symptoms including
ataxia, nystagmus, mydriasis, movement disorders and the anticholinergic toxidrome. Biological testing including routine blood counting
and urine examination were normal with exception of the increase in mean corpuscular volume. He had hyponatremia with sodium
levels of 127 mEq/L. Hyponatremia was asymptomatic. Two weeks after the initiation of treatment of low dose of risperidone and
quetiapine, a successful improvement was observed with clear reduction of agitation and aggressive behaviors that could be attributed
to a modification of psychotropic treatments. The history of substance abuse and male gender are known to be risk factors for substance
addiction. Clinicians should be cautious while using carbamazepine in treating patients with a history of drug or alcohol dependence.
Keywords: abuse, carbamazepine, misuse
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[Abstract:0211] Addiction
Abuse of cyclopentolate hydrochloride
Muberra Kilic, Leman Inanc, Ugur Kulu
Department of Psychiatry, Tokat Mental Health Hospital, Tokat-Turkey
e-mail address: [email protected]
Cyclopentolate hydrochloride is frequently used in ophthalmology practice to induce short-term mydrIASis and cycloplegia for
ophthalmologic examination. This drug may cause addiction similar to other anticholinergic agents. The existing reports of probable
abuse of cyclopentolate hydrochloride drops comprises three cases. We are reporting the case of a patient who presented with addiction,
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Case Report Abstracts
taking the drug directly through the nose. We have not yet encountered a case of cyclopentolate hydrochloride addiction in which the
drug was administered via the nasal route.
A 22-year-old single man, high school graduate, working irregularly. He has a previous psychiatric history of substance use disorder and
antisocial personality disorder. Past psychiatric history was significant for a 11-year history of alcohol and 8-year history of marijuana
abuse and a 4-year history of opiates abuse. He also abused a wide variety of drugs including ecstasy, clonazepam, LSD (lysergic acid
diethylamid), synthetic cannabinoids. Family history was significant for a brother and father with alcoholism. He was admitted to our ward
presenting irritability, agitation, anxiety and insomnia. Physical and neurological examination was within normal limits. On his visit to our
unit, the patient had already been using cyclopentolate hydrochloride drops for three years. It was often taken in combination with other
psychoactive compounds, most typically alcohol, marijuana and opiates. The patient used the drug for the first time after a friend told him
it could be used to get high. Patient reported developing tolerance to cyclopentolate hydrochloride. He increased the dose of the drug
gradually till a bottle per day. He reported withdrawal symptoms such as anxiety, restlessness, and insomnia.
The patient admitted that he had consumed approximately 100 drops (a half of a plastic dropper bottle) in each nostril and experienced
dizziness, nausea, anorexia, “open eye dreams,” hallucinations 10 minutes afterwards. This effect lasts for 8 hours. Later he started taking
it once a day to get high. He said that he felt satiated and did not need to eat or drink anything except water during the day while on
high doses of cyclopentolate hydrochloride. When not using the drug he becomes irritable, stretched, sweats, and has symptoms such
as anxiety, restlessness, and insomnia. At such times he has the desire to use the drug, which he buys from any pharmacist, as it does not
require a prescription.
The presented case began using cyclopentolate hydrochloride following the advice of a friend that used it so this leads us to believe
that anticholinergic are abused by other people who have never had applied to the psychiatric services. The clinician must pay special
attention to detect anticholinergic misuse in patients presenting with polysubstance use disorder.
Keywords: abuse, anticholinergic, cyclopentolate hydrochloride
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[Abstract:0231] Addiction
Methyl alcohol abuse in a patient with dissociative disorder, bipolar affective disorder I and ethyl
alcohol abuse
Bahar Kaplan, Filiz Izci, Merve Setenay Koc, Rabia Bilici, Murat Yalcin, Emrem Bestepe
Department of Psychiatry, Erenkoy Training and Research Hospital, Istanbul-Turkey
e-mail address: [email protected]
In this article; we report a patient with bipolar affective disorder I, NOS dissociative disorder, ethyl alcohol abuse and methyl alcohol
abuse. A 40-year-old male patient, divorced, high school graduate, veterinary technician who was admitted to our emergency room with
malaise, death thoughts, going away from home without remembering that period, feeling the presence of someone else inside him
and drinking cologne (methyl alcohol) when he couldn’t find ethyl alcohol. No known organic disease was present in the patient history.
He had a history of alcohol abuse for 17 years and had multiple alcohol/drug treatment center and psychiatry hospitalizations. He had
one manic and two depressive episodes. It was learned from the family history that his father had alcohol abuse. In the mental status
examination his mood and affect was depressed, anhedonia, insomnia, thoughts of worthlessness and hopelessness, passive suicidal
thoughts, dissociative convulsions and amnestic periods, memory and concentration difficulties were present and psychomotor activity
was partly decreased. Following the hospitalization routine complete blood count,biochemistry,blood levels of ethanol, substance levels
in the urine, chest x-ray and ECG were requested. The results revealed no abnormalities except a blood ethanol level of 12.47. The patient
was diagnosed with bipolar affective disorder 1, NOS dissociative disorder, ethyl alcohol and methyl alcohol abuse according to SCID-I
and patient history. Hamilton Depression Rating Scale (HAM-D), Dissociative Experiences Scale (DES), DDIS (The Dissociative Disorders
Interview Schedule) and Childhood Trauma Questionnaire (CTQ) were administered. HAM-D scale score was 23, DES scale score was 36,4.
Haloperidol 10 mg/day, biperidene 5 mg/day im treatment was started. EEG was normal. After the injection treatment was stopped,
escitalopram 10 mg/day, valproate 1000 mg/day and trifluperazine 1 mg/day treatment was started. Valproate dose was increased up
to 1500 mg/day in according to clinical follow-up and laboratory results. However the patient had pruritus and a complete blood count
was requested and it was seen that he had a Hgb value of 18.7 and a Htc value of 55.8. The patient was consulted to internal medicine
and was diagnosed with polycythemiaVera. Patient whose depressive and dissociative symptoms were improved was discharged from
the hospital.
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Although alcohol and drug use is common in bipolar affective disorder, also dissociative disorder comorbidity may be present. In our
case; presence of childhood traumatic experiences, mood disorder, dissociative symptoms, ethyl alcohol abuse and methyl alcohol abuse
draw attention to various comorbidities in bipolar affective disorder patients. Presence of multiple diagnosis especially in inpatient clinics
should be considered in terms of clinical course and treatment of these patients.
Keywords: alcohol abuse, bipolar affective disorder, dissociative disorder
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[Abstract:0232] Addiction
Addiction of oxybutynin: an adolescent case report
Mehmet Fatih Kinik1, Funda Donder1, Mustafa Kenan Duymaz2, Isik Doyurgan Karakaya1
Department of Child and Adolescent Psychiatry, Kocaeli University, Faculty of Medicine, Kocaeli-Turkey
1
Department of Child and Adolescent Psychiatry, Kocaeli Derince Training and Research Hospital, Kocaeli-Turkey
2
e-mail address: [email protected]
Oxybutynin is an antimuscarinic substance used frequently in the treatment of overactive bladder and nocturnal enuresis. It is known that
during the use of such anticholinergic substances, such effects as the decrease in depressive symptoms, euphoria effect, relaxation and
the alleviation of the side-effects of neuroleptic medications could be seen.
In a study it was reported that biperidene raised the mood. Several clinical cases have been reported as to the anticholinergic substance
abuse, and the most commonly misused agents are biperidene, benztropine and procyclidine.
In this case report, an adolescent case who applied to our clinic due to oxybutynin abuse and suicide attempt has been presented. A 17
-years and 3 -month old female adolescent patients were referred to child and adolescent psychiatry by the pediatric emergency service
due to a suicide attempt. According to history taken from the patient and her mother, the patient named A. had carried out a suicide
attempt by taking a drug containing oxybutynin after having a fight with her friend. She started to use oxybutynin by one of her friends
because she said that it is used to be heady. She also reported that she had taken 8 tablets (40 mg) once a month when she had started
on oxybutynin, then she had gradually increased the use of oxybutynin within a year and that she was taking about 20 tablets (100 mg)
almost everyday. The patient also told that despite the side-effects like xerostomia, somnolence, difficulty in breathing, blurred vision, she
need to take oxybutynin. She said that she had audio-visual hallucinations after taking oxybutynin.
On the other hand, she reported that when she stopped using oxybutynin, her hands started to tremble, her anxiety and perspiration
increased. She avoided approaching people due to her perspiration. She pointed out that she had no problem in finding oxybutynin, that
she could easily get it from a pharmacy without a prescription. She spent less time with her friends due to the use of oxybutynin and she
got easily bored in circle of friends.
In this case we presented an adolescent who use oxybutynin and met DSM-5 criteria for other substance use disorder. Oxybutynin
misuse has just been realized and is still on the increase which is among the non-controlled drugs and can be obtained easily without
any prescription. According to the information received from the case, the misuse rate of this drug is gradually increasing among the
youth due to both its easy accessibility and its cheapness. The euphoric mood and deliriogenic effects arising from such drugs lead to an
anticholinergic addiction. In our medical case, the symptoms such as the decrease in anxiety along with the hallucinations experienced
by taking pleasure of such effects, which all appear due to oxybutynin in particular, also seem to have triggered this addiction.
This case has been presented for the purpose of drawing attention to oxybutynin hydrochloride abuse, which is easily accessible and to
the increasing risk of the use of this drug among the youth.
Keywords: addiction, adolescent, oxybutynin
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Case Report Abstracts
[Abstract:0235] Addiction
Abuse of sinemet® (levodopa/carbidopa combination) in a patient with schizophrenia
Derya Arslan, Taha Can Tuman, Ugur Cakir, Osman Yildirim
Department of Psychiatry, Abant Izzet Baysal University, Faculty of Medicine, Bolu-Turkey
e-mail address: [email protected]
Antiparkinsonian drugs are used to treat the extrapyramidal movement disorders which are the among common side effects of the
antipsychotic treatment. Anticholinergic drugs are preferred in the first line of treatment for the extrapyramidal side effects however the
other antiparkinsonian drugs also can be used.
Sinemet® is a combination of carbidopa and levodopa for the treatment of Parkinson’s disease and syndrome. Drug abuse, is a patterned
use of a substance (drug) in which the user consumes the substance in amounts or through methods without the advice of medical
professionals. Levodopa, the metabolic precursor of dopamine, does cross the blood-brain barrier, and presumably is converted to
dopamine in the brain. The patients need dose escalation of dopamine agonist drugs progress of the Parkinson disease. Psychological
dependence and abuse of the antiparkinsonian drugs are developed after the dose escalation at these patients. Abuse potential of
anticholinergics are well known but there’s limited research about the abuse of dopamine agonist drugs in the medical literature. In this
paper, it has been aimed to report abuse of Sinemet® in a patient with schizophrenia.
Follow-up for 15 years with a diagnosis of schizophrenia, a 46 year-old male patient presented the positive psychotic symptoms like
auditory, visual hallucinations and delusions. He didn’t use to use antipsychotic treatment for 6 months but the negative symptoms were
forefront like anhedonia, avolition, introversion. Sinemet® 30 mg per a day was started to treat extrapyramidal motor symptoms caused
by antipsychotic drugs 2 years ago. Than the patient dropped out of the antipsychotic treatment but didn’t quit the using of Sinemet®
despite of the extrapyramidal symptoms disappear. For three months he had taken Sinemet® 30 mg from 3 tablets to 6 tablets up to
hospitalized. The positive psychotic symptoms emerged after the abuse of Sinemet®.
In psychiatric examination; he was cooperative when not distracted by hallucinations. He was childish, sometimes smiling inappropriately.
He had also developed conceptual disorganization, unusual thought content and blunted affect. He had psychomotor agitation and
choreiform movements at extremities. His PANSS score was 163 at first psychiatric examination.
Olanzapine 10 mg per a day started for psychotic symptoms and Valproic acid 1000 mg per a day started for choreiform movement
disorders. His PANSS score decreased 97 after a month from start of the antipsychotic treatment.
Anticholinergic and dopamine agonist drugs are widely used to treat extrapyramidal motor symptoms caused by antipsychotic or other
drugs with antidopaminergic effects. These drugs may be abused because of their stimulant effects, mostly by patients on antipsychotic
treatment. It is generally assumed that patients with Parkinson disease perceive their need for antiparkinsonian drugs on the basis of
emergent motor symptoms. Abstinence from dopaminergic drugs resulted in the appearance of drug-seeking behavior.
In our case, Sinemet® started to treat the side effects of the antipsychotic drugs and the patient abuse it. Than he had a psychotic episode
and especially the positive psychotic symptoms were outstanded in two months. Psychological dependence on levodopa has previously
been reported in 1985 in a small subset of Parkinson patients.
Keywords: abuse, antiparkinsonian drugs, levodopa/carbidopa
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[Abstract:0248] Addiction
Codeine addiction: a case report
Taha Can Tuman, Ugur Cakir, Osman Yildirim
Department of Psychiatry, Abant Izzet Baysal Training and Research Hospital, Bolu-Turkey
e-mail address: [email protected]
Codeine used for more than a century. In central nervous system codeine reduce the pain by binding to opioid receptors. A 80-year-old
elderly woman was admitted to our outpatient unit with complaints of widespread malaise, body pain, nausea, insomnia, restlessness,
weakness and irritability. Her complaints started fifteen days ago. She didn’t have any complaints up to fifteen days. There was no
psychiatric complaint in her personal history. Routine blood tests were normal. In her personal history she said “I left my drug before
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two weeks and my complaints were started after that. “It was learned that the patient used this drug “Geralgine” every day for five years.
Inıtıally she used once a day for a year, after she used twice a day and she used three or four times a day for two years. She used the
drug only orally. She said “When I left the drug, I felt anxious and restless so I continued to use this drug but my new family physician
cut my medication two weeks ago.” This drug contains codeine. Paracetamol was started for her body pain and hydroxyzine was started
for insomnia and anxiety as a diagnosis of “Codeine withdrawal” according to DSM5. Psychoeducation was given to the patient about
addiction and drug medication. The first case related to codeine addiction was reported in 1908 by Pelz. A tablet of Geralgine contains 30
mg codeine. Geralgine can be obtained with normal prescription in Turkey. All doctors are able to prescribe Geralgine in Turkey. In 2009,
Geralgine was included “To be suBMItted to the Joint Monitoring normal prescription drugs” by Ministry of Health. All physicians should
be informed about the addictive effects of these drugs. These drugs should not be prescribed repeatedly. Clinicians, especially general
practitioners should have consulted the patients for intractable pain.
Keywords: addiction, codeine, elderly
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[Abstract:0358] Addiction
A rare addiction: fuel oil (diesel and petrol) drinking
Taner Oznur1, Emrah Kizilay1, Suleyman Akarsu2, Abdullah Bolu3
Department of Psychiatry, Gulhane Military Medical Academy, Ankara-Turkey
1
Aksaz Naval Hospital, Mugla-Turkey
2
Aircrew’ s Health Research and Training Center, Eskisehir-Turkey
3
e-mail address: [email protected]
Recently, the number and the variety of substances used by the young people show a significant increase. Herein, we present the case
of a patient showing the addictive behavior as fuel-oil drinking. A 20-year-old male patient who had a history of difficulties in impulse
control, frequent alcohol use and self-mutilation was referred to psychiatric clinic after treatment for fuel oil drinking in the emergency
department. He was hospitalized for further evaluation and assessment. The premorbid characteristics were immature features, low
frustration tolerance, cluster B personality traits. He was using alcohol frequently and had a behavior of petrol sniffing and drinking. IQ score
was determined as 73 in the psychometric assessment. According to the anamnesis, he had been exhibiting diesel and petrol drinking as
well as sniffing behaviors for 8 years. He had an intense desire against these agents and if he was unable to drink, he became irritability.
Vomiting, severe dizziness, agitation were experienced as intoxication symptoms. Previously, he had admitted to the emergency service
twice, however he did not receive psychiatric treatment. In order to evaluate the organic pathology; routine biochemical tests, EEG, MRI
were performed. Results of EEG and biochemical tests were found to be within normal limits. Reduction in periventricular white matter
volume close to left frontal horn of the lateral ventricle and signal abnormalities characterized by hyper intense appearance consistent
with gliotic changes in FLAİR sequences were determined in brain MRI. Imaging findings were considered to be associated with gasolinediesel consumption. Consistent with the literature, diesel and petrol drinking- sniffing behaviors had begun in 12-year-old and the limited
mental capacity of the patient had been assessed to be associated with the fuel drinking behavior. Although there is case reports related
to the petrol sniffing behavior, case reports about drinking gasoline and diesel behavior are not available in the literature. Brain lesions
associated with fuel drinking have been demonstrated by this case. Psychotic symptoms (hallucinations and paranoid ideation) occurred
after the petrol sniffing is unclear whether the effects are acute or chronic. There might be non-specific EEG changes in these patients.
The studies had shown that exposure to petrol caused neurodegenerative changes in cerebellum, cerebral cortex, hippocampus, reticular
formation in the brainstem and basal ganglia.
Keywords: addiction, drinking, fuel oil
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[Abstract:0361] Addiction
Patient with treatment resistant psychotic disorder developed after the magic mushroom use
Taner Oznur1, Suleyman Akarsu2, Abdullah Bolu3, Ayse Nihal Erarslan1, Adem Balikci1
Department of Psychiatry Gulhane Military Medical Academy, Ankara-Turkey
1
Aksaz Naval Hospital, Mugla-Turkey
2
Aircrew’ s Health Research and Training Center, Eskisehir-Turkey
3
e-mail address: [email protected]
In this case report, we present a patient with treatment resistant psychotic disorder developed after the magic mushroom use a 24-yearold male patient. He had cluster B personality traits and history of multiple substance abuse in the premorbid. He was admitted to the
psychiatric clinic because of having intense irritability and somatic delusions. Recent alcohol and substance use was as a year ago but he
once had used magic mushrooms 6 months ago and after that psychiatric symptoms begun. He thought that his eyes and throat were
dissolved and all body was decayed. He stated that excessive use of eye drops had led to the this situation. He once admitted to the
psychiatry polyclinic for sadness complaint but he did not receive a drug therapy. His brother has been receiving treatment for 3 years
with the diagnosis of psychotic disorders. In psychometric assessment, Scale for the Assessment of Positive Symptoms (SAPS) score was
42 and Scale for the Assessment of Negative Symptoms (SANS) score was 45. Routine biochemical tests were within normal limits. No
pathology was detected in the brain tomography. The treatment was organized as quetiapine 600 mg/day, alprazolam 1 g/day. Liver
function tests increased 8-fold on the eighth day of hospitalization so that treatment was changed as risperidone 2 mg/day. Treatment
was organized as risperidone 6 mg/day and clonazepam 5 mg/day when improvement in liver function tests had been provided. Electroconvulsive therapy (ECT) was performed on the 35th day of hospitalization due to lack of improvement in symptoms and development
of suicidal thoughts. SAPS and SANS score was 31 on the 52nd day of hospitalization. Risperidone had been switched to olanzapine 15
mg/day gradually. Patient received a total of 12 sessions of ECT. Significant improvements in symptoms were observed on the 73rd day
of hospitalization (SAPS:10, SANS:18). Patient was discharged from the hospital and follow-up-treatment was performed in the polyclinic.
Magic mushroom is a fungus found in nature, can be grown in home conditions and freely marketed on the internet. So it is an easily
accesSIBle substance. Magic mushrooms are adopted in mild effective substance status. Psilocin and psilocybin are active ingredients
that are responsible for the psychoactive effects. They show their effects over serotonergic systems and exhibit agonist activity on 5HT1A
-5HT2A/C receptors. Psilocybin is used in experimental serotonergic models of schizophrenia. The effects of magic mushrooms last
approximately 2-6 hours. These effects are relaxation, drowsiness, uncontrollable laughing, being energetic, euphoria, see colors more
brilliant, visual impairments (moving surfaces, waves), delusions, hallucinations, anxiety and paranoia. Although it is believed that mostly
they have temporary effects so they are less harmful than most of the drugs, information about the long-term effects is insufficient.
Psychiatric symptoms should be permanent in very few cases.
Keywords: delusions, magic mushrooms, somatic
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S215
[Abstract:0364] Addiction
An outstanding case - venlafaxine addiction
Ugur Cikrikcili, Gasim Gasimzade, Ilhan Yargic
Department of Psychiatry, Istanbul University, Faculty of Medicine, Istanbul-Turkey
e-mail address: [email protected]
Presenting a rarely addiction case and drawing attention to prescribing antidepressants. Venlafaxine, a serotonin-norepinephrine reuptake
inhibitor (SNRI), is commonly used to treat depression. It has a 30- fold higher effect on serotonin reuptake than on noradrenaline, and a
weak effect on dopamine re –uptake. The noradrenaline reuptake mechanism also shows some dopaminergic activity on the prefrontal
cortex. Although rare, Venlafaxine can be abused by some patients and even addiction is possible. To date there is limited data published
on Venlafaxine addiction, perhaps because it rarely presents in clinical trials. Overdosage of Venlafaxine produces an amphetamine-like
‘’high’’ with experiences of euphoria by its ability to increase neurotransmitter levels. We present a 42 year-old male, referred to our
clinic for detoxification from self-medicated Venlafaxine addiction. He had been taking Venlafaxine up to 2100 mg/day without medical
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supervision for the past 10 years and had recently attempted suicide. He described the effect of Venlafaxine similar to amphetamine
and he said he took the medication for this effect not only to avoid withdrawal symptoms. During therapy he experienced withdrawal
symptoms of impulsive behavior, and an eating disorder. Physicians must be careful when prescribing antidepressants to patients,
especially those with a history of alcohol and/or drug addictions or abuse.
Keywords: addiction, antidepressant, venlafaxine
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[Abstract:0384] Addiction
Cannabis and synthetic cannabinoid use disorders and amotivational syndrome: a case report
Abdullah Akpinar, Kadir Demirci, Ekrem Didin, Arif Demirdas
Department of Psychiatry, Suleyman Demirel University, Faculty of Medicine, Isparta-Turkey
e-mail address: [email protected]
Amotivational syndrome (AS) becomes evident with chronic cannabis use and it is characterized by decrease at purposive activities,
introversion, ineffective communication, motivation decrease, apathy, incoherence, blunted affect, energy decrease, poor judgment,
lack of concentration and memory disorder. AS is under recognized, under diagnosed, and poorly researched clinical situation in spite
of studies show 16-21% frequency of symptoms such as energy and motivation decrease which are related with chronic cannabis use.
A 23-year-old male who has been using cannabis for nine years, has started using more frequently in past three years and for the past year
has used the substance almost every day and switched to synthetic cannabinoids after developing the syndrome.
Cannabinoid receptors are commonly present at the sites of brain which are responsible for pleasure, memory, planning, concentration,
perception, coordinated movements. It is interacted with the dopaminergic, gabaergic, and glutamatergic mechanisms. It was assumed
that AS is originated from long-term effects of cannabinoids at this systems by causing neuronal dysfunctions. It‘s detected that despite
of dopamine increase at acute use of cannabinoids there is decrease at dopamine in chronic use, which is may be related with down
regulation of dopamine receptors and desensitization of cannabinoid-1 receptors.
McGlothlin and West defined the motivational loss and, passive, introvert personalities of cannabis users; Maugh detected its relativeness
with the amount and duration of cannabis use. In this case there was 9 years history of cannabis use and last year he even used cannabis
daily so he develop AS. There are also reported AS cases which are related with organic solvents which have psychoactive substances,
methamphetamine and antitussives including opioids. But in our case there wasn’t any other substance use except synthetic cannabinoid.
In this case probably due to its stimulant effects he started to use synthetic cannabinoid after developing AS. Bozkurt et. al detected that
86% of synthetic cannabis users previously used cannabis. Considering this case we think that AS symptoms due to cannabis is a risk to
start synthetic cannabinoid use.
AS clinic can shows similar features with major depression. But AS clinic is separated from depression by cannabis use history, interacted
with the dopaminergic system, more resistant clinic, apparent psychomotor retardation and apathy unlike depressive mood. AS clinic also
shows similar features with schizophrenia negative symptoms. But like in our case there isn’t any detected delusion, hallucination and
disorganized speaking at AS which are diagnostic criteria of schizophrenia.
In AS treatment; cannabis use termination and dopaminergic or noradrenergic agent use despite of little data is recommended. In this
case bupropion 300 mg was started but response to treatment couldn’t be evaluated due to lack of follow-up.
Consequently; intoxication, dependency, withdrawal syndrome, psychosis and depression triggered by cannabis are well known but AS
is under recognized, under diagnosed, and poorly researched clinical situation. Recognition of this syndrome is important for providing
compliance with medication, fight with serious functionality disorders and lack of motivation. Also, AS can facilitate switching other
substances like synthetic cannabinoids.
Keywords: cannabis use disorder, synthetic cannabinoid, amotivational syndrome
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[Abstract:0407] Addiction
To be a substance dependent woman: evaluation of the cases
Nilufer Yalin Cetin1, Hacer Yalniz1, Melike Nebioglu2, Fatih Canan3, Omer Gecici1, M. Murat Kuloglu1
Akdeniz University Hospital, Alcoholism and Addiction Research and Application Center, Antalya-Turkey
1
Haydarpasa Numune Training and Research Hospital, Istanbul-Turkey
2
Department of Psychiatry, Akdeniz University, Antalya-Turkey
3
e-mail address: [email protected]
Objective: In women, the childhood traumas are related to an increase in substance abuse and addictive disorders. Women who are
subject to sexual, physical or verbal exploitation may head towards using substance as a coping method. In this case presentation
emphasis will be put on the difficulties of substance use disorder by investigating two female patients’ childhood traumas, substance use
pattern and treatment process.
Case 1: G.T. is a 20-year old woman; she is secondary school graduate, unemployed and got married when she was 18 years old. Her
marriage had lasted only 3 months, she had divorced 2 years ago and she had no child or history of pregnancy. She is using condom as a
family planning method. She stated that she had neglected to use condom during poverty period and shared injectors. At the serological
examination performed, a HCV positivity was detected.
Family History: Her father is an alcohol dependent man and spends most of his time outdoor. He often comes home late and applies
physical violence to her mother. Her parents had divorced when she was 12 years old and her father had died from pancreatic cancer
when she was 19.
History of substance use: G.T. had started smoking at 10 years old and heroin at 12 years. She was raped when she was 13 while under the effect
of heroin. She compensated the supply of heroin by prostitution. When she was referred to Alcohol and Substance Dependency Research and
Application Center (AMBAUM) of Akdeniz University on July 2014 she was using 1.5 – 2 gr heroin and approximately 1 gr cocaine daily.
Case 2: N.K. is an 18-year old, single, secondary school graduate and unemployed girl. She had experienced sexual intercourse when she
was 13. She started using heroin when she was 14. She is not using any family planning method.
Family History: Her mother and father can be defined as negligent. She had never felt her family next to her. Her father used to leave
home frequently. In the family there is no one who received psychiatric therapy.
History of substance use: She had started cigarette and heroin at the same time when she was 14. When she was 16, she tried to use it
via the intrevanous rout. The supply of substance is compensated by prostitution. She is not using any sexual protection method. When
she was 18, she become pregnant and pregnancy was eliminated through curettage. When she was referred to AMBAUM on May 2014
she was using 1-1.5 gr heroin daily.
Conclusion: Consequently, women with addictive disorders may very frequently encounter intense traumatic life experiences such
as being subjected to verbal, physical and/or sexual harassment. In these women unprotected sexual intercourse and prostitution for
supply of substance can be frequently seen. To treat these individuals completely would be impossible without continuous psychological
support and appropriate rehabilitation service.
Keywords: addiction, substance use, dependent woman
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[Abstract:0412] Addiction
Smartphone, social networking, and game addictions
Kadir Demirci
Department of Psychiatry, Suleyman Demirel University, Faculty of Medicine, Isparta-Turkey
e-mail address: [email protected]
There are two types of addiction, one is drug addiction such as drug, alcohol and the other is action behaviors such as game, internet,
even smartphone. Similarities between nondrug and drug addictions include craving, impaired control over the behavior, tolerance,
withdrawal and high rates of relapse. Behavior addictions are often difficult to define since they are related not only to physical, but also to
psychological and social aspects. Although smartphones have given enormous convenience to our lives, pathological use of smartphones
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has created a new mental health concern among the community. Smartphone addiction has many aspects that are similar to those
of internet addiction and as such the internet addiction criteria must be considered when developing smartphone addiction criteria.
Based on the definition of İnternet addiction in the literature, smartphone addiction was defined as the excessive use of smartphones
that interferes with the daily lives of the users. In a study conducted in South Korea in 2012, the frequency of smartphone addiction
(8.4%) was observed to be higher than the frequency of internet addiction (7.7%). The same study reported that 11.4% of 10-20 year-old
individuals and 10.4% of 20-30 year-old individuals suffer from smartphone addiction. In the last decade, the use of social networking sites
(SNSs) has grown exponentially. As a result of this popularity, scientists have recently begun to examine aspects of its use. Relationships
that were previously established and suSTAIned primarily through face-to-face interaction have come to be complemented by a social
technology that is creating a new type of interpersonal relationships. SNSs addiction has been defined as a failure to regulate usage, which
leads to negative psychosocial outcomes such as decreased real-life community involvement, poorer academic performance, and more
relationship problems. However, limited research has examined the potential for SNSs use to become addictive.
Online or video game addiction has attracted greater attention as a serious public mental health issue. Video game playing is prevalent
across many cultures with a wide range of different types, genres, and interfaces from which to choose. Researchers suggests that,
depending on game content, playing video games can have positive or negative effects on mental and physical health. Video
game playing is termed ‘pathologic’ when it ‘becomes dysfunctional, harming the individual’s social, occupational, family, school, or
psychological functioning’. It has been argued that to be addicted to video games, six core components need to be experienced by the
player, namely salience, mood modification, tolerance, withdrawal, conflict and relapse. Psychosocial effects of video games are varied.
Some studies have found that exposure to video game violence may promote increased aggressive behaviors and decreased prosocial
behaviors in social interactions.
Keywords: addiction, social networking, smartphone
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S217-S8
[Abstract:0420] Addiction
Topiramate add-on treatment cures alcohol dependence: a case report
Murat Eren Ozen
Department of Psychiatry, Adana Private Hospital, Adana-Turkey
e-mail address: [email protected]
Topiramate (TPM) is an anticonvulsant known both for its use in the treatment of epilepsy and in the prevention of headaches. Recently, its
utility is being tested in other conditions such as bulimia nervosa, binging disorders, smoking addiction and alcohol dependence. This is a
case to be an example of a 28-year old male patient with the diagnosis of alcohol dependence treated with TPM for migraine headaches
as add-on treatment to psychiatric drugs.
A 28-year-old man, was admitted to neurology clinics to cure headaches which was diagnosed as migraine type, having a history of
alcohol consumption for the last 6 years and had developed features of salience, tolerance, craving, and loss of control over drinking
over the last 3 years. Patient’s referral to psychiatry for alcohol dependence and have been on a treatment of venlafaxine 225 mg/day
and quetiapine 300 mg/day regimen and did not change alcohol problems. After initiation of TPM for migraine headaches and gradual
increasing doses revealed a reduced craving and alcohol consumption. At the dose of 200 mg of TPM, headaches resolved, need for
pain relievers ceased. After a month on TPM 200 mg treatment, also on aforesaid psychiatric treatment, patient’s alcohol dependence
behaviors changed. Patient’s six-month follow up showed as cured alcohol dependence. Neurology and psychiatric consultation made
the decision to maintain the treatment with TPM add-on to venlafaxine and quetiapine and planned to complete 1 year of duration.
TPM has been shown to reduce alcohol craving and heavy drinking and to improve abstinence among alcohol-dependent individuals.
TPM reduces mesocorticolimbic dopamine activity by potentiating the inhibitory effects of γ-aminobutyric acid (GABA) and depressing
glutamate receptors, which is a crucial pathway by which alcohol exerts its rewarding effects. In alcohol dependent patients, doses of
up to 300 mg per day have been found effective in reducing craving. In this way, it seems to reduce the mesolimbic cortical activity
of dopamine. This would be the principal mechanism to decrease alcohol consumption reward effects. This case shows patients with
psychiatric and/or neurologic problems having concomitant alcohol dependence or alcohol problems should benefit the TPM add-on
treatment.
Keywords: add on, alcohol dependence, topiramate
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[Abstract:0476] Addiction
Technology addiction in adolescents
Sarper Taskiran
Department of Psychiatry, Koc University, Faculty of Medicine, Istanbul-Turkey
e-mail address: [email protected]
As the cyber world has exploded with internet, electronic social communication, online and offline gaming, it is evident that the
fundamentals of our psychosocial lives has forever changed. Adolescents, who are more attune to changes in social structure have
responded to new technological advances with an unprecedented appetite. With the increasing reports of psychological and social
detrimental effects of overuse of electronic media (internet, social media, online gaming), psychiatric community responded by first trying
to establish and categorize this phenomenon as a psychopathology, and then develop tools to address and treat it.
Several researchers have understood pathological internet use as a subset of impulse control disorders, similar to pathological gambling.
Others modified DSM criteria for addiction to create scales that measure problematic internet use. In the fifth edition of the Diagnostic
and Statistical Manual of Mental Disorders (DSM-5), İnternet Gaming Disorder is identified in Section III as a condition warranting more
clinical research and experience before it might be considered for inclusion in the main book as a formal disorder.
The epidemiology of internet addiction seem to vary across different cultures and countries, between 4.3-36.7, and the variance most
likely is due to use of different scales and different cut-offs with similar scales depending on the study. Internet addiction is found to be
associated with other types of psychopathology such as obsessive-compulsive disorders, social anxiety disorder, depressive disorders,
disorders of attention and substance use disorders. Researchers have suggested addiction-prone phenotypes for substance use disorders
would also reflect sensitivity to other non-drug alternative reinforces in their environment, such as the internet. Biological determinants
of this susceptibility, such as abnormalities in striatal dopaminergic receptor systems may also be seen in internet addicts. The results
from several studies also show that internet addicted individuals and substance abusers share similar personal traits, albeit for low harm
avoidance. Adolescents with social anxiety and hostility are shown to be especially at risk, due to the fact that internet provides a cheap,
free and less problematic virtual world, which is an easy escape from their real worlds otherwise would have been filled with interpersonal
conflict. There are also convincing studies that behavioral addiction to online social networking sites arise as part of a cluster of symptoms
of poor emotion regulation skills and increased susceptibility to substance and non-substance addiction.
There are a number of treatment strategies that can be offered in internet addiction. Foremost, the underlying psychopathology
should be elucidated in order to shed light on the direction of treatment. Psychopharmacological interventions to treat anxiety,
depressive, obsessive compulsive or attention disorders may be utilized to treat comorbid disorders. Studies show that bupropion and
methylphenidate to target pathological internet use may help reduce hours spent on the internet, craving and improve quality of life for
internet addicted adolescents. Cognitive Behavioral models have been developed and begun to be used in internet addiction.
Keywords: addiction, internet, adolescent
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S219
[Abstract:0506] Addiction
Depressive disorder comorbid to dexamethasone and oxybutynin abuse: a case report
Bilge Cetin Ilhan, Memduha Aydin, Caner Yoldas, Ibrahim Eren
Department of Psychiatry, Konya Training and Research Hospital, Konya-Turkey
E-mail address: [email protected]
Anticholinergic drug abuse is a common problem in population of chronic mental illness using antipsychotics, however, it is very rare
among addicts not using any antipsychotics. Dexamethasone, a potent synthetic member of glucocorticoid class of steroids, is used to
treat inflammatory and autoimmune conditions. Oxybutynin is an antimuscarinic drug with possible adverse effects on CNS, including
memory impairment, confusion, delirium and hallucinations in elderly patients. To date, several case reports exist about association
between dexamethasone and/or oxybutynin abuse and psychiatric conditions. Here, we report a depression case coexisting with
dexamethasone and oxybutynin abuse, as no such case was apparent in the literature.
Mr. A, 36 year-old divorced male with standard state education of 5 years, applied to our clinic with depression symptoms. After admission,
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it was learned that he had been abusing dexamethasone (0.75 mg/day) and oxybutynin (15 mg/day) for two years. He also had a story
of cannabinoid and ecstasy usage of six years, yet ceased 7 mounts before admission. He had withdrawal symptoms in the form of loss
of energy and appetite, increase of sleep, fatigability and headaches occurring after the day of ceasing tablets and to be relieved only by
restarting them. He reported of even having tried taking tablets bi-daily yet still having mild withdrawal symptoms. We diagnosed him as
depressive disorder with dependence on other substances. His routine physical examination was normal, with no abnormalities found on
routine blood analyses except ACTH (4.61pg/ml; normal interval: 7.2-63.3 pg/ml) and cortisol (1.61 ug/dl; normal interval 6.2-19.4 ug/dl).
Electroencephalography did not reveal any other pathologies and MRI was normal. On the first day of admission, he was depressive and
anxious (HAM-D: 28). Bupropion (150 mg/day) and risperidone (0.5 mg/day) was administered orally, after which he was discharged with
prescription of bupropion (300 mg/day) and risperidone (0.5 mg/day). On his first follow-up as an outpatient, he was still on bupropion
and risperidone treatment, his depressive symptoms were almost resolved, and he wasn’t abusing dexamethasone or oxybutynin. After
4 weeks HAM-D was measured to be 7.
The occurrence of corticosteroid-induced psychiatric reactions depends on patient’s premorbid personality organizations. While somatic
adverse effects of corticosteroid therapy have been extensively researched and widely described, its neuropsychiatric adverse effects,
etiology and pathogenesis have either received less attention or poorly understood. Psychiatric disturbances induced by corticosteroids
are common and include mania, depression, psychotic or mixed affective states, cognitive deficits, and minor psychiatric disturbances
such as irritability, insomnia, anxiety, labile mood. Most patients are expected to develop symptoms during the first week of treatment
with more than 90% of the patients manifesting symptoms within 6 weeks. Neither dosage nor any other identified factors predicts onset,
duration, or severity of the psychiatric disturbance.
The accumulated literature on psychiatric reactions to corticosteroids is almost entirely composed of case reports and lacks scientific
validation. Hence, it is important that clinicians in all specialties become aware of potential psychiatric adverse effects associated with
corticosteroids. Controlled studies are needed to further understand corticosteroid-induced psychiatric adverse effects.
Keywords: abuse, dexamethasone, oxybutynin
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S219-S20
[Abstract:0508] Addiction
Bonsai (synthetic cannabinoid) use
Zeki Yuncu
Department of Child and Adolescent Psychiatry, Ege University, Faculty of Medicine, Izmir-Turkey
e-mail address: [email protected]
The increase in the number of deaths due to usage of SK is being perceived as a threat to public health. Even though there are legal
regulations to stop producing, trading and carrying SK, new SK’s of different chemical features that produce the same effect is constantly
being distributed to the market. Early Alert System that works in coordination with TUBİM has declared some SK’s and thus these SK’s have
been liable to the law related to controlling the usage of drugs. Application to clinics, related to SK usage has first started in 2010 and
has increased since then. This increasing pattern is the same for all the substances that have been recently introduced and have found a
place in the market.
The Effect Mechanism of SK’S: SK is made up of, functionally similar molecule groups as THC. However, there are basic pharmacological
differences when compared to heroin. The active component of heroin is Delta) THC is a partial agonist with low effect; however SK’s are
strong agonists. In contrast to Delta 9 THC’s metabolite, SK’s metabolites have a strong impact on CB1 and CB2 receptors. Delta 9 THC
shows a Plato effect but doesn’t have that effect with SK’s, and in addition SK’s effect is stronger. Synthetic marihuana has component like
cannabis, which affect the brain receptors and cause an affect hundred times bigger than THC found in marihuana. SK’s effects come out
through CB1 (central) and CB2 (environmental) receptors.
The Dangers Of Synthetic Cannabinoids: SK’s have similar effect as marihuana. However they have much more serious and strong side
effects. The effects of SK’s on people can be as follows; change in perception and temperament, redness in sclera, stomach upset, tremor
of heart, vomiting, numbness, high fever, dryness of mouth. Some users tend to have psychotic symptoms. The effect of SK2s on central
nervous system apart from psychosis is; confusion, blurriness of conscious, feeling sleepy, amnesia, indifference and aggression. SK has
negative effect on kidneys, heart, and gastrointestinal system as well.
Laboratory Observations: One of the reasons for preferring SK’s is the difficulty in stopping them in toxicological analysis. Although it
is possible to spot some SK’s for guiding treatments and for judicial processes. The number of SK’s that can be spotted with laboratory
methods need to be increased.
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In order to overcome judicial restrictions new SK’s are being introduced to the market and this is creating a barrier for spotting them in
laboratory tests. Another barrier is the complex structure of materials containing SK and the fact that they contain elements that masks
the actual content and thus makes it difficult to spot SK.
Results: Synthetic cannabinoids (Bonsai) is becoming more popular every other day and the number of users is increasing rapidly and the
effects are becoming more evident. Producers keep changing the components of SK’s frequently and keep producing different products
and this is preventing countries to come up with laws to prevent the usage of the content of these SK’s.
Keywords: addiction, synthetic cannabinoid
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[Abstract:0568] Addiction
Accidental marijuana ingestion: a case report
Hicran Dogru, Gizem Mujdecioglu Demir, Esin Ozatalay
Department of Child and Adolescent Psychiatry, Akdeniz University, Faculty of Medicine, Antalya-Turkey
e-mail address: [email protected]
Marijuana is the most widely used illicit drug among adolescents and young adults. Unique cognitive, emotional, and social changes
occur during this critical period of development from childhood into adulthood. The endocannabinoid system plays an important role
in development by acting on synaptic plasticity, neuronal cell proliferation, migration, and differentiation. Delta-9-tetrahydrocanabinol
(THC), the principal psychoactive component in marijuana, acts as a partial agonist of the cannabinoid type 1 receptor (CB1R).
In humans, CB1R expression increases dramatically from infancy to young adulthood in regions such as the frontal cortex, striatum and
hippocampus. The psychoactive effects of cannabis are due to the action of THC on CB1R receptors, which are present at high density in
brain areas that play a role in processing emotional information, learning, and memory (e.g., the amygdala, PFC, and hippocampus). Here
we report a case of a child who experienced depressed mental status lasting more than 72 hours after ingestion of marijuana. A 3-yearold, previously healthy boy presented with the sudden onset of ataxia, alteration of conscious perception, euphoria, bursts of laughter,
dizziness, and meaningless expression (e.g.: looking to the wall for a long time ). There was no indication of an infectious process, history
of ingestion of toxic substance/drugs or head or other trauma. Pregnancy, delivery and early development were normal. He lived at
home with his mother and father. Electrolytes, serum urea nitrogen, creatinine, and aminotransferases were within normal limits. Serum
ethanol and acetaminophen levels were undetectable. A urine toxicology screen was obtained, which was positive only for cannabinoids.
Our patient regained normal mental status after 72 h. Clinicians should be aware of the possibility of cannabinoid ingestion in children.
Besides, substance-abusing caretaker is a risk factor for abuse and neglect. In this case, a positive cannabinoid urine test of the child, which
the caretaker was unable to explain, led to the suspicion of cannabis use and child abuse or neglect by the caretaker. THCs metabolites are
excreted into the gut and reabsorbed, and it has a half-life of 18–24 h. The standard urine is positive for 1–7 days after single acute usage.
Child abuse is strongly related to parental substance abuse, including cannabis. Accidental childhood exposure may occur when
caretakers are careless because of their acute intoxication or withdrawal from drugs or alcohol. Physical or mental illness and social
dysfunction are common in these families. These problems tend to be intergenerational, creating vicious cycles of neglect and abuse. It
is crucial to break these cycles by identifying and caring for these children. Screening with an accurate history taking regarding parental
drug and alcohol use is critical and should be routine. When such a substance abuse identified in a family, it permits appropriate medical
management of the child and present an opportunity for rehabilitation and monitoring of the family.
Keywords: child, neglect, substance abuse
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[Abstract:0602] Addiction
Synthetic cannabinoids, process outgoing death: pharmacokinetics and pharmacodynamics
Abdullah Bolu
Aircrew’s Health Research and Training Center, Eskisehir-Turkey
e-mail address: [email protected]
Cannabis is a compound, which entered Mankinds’ life BC. Natural cannabis was isolated in the sixties, cannabinoid receptors (CB1, CB2) were found
in the next years. The most significant event in the history of the synthetic cannabinoid is the synthesize of compounds which have cannabinoid
receptor activity and known as “JWH agents “ in 1990s. These agents are the main component of the new substances, which contain synthetic
cannabinoids (SC). Ninety eight percent of the SC in our country was identified as JWH-018 compound.SC is frequently taken into the body by
inhalation. It is absorbed via the lungs. The effect begins within minutes. A large part undergoes hepatic conjugation and excreted by the kidneys.
JWH-018 can make intoxication showing agonistic activity to the CB1 and CB2 receptors in the brain when as small amount as 1 mg
of the compound is taken by inhalation. This compound is more effective than the partial agonist THC. JWH-018 shows 5 times more
affinity to CB1 receptors. The inhibition of GABA neurotransmission is higher than THC. It can cause serotonin syndrome by affecting the
serotonin metabolism. Some SC conjugates retain their CB1 receptor affinity. SCs constitute heterodimeric structure between receptors by
interacting with non-cannabinoid receptors. SCs can also bind directly to receptors such as vanilloid receptor type-1. Certain substances
beside SC compounds show β1 agonist effects. All these can cause still not understanding the action of SCs clearly.
Keywords: pharmacodynamics, pharmacokinetics, synthetic cannabinoids
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[Abstract:0612] Addiction
Premature ejaculation with buprenorphine: a case report
Esra Kaymak Koca, Esra Aydin Sunbul, Emel Basoglu, Serhat Citak
Department of Psychiatry, Erenkoy Training and Research Hospital, Istanbul-Turkey
e-mail address: [email protected]
Opioid dependence is a chronic relapsing disorder. It has a high mortality rate and a high rate of psychiatric and somatic comorbidities.
The Buprenorphine (BUP) and Buprenorphine/Naloxone (BUP/NLX) combination are established first-line medications for the treatment of
opioid dependence. Opioid-dependent men suffer from sexual dysfunctions in the short and long term. The medications used for long-term
pharmacotherapy of opioid dependence also affect sexual functioning. The prevalence of sexual dysfunction (libido, erectile, and orgasm dysfunction)
about this subject is not so clear. Here we present a case of 28 year-old patient suffering from premature ejaculation after treatment with BUP/NLX.
T.D is a 28-year-old male. He graduated high -school. He is living with his girlfriend for two years. He consulted outpatient clinic for opioid
dependence. He reported use of cannabis since his teenage years and had been taking 10 mg/day. For 4 years, he uses opioid 3 gr/
day. He did not have any psychiatric dısorder comorbidity. His laboratory variables and serologic tests were normal. Opioid and opioid
metabolites were detected in urine toxicological investigation. buprenorphine/naloxone treatment was began as 4 mg/day and his dose
was titrated to 8/2 mg bup/nlx daily.This checked craving and managed his pain. There were not any substance metabolites except BUP in
weekly control urine samples. After two weeks of treatment initiation, he reported that ejaculation time (E.T) reduced from 15 minutes to
10 second with BUP/NLX. He also mentioned that his E.T could be increased up to 30 minutes before using this drug. He had not decrease
in sexual desire. Paroxetine 20 mg/day was added to treatment due to this complaint. His E.T was 10 minutes in the second month of
follow up. He has been followed in outpatient clinic for 7 months and he has not any problem about substance use and sexual functions.
Buprenorphine/naloxone maintenance treatment is an alternative effective treatment for opioid addiction. Sexual dysfunction has been
reported as an adverse effect of opioids including buprenorphine. Various mechanisms can explain the sexual dysfunction as an adverse
effect of buprenorphine. Whatever the reason, sexual dysfunction may be a factor associated with initiation, continuation, or relapse of
drug abuse so the sexual dysfunctıon may also influence the compliance on and outcome of maintenance treatment.
Keywords: buprenorphine/naloxone, opioid dependence, premature ejaculation
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[Abstract:0648] Addiction
Pheniramine dependence: a case report
M. Hanifi Kokacya, Umit Sertan Copoglu, Canan Demircan, Faruk Kurhan, Mustafa Ari
Department of Psychiatry, Mustafa Kemal University, Faculty of Medicine, Hatay-Turkey.
e-mail address: [email protected]
Pheniramine is an alkylamine derivative antihistaminic agent, which has anticholinergic properties and block histamine H1 receptors.
It is used in the treatment of allergic conditions such as hay fever and urticaria because of it is antagonizes the effects of histamine as
competitive. Pheniramine cause sedative effects ranging from deep sleep to light-headedness more frequently than other antihistaminics.
In this paper it will be presented a case that were treated with a diagnosis of pheniramine dependence in Mustafa Kemal University
Psychiatry Service.
F. E. 23 year old single girl. She has been working as chief of staff in a private hospital. When she admitted to our internal medicine
service, she was using my pheniramine 25 per day intravenously. She complained about irritability, hand tremors, drowsiness, headache,
and sweating, hot flushes especially the hands and feet, fatigue, dry mouth, nervousness and fear when she doesn’t received the drug.
Because of the tolerance development she increases the daily dose intake. Her functionality and interpersonal relations deteriorated.
There is alcohol and substance abuse in her history. Neurological examination and laboratory tests (complete blood count, routine
biochemical tests, liver, kidney and thyroid function tests) were within normal levels. Treatment was started with diazepam 20 mg/day
and venlafaxine 150 mg/day because of her anxiety and withdrawal. Then during follow because of her insomnia, firstly quetiapine
300 mg/day, and then olanzapine 10 mg/day added to treatment. Five days after her initial visit, it was observed that her withdrawal
symptoms were still ongoing. Therefore her diazepam dose firstly increased to 40 mg/day and then 60 mg/day. Because of insomnia
complaints persisted mirtazapine 15 mg/day was added to the treatment. In third week of the treatment patient’s complaints continued,
although partly reduced. In the third week patient’s treatment motivation decreased and nonetheless her craving increased. And she was
separated from service with the purpose of using substance. Although there are few papers about pheniramine dependence, it is thought
that there are more cases than reported. In a study it is reported that an antitussive drug, which contains chlorpheniramine, abused by
patients although it prescribed for indication. In a case report about pheniramine dependence from our country was similar to our case
in term of that the patient’s health care worker and drug use pattern and drug use pattern and method. Regulations banning the use
of nonprescription drugs will prevent the increase of these cases. It is also important that physicians are aware of the risk of misuse of
antihistaminics.
Keywords: antihistaminic, dependence, pheniramine
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S223
[Abstract:0703] Addiction
An unusual cause of transverse myelitis: heroin abuse
Esref Akil1, Abdullah Atli2, Velat Sen3, Unal Ozturk3, Abdullah Acar1, Aslihan Okan Ibiloglu2
Department of Neurology, Dicle University, Faculty of Medicine, Diyarbakir-Turkey
1
Department of Pscyhiatry, Dicle University, Faculty of Medicine, Diyarbakir-Turkey
2
Department of Pediatry, Dicle University, Faculty of Medicine, Diyarbakir-Turkey
3
e-mail address: [email protected]
Transverse myelitis (TM) is a disorder caused by inflammation of the spinal cord. It is characterized by symptoms and signs of
neurologic dysfunction in motor and sensory tracts on both sides of the spinal cord.Heroin is known to cause various medical and
neurological problems. Some of the related diseases of heroin overdose are noncardiogenic pulmonary edema, wound botulism,
neurological complications stroke, toxic amblyopia, transverse myelopathy, mononeuropathy, acute inflammatory demyelinating
polyradiculoneuropathy, rhabdomyolysis and acute bacterial myopathy consequently, sudden onset of focal weakness has a broad
differential diagnosis.
Here we report unusual manifestation of heroin in a young addict who presented with the arms and legs weakness within a few hours
of oral administration. A 17-year-old boy is evaluated in the emergency department for the arms and legs weakness. He noticed back
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pain and leg weakness yesterday evening but he was able to walk on his own to go to bed and slept. Then he realized he couldn’t walk
due to leg weakness when you wake up in the morning. Foley urethral catheter placed because urine retention, and was transferred
to Dicle University hospital for further evaluation. He and his mother report no history of trauma. He takes no medications and has no
known drug allergies. A social history is significant for drug use including marijuana that was took several times a month the last two
years, and heroin abuse three times the last month. Cranial nerves were functioning normally, with pupils equal, round, and reactive to
light, muscle tone and mass was normal. Manual muscle testing of strength found moderate weakness of upper extremity and severe
weakness of lower extremities. The intoxication was confirmed by demonstration of marijuana but could not be demonstrated of heroin
metabolites O-monoacetylmorphine in the urine because we made urinalysis from the event one week later. The results of tests for
cocaine, benzodiazepine, barbiturate, cannabinoids and amphetamine metabolites were negative. MRI of the cervical spine cord, sagittal
T2-weighted image shows discrete lesions without cord swelling with patchy increased intramedullary signal intensity extending from C6
to D2 level with effacement of ventral and dorsal subarachnoid spaces suggestive of transverse myelitis.TM is characterized by symptoms
and signs of neurologic dysfunction in motor and sensory tracts on both sides of the spinal cord. The cause of 60% of TM cases may
remain unknown despite the presence of inflammatory mechanisms. Heroin overdose rarely lead to acute TM. Heroin is amongst the
most widely used drugs of abuse. Commonly administered intravenously, it is also sometimes used through intramuscular, subcutaneous,
or intranasal routes. Heroin is known to cause various medical and neurological problems. Some of the rare reported related diseases
of heroin overdose are noncardiogenic pulmonary edema, wound botulism and neurological complications stroke, toxic amblyopia,
transverse myelopathy, mononeuropathy, acute inflammatory demyelinating polyradiculoneuropathy, rhabdomyolysis and acute
bacterial myopathy consequently, sudden onset of focal weakness has a broad differential diagnosis. An important etiologic category is
that of toxic exposures drug-induced focal weakness should be a particularly strong consideration in the adolescent.
Keywords: heroin, transverse myelitis, focal weakness
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[Abstract:0710] Addiction
Food and eating addictions
Kadir Karakus
Department of Psychiatry, Adnan Menderes University, Faculty of Medicine, Aydin-Turkey
e-mail address: [email protected]
The term “food addiction’’ (FA) was introduced in the scientific literature by Theron Randolph at about 60 years ago. Recently, increase
in the worldwide prevalence of obesity has made the notion of “FA” a focus of interest for researchers. The interest of researchers on this
topic led to more precise definitions and assessment methods. For example, the Yale Food Addiction Scale (YFAS) has been developed
to assess the degree of addiction like eating behavior in 2009. Since then, the YFAS has been used in many studies. This scale has
provided a standardized self report instrument for the assessment of FA based on the diagnostic criteria for substance dependence of
the fourth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). FA can be diagnosed if at least three symptoms
of YFAS and clinically significant impairment or distress are present. The weighted mean prevalence of FA diagnosis in adult population
samples was found 19.9 % in a meta-analysis of studies used YFAS. Foods are a natural reward and have both homeostatic and hedonic
components. Certain foods, particularly hyperpalatable ones; for example, high sugar, high fat combinations are rewarding for animals
and humans and have multiple features similar to addictive drugs. This reward system could cause an increase of food intake and reveal
symptoms associated to withdrawal, suggesting a behaviorsimilar to substance use. For many individuals, food can become as addictive
as drugs, pointing to FA, which has been implicated as a possible causal factor in binge eating, overeating, and obesity. Neurobiological
studies have demonstrated similarities in brain reward processes between obesity and substance use disorders, e.g., PET studies have
shown lower dopamine receptor levels in both obese and drug addicted persons. But human neuroscience literature is inconsistent on
this issue. Binge eating disorder (BED) has similar features with addiction like behaviors including excess consumption despite adverse
consequences, and diminished control overeating. In animal studies, animals provided intermittent access to sugar have demonstrated
neurobiological and behavioral indicators of tolerance and withdrawal and animals given diets high in sugar and fat have showed
reward dysfunction associated with drug addiction. In some animal studies, the opposite results were found, e.g., rats binge eat sweet-fat
combinations did not show signs of opiate-like withdrawal.
Some researchers also argue that “FA” is a incorrect naming. They propose to use the term ‘’eating addiction’’ to emphasize behavioral
addiction to the process of eating and the reward system of it.
Gambling disorder has been included along substance use disorders (SUDs) as a behavioral addiction in the fifth revision of the DSM
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(DSM-5), but DSM-V did not categorize similar disorders related to natural rewards as a behavioral addiction or SUDs. Currently, the notion
of ‘’FA’’ is still a controversial issue, because there are definitional and conceptual difficulties and there is no conclusive scientific evidence.
Further research is required to explore the cognitive, psychological and neurobiological processes of FA, thus it will become clear to
understand the existence of behavioral addiction.
Keywords: addiction, eating, food
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[Abstract:0711] Addiction
A case study; amantadine treatment for alcohol withdrawal syndrome
Serkan Demir1, Ozer Ozmut1, Ozgecan Buyuk1, Recep Tutuncu1, Hakan Balibey1, Servet Ebrinc1, Cengiz Basoglu1, Mehmet Fatih Ozdag2
Department of Psychiatry, GATA Haydarpasa Training Hospital, Istanbul-Turkey
1
Department of Neurology Psychiatry, GATA Haydarpasa Training Hospital, Istanbul-Turkey
2
E-mail address: [email protected]
Objective: The spectrum of alcohol withdrawal symptoms ranges from such minor symptoms as insomnia and tremulousness to severe
complications such as withdrawal seizures and delirium tremens.
Case: The case mentioned here is about 56 year old man. He has two children. He divorced his wife ten years ago. So he felt unhappy,
depressed and he started to drink alcohol. He lives alone and he drank %37 ethanol 1000 cc/day. After he had come to Faculty of Medicine
at the University, he lost consciousness. Doctors gave medication. He took vitamin C, vitamin B, vitamin E, lorezepam 10 mg, and diazepam
40 mg. At the end of the fourteenth day; he regained consciousness and had paranoid thoughts. His orientation and cooperation were
impaired. The patient was treated in hospital for forty days. During this period; the patient was lethargic.
Conclusion: The patient got a neurological examination; they found slurred speech, ataxic walking, orientation and cooperation
impaired. In mental examination; he did not communicate with his social environment, he did not talk much, he did not make eye contact
and sleep and his appetite decreased. He had alcohol withdrawal syndrome. So; he took Amantadin and the patient was treated. At the
end of this period; amantadin treatment was applied. So he regained consciousness for three days.
Keywords: amantadine, treatment, alcohol withdrawal syndrome
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[Abstract:0717] Addiction
Internet addiction
Kerem Senol Coskun
Department of Psychiatry, Afyon Kocatepe University, Faculty of Medicine, Afyonkarahisar-Turkey
e-mail address: [email protected]
The prevalence of internet use has increased worldwide in the last two decades. Internet penetration rate is 42.3% in the World, 68.6%
in Europe and 46.3% in Turkey and the number of internet subscribers including dial-up and all other subscription packages (xDSL,
mobile, cable, fiber etc.) reached 37 million in Turkey in 2014. The use of internet provides an easy and immediate way for people to
explore information, to communicate with other people over the world, social interaction and to deal with daily requirements (e.g.,
making reservations, shopping, paying the bills etc.); but its uncontrolled and excessive use has been frequently reported that it might
lead to negative impacts on daily live, school and/or work performance, family relationships, emotional stability and cause problematic
behaviors. Additionally, the Internet provides multiple applications that can cause addiction such as gaming and gambling, pornography,
social networking sites and so on.There are different psychopathological definitions of excessive internet use such as computer addiction,
compulsive internet use, internetomania, problematic or pathological internet use, internet addiction, internet dependence and is
suggested to be a type of behavioral addiction. Firstly, Ivan Goldberg introduced the definition of internet addiction disorder in 1995 and
Young defined the pathological use of the internet as being preoccupied by the Internet, feeling the need to use it, repeated unsuccessful
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efforts to stop using it, being restless without it, staying longer than intended, taking risk to lose social relationships, lying to close friends
or family, and using the Internet as a way of escaping from problems or of relieving a dysphoric mood in 1996. Today the loss of control
over the internet use is most frequently met criterion in patients suffering from internet addiction (IA) and this might be due to reductions
of prefrontal control processes.IA prevalence rates vary between 0.8% and 26.7%. This variance might be due to some cultural effects,
absence of standard assessment tools, clearly defined cut-off scores and fully accepted diagnostic criteria. Yet, only the internet gaming
disorder was included in DSM-5 as a condition warranting further study. The psychiatric disorders like depression, social anxiety, attention
deficit hyperactivity disorder (ADHD) and dysfunctional personality features such as low self-efficacy, shyness, stress vulnerability, and
procrastination tendencies could be predisposing factors for developing IA. Furthermore, IA was found to be associated with substance
use disorder, ADHD, depressive disorder, social phobia and hostility. Possible mechanisms have been described to explain the association
between addictive behaviors and psychiatric disorders. The psychiatric disorders may result in, contribute to or deteriorate the symptoms
of the addictive disorder. Conversely, the addictive disorder may lead to or contribute to the symptoms of other psychiatric disorders
or there might be underlying biological, psychological, or sociological mechanisms shared by both of them.There are still no standard
clinical treatment protocols or approved medications for IA. Besides, there are studies in the literature in which escitalopram, bupropion,
naltrexone, quetiapine and methylphenidate used. Cognitive behavioral therapy and psychosocial treatments have also shown to be
effective.
Keywords: internet addiction, comorbidity, treatment
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[Abstract:0719] Addiction
Former illicit substances and novel addictions (steroids, pregabalin and beyond)
Osman Yildirim
Department of Psychiatry, Abant Izzet Baysal Training and Research Hospital, Bolu-Turkey
e-mail address: [email protected]
Pregabalin, first of all was started to use as an antiepileptic. Then, pregabalin is used in the treatment of neuropathic pain and fibromyalgia
in our country. Pregabalin is approved for use in generalized anxiety disorder in some countries but not yet in Turkey. Despite this
situation case reports about pregabalin abuse began to be published. In clinical observation, patients mentioned about euphoric effect
of pregabalin. Especially patients with a history of substance dependence demanded to prescribed pregabalin. Anabolic steroids are
synthetic derivatives of testosterone. Because of the effect of increasing tissue mass, anabolic steroids are used commonly by athletes.
Common use of these drugs increases the risk of abuse. In this part of the New Addictions panel, former drugs and new addictions will
be discussed.
Keywords: pregabalin, steroids, new addictions
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[Abstract:0723] Addiction
Acceptance and commitment therapy for addiction
Basak Demirel
Konya Research and Training Hospital, Konya-Turkey
e-mail address: [email protected]
Drug addiction has been assumed as a chronically relapsing disorder of compulsive drug seeking and taking that progresses through
three stages: preoccupation, binge using, withdrawal. Relapse and vulnerability to relapse are key elements in the maintenance of a
chronic relapsing disorder such as addiction. There are two factors for relapsing risk: craving and negative affect.
Acceptance and commitment therapy is an approach designed to increase psychological flexibility. Psychological flexibility can be
described as willingness to aspect of one’s experience without engaging in unnecessary avoidance behaviors that describes six functional
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processes: acceptance, defusion, present-moment awareness, self processes, values-based living and committed action. This six core
processes are as relatively distinct, but there is a considerable degree of interaction among them. Within the psychological flexibility
model, addiction is conceived as a learned pattern of behavior.
Keywords: acceptance and commitment therapy, addiction, psychotherapy
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S226-S7
[Abstract:0821] Addiction
Addiction and abuse of cyclopentolate hydrochloride eye drops: case series
Ali Emre Sevik1, Ozge Sevik2, Hakkı Zeki Buyukyildiz2
Department of Psychiatry, Karabuk University Hospital, Karabuk-Turkey
1
Department of Ophtalmology, Karabuk University Hospital, Karabuk-Turkey
2
e-mail address: [email protected]
Cyclopentolate hydrochloride, is a synthetic anticholinergic agent of the widespread use for 50 years in ophthalmology because of
its cycloplegic and mydriatic effects. It is widely used in particular, in refractive defects and for evaluation pediatric eye examination
more accurately by minimizing the effect of accomodation reflex. In general, because of the anticholinergic effects of drug especially
stimulating and euphoric effects, it has attracted attention with the potential of abuse. Especially the widespread use of the drug during
routine eye exam, especially in children, there have been frequently reported cases that look with atropine poisoning like appearence
in conjunction with the dose. The possible misuse or dependencies of eyedrops containing Cyclopentolate hydrochloride have been
reported rarely in the literature. In this case presentations we try to focus on the reasons of the continuation Cyclopentolate hydrochloride
eye drops by all 5 patients form different perfectives. In all cases, individuals continued to use it somehow because of the relaxing effect
of Cyclopentolate hydrochloride eye drops (% 1; 5 ml). The common features of the disorders through the use of eye drop, motivations to
continue and what to be done by physician when it is detected if there is a abuse or dependency in an ophtalmic patient will be discussed.
All five cases clinically presented with eye complaints such as itching, redness, pain in the eye and all attented to the ophtalmology
department of our hospital. Patients are 4 men and 1 woman in between 29 to 75 years of ages. Although nevertheless, non of
the patients found in need to use cyclopentolate hydrochloride clinicaly according to ophtalmological examination, all have high
motivation to continue their tratments even higher than adviced doses. They have different histories related to starting to cyclopentolate
hydrochloride eye drop use, but subjective relaxation and achiving lower anxiety levels while taking drug discribed as main goals by all.
Four patients using drops by eye and all taking their drug higher than adviced doses by ophtalmologists. Only one patient confessed the
way he uses drug by droping it into water (PO) and enlightens abuse potential and addictive characteristics of drug directly. Although all
of the patients adviced to apply psychiatry department only one take the advice. In this presentation, we try to focus on the reasons of
the continuation Cyclopentolate hydrochloride eye drops by all 5 patients form different persfectives.
Thus, close examination and focused history taking during eye exams may let us see even more cases related with cyclopentolate
hydrochloride abuse or addiction, taking the patient to psychiatric exam is an other issue which we have to manage. Cyclopentolate
hydrochloride abuse and addiction rates can be expected high in our country for severel reasons, to be able to overcome this issue
ophtalmologists and pyschiatrists have to work in cooperation.
Keywords: cyclopentolate, addiction, treatment
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[Abstract:0855] Addiction
Exercise addiction
Ahmet Hakki Asik
Department of Psychiatry, State Hospital of Afyonkarahisar, Afyonkarahisar-Turkey
e-mail address: [email protected]
Regular exercise could be conceptualized as a set of planned, structured, and repetitive complex movement activities carried with
sufficient frequency, intensity, and duration to be effective in health promotion, while also playing a significant role in disease prevention.
Morgan (1979) psychiatric case studies had shown that exaggerated exercise could lead not only to physical injury but also to the
negligence of the most paramount everyday responsibilities such as work and family life. Morgan presented arguments that the most
typical symptoms of addiction could also be applied to excessive exercise behavior, primarily through the presence of withdrawal
symptoms, detrimental social consequences, and several other negative effects such as disturbed psychological functioning, exercising
despite medical contraindications.
Some meta-analyses have claimed a 3% estimate in the general population. When exercise is used to cope with stress, apart from the
negative psychological feelings, there is also a loss of the coping mechanism (exercise). Concomitantly, exercisers lose control over the
stressful situation(s) that they used to deal with through exercise.
Szabo (1995) proposed a cognitive appraisal hypothesis for the better understanding of the etiology of exercise addiction. According to
this theory, once the habitual exerciser uses exercise as a means of coping with stress, the affected individual learns to depend on (and
need) exercise at times of stress.
All possible interventions should find a smart balance between the promotion of exercise and workout on one hand, while prevention of
excessive exercise on the other hand.
Keywords: exercise, addiction, disorder
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S228
[Abstract:0881] Addiction
Pharmacogenetic approaches to alcohol use disorder: from research to clinical practice
Wolfgang Sommer
Heidelberg University, Institute of Psychopharmacology & Clinic for Addiction Medicine, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim,
Mannheim-Germany
e-mail address: [email protected]
Although alcohol use disorders rank among the primary causes of preventable death and disability, treatment options for this
neuropsychiatric disorder are very limited. The few available medications, with opioid antagonists as prototypical examples providing
proof-of-concept for successful pharmacotherapy, suffer from modest effect sizes and low impact on clinical practice. Heterogeneity
within the clinical population is recognized as an important factor for the poor outcome of treatment efforts. With the arrival of
personalized medicine, precisely defining characteristics of patients for whom therapies are developed needs to be an integral part of
the development effort from its inception.
An important contributor to the observed heterogeneity is genetic variation. Here, I will review research on the pharmacogenetic impact
of the most common functional variant of the mu opioid receptor (rs_1799971) on alcohol and other addictive behaviors based on recent
clinical investigations, meta-analyses, and studies in ‘humanized’ transgenic mice. I will propose a framework how this knowledge could
be used in clinical practice.
Keywords: pharmacogenetic approaches, alcohol use disorder, addiction
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ADHD
[Abstract:0130] ADHD
Methylphenidate-induced awake bruxism: a case report
Ayhan Bilgic, Rukiye Colak Sivri
Department of Child and Adolescent Psychiatry, Necmettin Erbakan University, Meram Faculty of Medicine, Konya-Turkey
e-mail address: [email protected]
Methylphenidate (MPH) is a stimulant that is commonly used in the treatment of attention-deficit/hyperactivity disorder in children and
adults. Several reports are available regarding the relationship of MPH use and sleep bruxism. We report the case of a 9-year-old boy
who presented with severe awake bruxism after his second dose of sustained releaseform of MPH treatment, which was confirmed on
rechallenge. This is the first report of its kind showing such relationship in the literature.
Bruxism is a jaw-muscle activity disease characterized by repetitive clenching or grinding of the teeth, which results in inconvenience
and injury to dentition as well as facial pain and damage to temporomandibular joint. It is divided into 2 types that are thought to
be clinically irrelevant: sleep bruxism and awake bruxism. Sleep bruxism is involuntary and is classified as a sleeprelated movement
disorder. However, awake bruxism is defined asthe awareness of jaw clenching and seems to be semivoluntary. Methylphenidate
(MPH) is 1 of 2 stimulant agents that is used in the management of the attention deficit/hyperactivity disorders(ADHDs). The
common adverse effects with MPH are insomnia,stomachache, headache, and decreased appetite. A study conducted by Malki et al.
showed an association between the use of stimulants and worn teeth in children with ADHD. There were several reports regarding
the relationship with MPH use and sleep bruxism. In this report, we present a school-age child with ADHD who displayed awake
bruxism during MPH therapy. To the best of our knowledge, this is the first report of MPH-related awake bruxism in the existing
literature.
A 9-year-old boy was referred to the outpatient clinic with complaints of poor concentration, hyperactivity, and school failure.He was
hyperactive since his preschool ages, and he showeda significant decline in academic performance, especially in recent years. His behavior
was clinically observed to be characterized by constant fidgetiness, inattentiveness, hyperactivity, and impulsiveness. No other past or
existing history was important. Physical examination and laboratory assessment were in normal range. He was diagnosed with ADHD
combined subtype in accordance with the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (American
Psychiatric Association 2013) based on clinical evaluation and the information received from teachers and family.He was started on
sustained release formof 18mg/d ofMPH.On the second day of the treatment, his mother reported that he started to grind his teeth during
daytime. The teeth-grinding sound was so loud enough to disturb other people next to him. No nocturnal abnormal movements were
noted. At the third day of the treatment, his mother did not give the pill and no bruxism existed during the day. His mother thought that
it might be coincidental, and without consulting his physician, he was reinitiated with sustained release form of 18 mg/d of MPH again.
Although not as drastic as the second day of the treatment, awake bruxism started back again and continued for 4 days. Throughout the
MPH use period, there was no evidence of dyskinesia involving any other part of the body. At the eight day of the treatment, MPH was
discontinued,and this adverse effect completely disappeared.
In the present report, we established the temporal relationship betweenMPH treatment and awake bruxism.We believe that,in this
case, bruxism was the direct effect of MPH on the grounds that there was no history of such behavior before MPH and confirmed
in an on-off-on treatment sequence. In the literature, there is no report of awake bruxism with MPH. However, a preliminary
study reported a relationship among the presence of ADHD and both parent-reported daytime and sleep bruxism in childhood.
This study also showed an association between the use of stimulants and tooth wear in children with ADHD. Furthermore, we
could find 2 different case reports that examined MPH-induced sleep bruxism. In the first report, an adverse effect of rapid
dyskinesia and bruxism after initiating MPH in 2 distinct cases who were maintained on valproic acid was presented. In the second
report, the authors notified a case of a 9-year-old boy who experienced sleep bruxism while on MPH monotherapy treatment.
The causes of bruxism are poorly understood and it is considered to have a multifactorial etiology. Defectiveness of the central
dopaminergic neurotransmitter systems, especially in the mesocortical tract, has been usually blamed for the etiopathogenesis of
bruxism. Moreover, it has been speculated that bruxism may be an unusual manifestation of dyskinesia in vulnerable individuals.
Data related to cases with stimulant-induced dyskinesia that occurs shortly after drug ingestion and rapidly disappears with
discontinuation have been shown as evidence for this view. In this context, the rapid-onset bruxism of our case may thought to
occur as a result of excessive stimulation of dopamine receptors caused by MPH. However, selective norepinephrine reuptake
inhibitor atomoxetine was also reported to be related with bruxism in patients with ADHD. It is worthy to mention that MPH may
act on other neurotransmitters, including norepinephrine. This means that additional research should be done before drawing
definite conclusions on the effects of MPH on this parafunctional activity with multiple potential mechanisms. In conclusion, this
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report suggests that clinicians should be aware of the possibility that MPH may induce awake bruxism in the short-term period
after administration of the initial dosages. Further research is required to determine the frequency and clarify the mechanism of
this adverse effect.
Keywords: awake bruxism, methylphenidate, side effect
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[Abstract:0297] ADHD
The possible effect of methylphenidate on secondary encopresis in children with attention deficit
hyperactivity disorder; a case report
Gizem Mujdecioglu Demir, Hicran Dogru, Esin Ozatalay
Department of Child and Adolescent Psychiatry, Akdeniz University, Faculty of Medicine, Antalya-Turkey
e-mail address: [email protected]
Attention deficit hyperactivity disorder (ADHD) is a common psychiatric disorder, affecting about 5% of children and adolescents and 3%
of adults. Comorbidity of ADHD with other psychiatric disorders is a common condition and frequently causes difficulties in treatment.
The prevalence of ADHD among children with encopresis was found to be 10 timesmore frequent than in the general population.
Despite an increase in our knowledge regarding encopresis and its manifestations and the variety of intervention strategies available, the
disorder remains difficult to treat.There is no enough evidence that psychiatric treatments have a therapeutic effect in encopretic children.
This report presents one children with ADHD and coexisting secondary encopresis who displayed improvement in ADHD symptoms
accompanied by complete resolution of encopresis with long acting methylphenidate ( LA-MPH) treatment.
A 10-year-old boy was referred to our outpatient clinic with complains of easily distracted, day-dreaming, not finishing work, difficulty
listening, excessive talking in the lessons, forgetfulness, academic failure in the school, jumping from one activity to another. He also
had encopresis occurring 4 to 5 times a week for 3 years. He had normal physical examination and no history of significant medical
illness. He had no history of enuresis and additional psychiatric conditions. In his psychiatric examination; he was conscious, oriented, his
cooperation was suent and understandable. He had concentration problems, hyperactivitiy and impulsivitiy. His condition was diagnosed
as ADHD and coexistent encopresis according to DSM-5 criteria. He was 143 cm tall and weighed 30 kg. We chose to 18 mg/ day of LA-MPH
for ADHD as medical treatment and after four weeks LA-MPH dose was increased to 27 mg/day. In the first week of the 27 mg daily dose
LA-MPH symptoms of attention deficit and school behavior problems were dramatically reduced. During this period, he had encopresis
only twice. He had no signs of encopresis at follow-up after 3 months.
Despite behavioral methods are known to be effective in treatment of encopresis, some psychotropic drugs are stated to be effective
in treatment of encopresis in the literature. However, the mechanisms of these drugs in treatment of encopretic symptoms are not
known exactly. It seems that the LA-MPH treatment is responsible for the disappearance of encopretic behavior in the present cases and
LA-MPH also could be effective for secondary encopresis coexisting ADHD. It is unknown which underlying mechanisms contribute to the
improvement in encopresis in children, but one can speculate that successful treatment for ADHD with LA-MPH, in addition to improving
executive functioning, working memory, and impulse control,may also improve self-organizing skill sand lead to alleviation and stable
remission in primary encopresis. The neurobiological relationship between ADHD, primary encopresis, and LA-MPH administration is as
yet unclear; however, it seems that some ADHD/encopretic patients may benefit from LA-MPH.
Keywords: attention deficit hyperactivity disorder, encopresis, methylphenidate
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[Abstract:0333] ADHD
ADHD like features after basal ganglia infarct
Saliha Kılınc, Sabri Herguner
Child and Adolescent Psychiatry, Necmettin Erbakan University, Meram Faculty of Medicine, Konya-Turkey
e-mail address: [email protected]
Stroke has emerged as an important cause of acquired brain injury in children. Childhood stroke can have consequences on motor, cognitive and
behavioral development. Stroke in childhood can result in significant residual physical and cognitive impairments in two thirds of survivors. Arterial
ischemic stroke (AIS) is an acute focal neurological deficit attributable to cerebral infarction in an arterial distribution and affects approximately
3 per 100.000 children a year; an incidence rate as frequent as children with brain tumors. Experiencing an ischemic stroke during childhood has
been shown to significantly lower a young person’s quality of life across physical, emotional, school, social and cognitive areas.
ADHD is one of the most common psychiatric disorder which manifest after a variety of brain injuries including traumatic brain injury,
very low birth weight or premature infants, cerebral palsy, epilepsy, childhood hemiplegia and encephalitis. Such diverse etiologies would
tend to suggest that the syndrome is a final common pathway of varied pathophysiological processes. It may be associated with a varied
pattern of symptom clusters and neurocognitive correlates depending on the nature and extent of the brain injury. Pathophysiological
and neurocognitive research in idiopathic ADHD is more advanced than corresponding research in ADHD that follows brain injury, yet it
is far from conclusive. Children with focal stroke lesions provide a potentially useful model for the investigation of ADHD after brain injury.
Herein, we report a child who presented with ADHD like features, learning problems, and seizures following right basal ganglia infarct
after median cerebral artery thrombus while taking chemotherapy for Acute Lymphocytic Leukemia (ALL).
A 13-year-old boy was admitted to our clinic because of inattentiveness and learning problems. He had ALL diagnosis 4 years before and
while he was taking chemotherapy he had lived a thrombus on right median cerebral artery. His cranial magnetic resonance revealed that
infarcts were found in the right MCA territories, in the right cerebral hemisphere; in the internal capsule, globus pallidus and putamen
portions supplied by the lenticolostriate branch. Soon after thrombus, he had epilepsy characterized by focal non-generalize seizures.
He also developed inattention problems and learning difficulties. He was experiencing severe problems during making homework and
listening classes. His concentration span was decreased significantly. His grades dropped down after the medical condition. Before
the event, he had no such problems both at school and at home. His WISC-R test revealed a borderline intelligence. In his psychiatric
assessment a diagnosis of ADHD (Inattentive Type) was given.
In ADHD there is gray matter reduction in the right putamen/globus pallidus region. This may be an anatomical marker for dysfunction
in frontostriatal circuits mediating cognitive control. Right basal ganglia lesions have been specifically associated with ADHD symptoms
after brain injuries in children.
Keywords: ADHD, basal ganglia, childhood stroke
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[Abstract:0349] ADHD
The marked kid in school
Arzu Onal
Acibadem University, Istanbul-Turkey
E-mail address: [email protected]
Children who have Attention Deficit Hyperactivity Disorder are at extreme risk of poor psychosocial outcomes both in their schools
and lives. Patients suffering from ADHD are at high risk to be confronted with stigma, prejudices, and discrimination. It appears that the
existence of stigma and its impact on the diagnosed individual’s life is highly under-investigated.
ADHD and its association with a range of educational, emotional as well as social adjustment problems might therefore be very likely to
become the focus of public debates concerning the possible dangerousness of people diagnosed with ADHD.
Aim of this presentation is to raise awareness about this stigma in ADHD children at school.
Keywords: awareness, hyperactivity, stigma
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[Abstract:0353] ADHD
Non-pharmacological treatment of adult attention and hyperactivity disorder
Ugur Cakir
Department of Psychiatry, Abant Izzet Baysal University, Faculty of Medicine, Bolu-Turkey.
e-mail address: [email protected]
Longitudinal follow-up studies reported that estimately 50% of people with attention deficit and hyperactivity disorder (ADHD) may
suffer from the disease even in the adulthood. ADHD cause significant amount of functionality in various domains of life such as work,
academic and social.
While pharmacological interventions such as stimulant and/or non-stimulant drugs can ameliorate the severity of core symptoms of
ADHD, they often insufficiently address difficulties in executive self-management with respect to time and organization, as well as
problems in social and emotional self-regulation, leading to continued distress and impairment for adults with ADHD.
Cognitively based psychotherapies therapies have been developed to address these problems. In this symposium it has been aimed to
discuss use of cognitive and behavioral therapy in the treatment of people with adult attention and hyperactivity disorder.
Keywords: ADHD, treatment, nonpharmacological
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[Abstract:0416] ADHD
The struggle of the ADHD person with addiction
Sinem Gonenli Toker
Istanbul Medipol University, Faculty of Medicine, Istanbul-Turkey
e-mail address: [email protected]
Attention-deficit/hyperactivity disorder (ADHD) may last into adulthood about a third to half the time, and some studies have shown that
children with ADHD may be more likely than the general population to develop alcohol and substance abuse problems when they get
older. Several studies have shown a strong connection between ADHD, drug abuse, and alcoholism (Nelson et al. 2012).
People with ADHD tend to be more impulsive and likely to have behavior problems, both of which can contribute to drug and alcohol
abuse, researchers say. Several studies have already demonstrated that attention-deficit/hyperactivity disorder indeed represents a
risk factor for the exacerbation of addictive illnesses. Jacob et al. (2007) found in a large cohort study a lifetime prevalence of 45% for
substance use disorder in adults with ADHD. Patients with ADHD and drug addiction showed a tendency to commence early and to
experiment more freely with substance abuse than those addicted patients without ADHD (Ohlmeier et al. 2007).
Researchers have also found links between ADHD and the use of marijuana and other recreational drugs, particularly in people who also
have other psychiatric disorders. There is a greater likelihood of adolescents with ADHD developing an addiction to cigarettes compared
to adolescents without ADHD (Wilens 2004). Current estimates of regular tobacco use by adolescents with ADHD are twice as high
compared to unaffected adolescents.
Keywords: ADHD, addiction, drug ab
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[Abstract:0423] ADHD
Treatment of ADHD using treatment guidelines
Abdullah Akpinar
Department of Psychiatry, Suleyman Demirel University, Faculty of Medicine, Isparta-Turkey
e-mail address: [email protected]
Attention deficit hyperactivity disorder (ADHD) can be an extremely debilitating neurodevelopmental disorder that often persists beyond
childhood, perhaps in about one-third to two-thirds of patients. Reports indicate that ADHD affects 3%–5% of adults in the general
population. However, fewer than 20% of adults with ADHD are currently diagnosed and/or treated by psychiatrists. This presentation is
summarized current literatures, generating consensus recommendations for the treatment of ADHD.
Various guidelines are available for the diagnosis and treatment of ADHD in adults. Guidelines on the treatment of adult ADHD, with
focus on European countries and also just one of was United States. However appropriate resources for the diagnosis and treatment of
adult ADHD have some scarces, and many cases go untreated, particularly because of the frequent presence of psychiatric comorbidities.
Treatment adherence, side-effects, and patient preferences are also important clues for the treatment of ADHD. These aspects long-term
prospective studies are also important, on the other hand few long-term prospective studies have been conducted on adult ADHD
patients in a practical clinical setting.
Apart from atomoxetine, and an extended-release form of methylphenidate, no other medications have been approved for starting
treatment in adult ADHD patients in most countries. However, a variety of stimulant and non-stimulant medications are used off-label,
and a number of studies have confirmed that these medications are well tolerated and effective in adult patients with ADHD.
Stimulant medications are the first-line drugs in adults with ADHD. Although amphetamines, methylphenidate and atomoxetine are all
effective in adults with ADHD, they cannot be considered equivalent because they have different mechanisms of actions and hazards.
There are some recommendations for treatment of ADHD: Stimulants are first-line treatment for adults, atomoxetine is considered firstline treatment in patients with substance use disorders. Drug treatment should be continued as long as clinically useful. Careful titration
and monitoring of side effects is required, particularly when using stimulants. Drug holidays may be useful to ascertain the need of
continuation of treatment. Co-administration of drugs is relatively common in clinical practice for resistant cases but there is a lack of
studies investigating its efficacy.
Also some research areas are needed for ADHD, for instance; elucidate the effects of flexible dosing and co-administration of drugs, more
pharmacological studies in humans are necessary to understand the full range of actions of ADHD medications in the brain and the
individual variations that may limit efficacy or cause side effects.
Keywords: ADHD, guidelines, treatment
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[Abstract:0432] ADHD
Manic symptoms due to methylphenidate use in an adolescent with traumatic brain injury
Ozalp Ekinci1, Cetin Okuyaz2, Nuran Ekinci1
Department of Child and Adolescent Psychiatry, Mersin University, Faculty of Medicine, Mersin-Turkey
1
Department of Pediatric Neurology, Mersin University, Faculty of Medicine, Mersin-Turkey
2
e-mail address: [email protected]
Treatment-limiting psychiatric adverse effects are rarely encountered with methylphenidate (MPH) use in healthy children and
adolescents. There is limited experience on using MPH in children with a history of traumatic brain injury (TBI). In this case report, the
emergence of manic symptoms with MPH use in an adolescent with TBI will be summarized.
A 17-year-old male was admitted to the child and adolescent psychiatry clinic with the complaints of attention difficulties on schoolwork
and forgetfulness. Patients’ medical history revealed that he had a car accident 3 months ago which included a traumatic brain injury. At the
time of the accident, his neurologic assessment was marked with upper and lower muscular weakness, memory deficits and frank mutism.
This clinic picture resolved in 2 months, however, he has been speaking slowly since then. Before the accident, he was reported to have
a successful academic life in both elementary and secondary school. He never had attention problems, hyperactivity or impulsivity. After
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the accident, he had difficulty on suSTAIning attention on school work and forgetfulness on daily duties. He also complained about doing
careless mistakes at school exams. His MRI revealed right frontal lob injury. A diagnosis of major neurocognitive disorder due to traumatic
brain injury was made and OROS MPH was administered with the dose of 18 mg/day for attention problems. After one week, patient was
admitted to the clinic with the complaints of talking to himself, irritability, and delusional thoughts. He was reported to speak everyone
that he and his father were prophets. He was reported to be more talkative than usual especially in social situations. His psychiatric
interview revealed incongruent affect and delusional thoughts on his mission to save the world. With the suspect of a medication
induced adverse reaction, MPH was discontinued and all of the symptoms resolved in 3 days.TBI may be defined as traumatically induced
physiological disruption of the brain. Mood symptoms, irritability and personality changes can be encountered following TBI. TBI may
also present with neurocognitive symptoms including impaired attention, memory problems, and deficits in executive functions. Previous
literature indicated the role of MPH in children and adolescents with brain injury suffering from neurocognitive deficits, particularly in
attention, memory, cognitive processing, and speech. In the present case, manic psychotic symptoms emerged with MPH use which led
to discontinuation of the medication. Clinicians should be careful when using MPH in children with TBI. Future studies are needed to
determine the tolerability and efficacy of MPH in children with TBI and attention problems.
Keywords: methylphenidate, traumatic brain injury, adolescent
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[Abstract:0437] ADHD
Exacerbation of alopecia areata with methylphenidate treatment
Nuran Ekinci, Ozalp Ekinci, Fevziye Toros
Department of Child and Adolescent Psychiatry, Mersin University, Faculty of Medicine, Mersin-Turkey
e-mail address: [email protected]
Alopecia areata (AA) is defined as hair loss with a patchy, confluent or diffuse pattern. AA due to psychotropic medications is rarely
encountered in children and adolescents. Hereby, we present a child with Autism Spectrum Disorder and Attention Deficit Hyperactivity
Disorder (ADHD), who hadexacerbation of AA with methylphenidate (MPH) treatment.
A 6-year-old boy was referred to our clinic with the complaints of forgetfulness, day-dreaming, difficulty listening and excessive talking
at school. At the age of 3, he had been diagnosed with pervasive developmental disorder not otherwise specified (PDD-NOS) diagnosis
and had received special education for 2 years. Currently, he was reported to have minor difficulties in reciprocal social interaction. Both
the clinical interview and the parent and teacher reports were suggestive of an ADHD diagnosis. His medical history revealed that he was
diagnosed with AA previously for which he had undergone dermatological treatment for 1 year. At the time of admission, his hair loss
was reported to be resolved for 6 months and he was not taking any medication. With the ADHD-combined diagnosis, MPH 18 mg/day
was started. Approximately three weeks after starting MPH, his mother noticed scalp hair in his comb and pillow daily. A detailed physical
examination revealed patchy AA lesions in the scalp. Hair pulling or any other stereotypical behavior on scalp was not reported and a
possible MPH induced behavioral adverse effect was excluded. No stressful life event at home or at school was reported. The patient was
consulted to the dermatology clinic for further evaluation. Complete blood count, biochemical analysis, thyroid function tests, vitamin
B12, folic acid, ferritin, serum iron and total iron-binding capacity, serum zinc and copper levels were all in normal range. With the
suspection of a medication induced exacerbation of AA, MPH was discontinued. His hair loss resolved back to the previous level within
2 months of medication discontinuation.
Drug-induced alopecia was previously reported with lithium, valproic acid, venlafaxine, fluoxetine and sertraline. Alopecia due to MPH,
amphetamines and atomoxetine have also been reported in previous case reports. To the best of our knowledge, no previous study
reported exacerbation of AA with MPH. Etiological mechanism of this reaction remains largely unknown. Given the known mechanism of
action of MPH, increased peripheral dopaminergic activity appears to be the main possibility. Various dopaminergic drugs that include
levodopa and types of dopamine receptor agonists have been shown to cause hair loss. There is limited evidence that sympathetic nerve
fibers are involved in hair growth control. Clinicians should be aware of alopecia as a very rare side effect of psychotropic medications.
Patients with a current or history of alopecia may a have a higher risk of this adverse effect.
Keywords: methylphenidate, alopecia areata, ADHD
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[Abstract:0474] ADHD
Clinical diagnosis problems in attention-deficit/hyperactivity disorder
Murat Semiz
Department of Psychiatry, Gulhane Military Medical Academy, Ankara-Turkey
e-mail address: [email protected]
Attention-deficit/hyperactivity disorder (ADHD) is characterized by an inability to sustain attention, impulsivity, and hyperactivity that
is a childhood-onset, lifelong disease which affects daily functions in many ways seriously. Recent studies suggest that ADHD affects
approximately 3-7% of the pediatric and 4% of the adult population. ADHD is a common disorder in adulthood, associated with
psychological, social, academic and occupational problems. Results of the studies showed that individuals with adult ADHD had lower
employment status, more frequent job changes, more frequent suicide attempts, more cigarette consumption, more comorbid psychiatric
disorders, more family history of psychiatric diagnoses when compared to general population. Additionally, patients with adult ADHD
typically have fewer years of education, lower occupational achievement and poor social skills. Moreover, patients with adult ADHD have
higher levels of anxiety and depression than general population. The cause of anxiety or depression may be associated with previous
failures in academic or social areas. The prevalence of ADHD has been reported to be even higher in prisoners than general population,
and prisoners with ADHD have been found to commit crimes at earlier ages. Prisoners with ADHD have lower academic skills and higher
rate of drug use, and the tendency to crimes increases due to reasons like higher rate of changing jobs. Adult ADHD should be considered
as a common co-morbid disorder for patients, especially for those who show continued impairment despite appropriate treatment or
the presenting disorder. Further, adult ADHD is a common disorder and associated with high rates of psychiatric co-morbidity but has
not been diagnosed sufficiently in psychiatric settings. The purpose of this panel is explain to clinical diagnosis problems in adult ADHD.
Keywords: attention-deficit/hyperactivity disorder, clinical features, diagnosis problems
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[Abstract:0469] ADHD
How to deal with child abuse, treating ADHD or migrating: a case study
Esen Yıldırım Demirdogen, Onur Burak Dursun, Ibrahim Selcuk Esin, Ali Karayagmurlu
Department of Child and Adolescent Mental Health, Ataturk University, Faculty of Medicine, Erzurum-Turkey
e-mail address: [email protected]
ADHD is among the most common childhood psychiatric disorders which is characterised by inattention and hyperactivity-impulsivity.
Children with ADHD are more likely to be victims of violence, child abuse and neglect due to their high levels of impulsivity and their
behavioral difficulties. In this case report we’ll pressent an eight year old girl with ADHD who was subject to recurrent sexual abuse. After
each abuse the family moved to an other city but the child was not treated for ADHD and exposed to an other sexual abuse. She was also
sexually abused again in the city where they have moved.
A 8-year-old female 1st-year student presented to our clinic with his parents because of reccurent sexual abuse. According to the information
obtained from the parents, she was subject to sexually abused two years ago and then her family emigrated to another city. She was also
sexually abused again in the city where they have moved. After the reccurent sexual abuses, her complaint that relive the event itself,
nightmares, sudden awakening from sleep, quick temper and desperation were initiated. So she didn’t want to go school. Her detailed
evaluation revealed that she has moved about uneasily or restlessly, talked excessively, interrupted conversations and she often failed to
finish her assignments since her childhood. The patient was diagnosed with ADHD and Posttraumatic Stress Disorder. Drug therapy with
methylphenidate 18 mg/day and sertraline 25 mg/day was started. Follow-up with 1-month intervals at outpatient clinic was suggested.
ADHD is well known to be more common in child abuse victims compared to non abused peers. But it can be underestimated because of
focusing on internalising disorders which causes strong emotions in psychiatrists. Clinicans should try to keep in mind that patients with
sexual abuse may also have comorbid ADHD in order to have chance for prevention. Identifying and treating ADHD should be considered
for both enhancing the quality of life children and preventing further abuses.
Keywords: attention deficit and hyperactivity disorder, child abuse, migration
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[Abstract:0482] ADHD
Emotional problems of an adult with attention deficit hyperactivity disorder; having hard times
regulating heightened emotions
Burcu Yavuz
Department of Psychiatry, Acibadem University, Istanbul-Turkey
e-mail address: [email protected]
Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder estimated to affect up to 10% of children and 5% of
adults worldwide. It is associated with high levels of morbidity and disability across lifecycle. Adults with ADHD suffer from cognitive,
behavioral and emotional problems. This presentation will focus on emotional aspect of ADHD and its consequences.
Attention problems, disorganization, hyperactivity, impulsivity, mood swings and low stress tolerance are associated with disability
in multiple domains such as educational, occupational or social functioning. Adults with ADHD not only cope with inattention,
disorganization, lack of motivation they also struggle with affective lability, impatience, being easily frustrated and communication
problems. Among youth with ADHD comorbid major depressive disorder (MDD) range from 12-50%. Comorbidity is associated with
higher levels of substance use and psychosocial impairment. Similar findings have been reported among adults. Epidemiological studies
have shown that bipolar disorder (BD) is found in approximately 20% of subjects suffering from ADHD. Comorbidity between ADHD
and BD has been associated with early onset of BD, with higher numbers of depressive and mixed episodes, worse outcomes, and poor
response to treatment.
Recognizing concurrent mood disorders is important in terms of treatment strategies and improve psychosocial functioning.
Keywords: ADHD, depression, emotions
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[Abstract:0493] ADHD
Atomoxetine treatment in mucopolysaccharidosis III b disorder: a case report
Sabide Duygu Tunas, Cagatay Ugur, Ozden Sukran Uneri, Zeynep Goker, Miray Cetinkaya
Department of Child Psychiatry, Ankara Pediatric Hematology Oncology Training and Research Hospital, Ankara-Turkey
e-mail address: [email protected]
Sanfilippo syndrome, or Mucopolysaccharidosis III (MPS-III) is a rare autosomal recessive lysosomal storage disease. It is composed of
four different subtypes (A, B, C and D). There is a limited number of drug treatment studies on comorbidities and psychiatric symptoms
in patients with Sanfilippo syndrome. In this case report, atomoxetine was administrated to a patient with MPS-IIIB diagnosis, who had
ongoing hyperactivity symptoms despite long term use of risperidone.
A twelve-year-old girl with MPS-IIIB admitted to Child Psychiatry Department in Ankara Pediatric Hematology Oncology Training and
Research Hospital for hyperactivity, impulsivity, short attention span and distractibility of 7 years duration. According to her parents,
the child’s development was normal until the age of 2 years. However, she began using single, simple words (i.e. mum, dad) at the age
of 18 months. Beginning from the second year of life progressive psychomotor developmental delay, lack of social relationships and
poor eye contact became apparent; therefore she was referred to a child and adolescent psychiatrist. On physical examination, the girl
appeared to have mildly coarse facial features, so she was referred to a pediatric neurologist and a metabolic disease specialist. About
the age of five years regression in speech and toilet control were noticed. The patient was diagnosed by MPS-IIIB when she was five
year-old, and also diagnosed with mental retardation and she started to attend a special education program. There was no history of
any medication use, epilepsy and other medical pathologies such as heart, kidney and liver diseases. She had started on risperidone
treatment at the age of eleven for sleep disturbances and aggressivebehaviors. Treatment dosage had been increased from 0.25 mg to 1
mg/day gradually. When she was accepted to our clinic, twelve years of age, she was taking 1 mg/day of risperidone regularly. Symptoms
as hyperactivity, impulsivity, short attention span, distractibility, poor organization and inability to follow directions was prominent in
education environment; because of these she could not be able to learn most of the important subjects. After clinical evaluation and
psychiatric measures, she was diagnosed with attention-deficit/hyperactivity disorder (ADHD). Atomoxetine was prescribed at 0.5 mg/kg/
day firstly and then increased at 1.2 mg/kg/day. The patient was followed regularly at 2 months and 6 months after the first evaluation.
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During these control evaluations, ADHD symptoms were determined as much improved by her parents and teachers. She seemed to listen
when spoken to directly and was sitting on seat in situations when remaining seated is expected. She made better progress on special
education program.
Psychiatric symptoms and comorbidities seen with chronic diseases not only affect the quality of life for patients and their families
negatively but also impair treatment compliance. In this report, improvement in hyperactivity and impulsivity symptoms was observed
by adding atomoxetine to risperidone. In this case, even with risperidone treatment, hyperkinetic behaviors and impulsivity that were in
the forefront and ongoing, atomoxetine was found to be an effective and safe option.
Keywords: ADHD, Sanfilippo syndrome, treatment
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[Abstract:0498] ADHD
Atomoxetine-induced nocturnal enuresis: two case reports
Ali Ibis, Esra Ozhan Ibis, Onur Burak Dursun
Department of Child and Adolescent Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
e-mail address: [email protected]
Nocturnal enuresis is a common disorder in childhood and may cause social, emotional and psychological problems. Attention Deficit
Hyperactivity Disorder (ADHD) is the most common disorder encountered in child psychiatry clinics and the rate of ADHD-induced
enuresis is around 30%. Atomoxetine is a selective norepinephrine reuptake inhibitor, which is used as a reliable treatment in patients
with ADHD. Although there are some case reports and new studies suggesting that atomoxetine is beneficial in case of comorbidity of
enuresis, very little known on the effect of Atomoxetine on Nocturnal enuresis. In this article, unlike the scientific literature, two cases will
be presented who developed secondary enuresis after atomoxetine treatment.
8 year-old male patient was admitted with complaints of hyperactivity, inability to concentrate on the course, the inability to complete
tasks and getting bored quickly. In the psychiatric examination; psychomotor activity, attention deficit disorder and impulsivity (time
to time) were observed. After observations of his parents and teachers as well as clinical evaluations conducted; he was diagnosed
with ADHD and 0.5 mg/kg/day of atomoxetine treatment was started. When he came for the check-up, it was learnt that he quitted
the treatment spontaneously due to the bedwetting started in the 2nd day of treatment and happened 5 days a week. In the urinary
examinations, no pathologies were detected. Although the treatment with atomoxetine was resumed with a lower dose, it was ended
due to bedwetting complaint. Bed-wetting stopped after atomoxetine treatment was ended up.
A 12-year-old boy was admitted with complaints of attention deficit in classroom, having quarrels with his friends frequently and
complaints of forgetfulness since elementary school. After having a psychiatric examination and based on observations of his parents
and teachers, he was diagnosed with ADHD and 1 mg/kg/day of OROS methylphenidate treatment was started. In the 2nd week of the
treatment, methylphenidate treatment was stopped due to the emergence of motor tics and 0.5 mg/kg/day of atomoxetine treatment
was started. After 4 weeks of increasing the dose of drug up to 1.2 mg/kg/day, despite the reduction in ADHD symptoms and motor tics,
the frequency of bedwetting, which they didn’t share with us before, has increased up to 1-2 nights a week from 1 night a month. His
urinary tests were normal; therefore, the drug dose was dropped down to 0.8 mg/kg/day and bed-wetting complaints were also reduced.
There are controversial results in literature about the effect of atomoxetine on enuresis in literature but majority of studies conducted
on this subjects, suggest that atomoxetine may be beneficial for enuresis. Possible mechanisms explaining this beneficial effect can
be counted as having anti-enuretic effects by reducing the deep sleep at nights; possible anticholinergic effects on the bladder or
normalizing the ADH level in enuretic children, who have lower ADH level compared to others. The reliable use of atomoxetine treatment
for enuresis is still controversial in the pediatric population; therefore, we think that its effect should be investigated with double-blind,
randomized and controlled studies and sharing both positive and negative cases related to enuresis would be useful.
Keywords: atomoxetine, ADHD, enuresis
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[Abstract:0624] ADHD
OROS-methylphenidate-induced Raynaud’s phenomenon: a dose related side effect
Ozlem Bayram, Sabri Herguner
Department of Child and Adolescent Psychiatry, Necmettin Erbakan University, Meram Faculty of Medicine, Konya-Turkey
e-mail address: [email protected]
Raynaud’s phenomenon (RP) is a peripheral vasculopathy characterized with recurrent reversible episodes of vasospasm, which is triggered
by cold and emotional stress. Color changes including pallor, cyanosis, and erythema are observed and patients may have complaints of
numbness, and pain. Vascular, neuronal, and intravascular abnormalities have a role in its pathogenesis. Some reports described cases
with RP induced by attention deficit hyperactivity disorder (ADHD) medications including methylphenidate and dextroamphetamine.
A 14-year-old girl, referred to our outpatient clinic with complaints of inattentiveness, concentration and learning problems. She had
low grades in her classes. According to her mother, she had similar problems since elementary school and never had hyperactivity and
impulsivity. According to her psychiatric assessment, she was diagnosed with ADHD – Inattentive Type and OROS - MPH 27 mg was
initiated. In her second visit to our clinic, four weeks after, significant improvement was seen in her symptoms of inattention. However
she had complaint of feeling cold in her both feet and hands, which emerged three days after she started to take OROS-MPH. Coldness in
her feet and hands was developing three hours after drug intake and went on for 12 hours. We decided to cease OROS-MPH for two days
and her complaints improved. When she restarted taking OROS-MPH, her symptoms of coldness reemerged. Then we decided to taper
the dose of OROS – MPH to 18 mg. During this dose she did not experience coldness in her feet and hands, and we decided to continue
her treatment in this dosage.
A rheumatologist found no joint stiffness, rash, arthralgia, fatigue, fever, and nail changes. There were no drug allergies. There was no
family history of connective tissue diseases, vasculitis and antiphospholipid syndrome. Laboratory investigations of rheumatic illness,
including erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor, antinuclear antibodies (ANA) were unremarkable. In
order to exclude peripheral vessel diseases, Doppler USG examination was made in the radial and digital vessels after the administration
of single dose OROS - MPH and blood flow velocity was in the normal range.
In the literature, there are a limited number of reports on RP and stimulant treatment association. Syed and Moore described two pediatric
cases with ADHD who developed RP during methylphenidate treatment. Yu et al. also reported four boys with ADHD who experienced
vascular changes in their hands and/or feet during psychostimulant treatment. In a retrospective case-control study, Goldman et al.
Investigated the relationship between stimulant medication treatment and RS in children and found a significant association between
use of stimulant and presence of RS. All these findings suggest a significant association between development of RP and stimulants used
to treat ADHD
The mechanism of RP is suggested to be due to the imbalance between vasoconstriction and vasodilatation. RP associated with MPH is
suggested to be due to stimulation of dopaminergic and noradrenergic systems that in turn causes release of catecholamine and promotes
vasoconstriction. Physician should be aware of this rare symptom in children and adolescent when prescribing psychostimulants for the
treatment of ADHD.
Keywords: attention deficit hyperactivity disorder, Raynaud’s phenomenon, methylphenidate
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[Abstract:0628] ADHD
A case report of attention deficit and hyperactivity disorder following acute disseminated
encephalomyelitis
Yasemin Cakan Celik1, Funda Suleyman1, Coskun Yarar3, Ahmet Zihni Soyata2, Ayse Kilincaslan1
Department of Child and Adolescent Psychiatry, Istanbul University, Cerrahpasa Faculty of Medicine, Istanbul-Turkey
1
Department of Psychiatry, Istanbul University, Cerrahpasa Faculty of Medicine, Istanbul-Turkey
2
Department of Child and Adolescent Neurology, Eskisehir Osmangazi University, Faculty of Medicine, Eskisehir-Turkey
3
e-mail address: [email protected]
Childhood illnesses associated with attention-deficit and hyperactivity disorder (ADHD) include virus infections, meningitis, encephalitis,
head injury, epilepsy, toxins, and drugs, but as far as we know there is no report of subacute-onset ADHD in a child with acute disseminated
encephalomyelitis (ADEM). Here we present a 7 year old boy who developed ADHD after ADEM.
A 7-year-old boy was referred to our clinic for irritability and attention problems. At 5 years of age, he presented with diplopia, headache,
irritability, lethargy, and walking problems preceded by a 2-week history of sore throat and fever diagnosed as upper airway infection. The
neurologic examination at presentation demonstrated an altered level of consciousness without any response to stimulus. Cranial MRI of
the brain initially showed increased signal in the thalamic area and general edema. A diagnosis of ADEM was made, he was treated with
high-dose methylprednisone, and his neurologic symptoms resolved. After his illness, he had poor attention, distractibility, and worsening
of his relationship with his mother and peers. The patient experienced a subacute onset of ADHD symptoms within 1 month of being
hospitalized for ADEM. At that time, the school expressed concern that he was having excessive fights with her peers and usually being
angry and irritable. In the treatment; 36 mg/day metihylphenidate, 10mg/day atomoxetine, and 5mg/day aripiprazole had been used. His
behavioral symptoms relieved but attention and academic problems persisted.
ADEM is a demyelinating disease of the central nervous system usually preceded by a viral or bacterial infection. Exact pathogenesis is
still not completely understood. Our patient developed ADEM after 2 weeks of upper airway infection. Cognitive and behavioral problems
have been reported even in the absence of other persistent neurological deficits. Our patient did not have any neurological sequel after
ADEM but his attention, academic and behavioral symptoms persisted. Thalamic lesions, especially those involving the medial nuclei most
frequently associated with deficits in arousal and attention. Our patient also had thalamic lesions and attention problems.
Keywords: acute disseminated encephalomyelitis, attention deficit and hyperactivity disorder, organic etiology
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S239
[Abstract:0726] ADHD
Long-acting methylphenidate-induced mania in a child of comorbid attention-deficit hyperactivity
disorder and autism spectrum disorder
Nermin Yucel1, Atakan Yucel2, Mutlu Karakus3
Department of Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
1
Department of Child and Adolescent Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
2
Department of Psychiatry, Agri State Hospital, Agri-Turkey
3
e-mail address: [email protected]
Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by impulsivity, hyperactivity and
inattention. Autism spectrum disorder (ASD) often co-occurs with ADHD. Psychostimulants constitute the basic treatment approximately
one third of children with ASD and ADHD. We report a case of methylphenidate-induced mania like symptoms in comorbid ADHD and
ASD, which is predicted by insomnia.
An 8-year-old boy was brought by the mother to psychiatric outpatient clinic. In the patient history, normal vaginal born at home
after full-term pregnancy, postnatal febrile convulsion at three year-old, delayed speech and toddle, lack of verbal and non-verbal
communication, inadequacy self-care, poor eye contact, indifference, repetitive behaviors, restricted interests and failure in social skills
since early childhood were stated. In addition, short attention span, purposeless running and jumping, hitting siblings and friends,
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loosing things, teasing others around him, noncompliance with the rules, straying at the school and home were observed since 4
year-old. Because of his behavior problems He dropped out of school and could not complete his training. He has still not got toilet
sphincter skills. There was no any family history of psychiatric or medical illness. Examination revealed a thin stature, 25 kg body weight
boy, normal vitals, neurological and other system examination were normal. Mental status examination was including easily distractible,
fidgety, hyperactivity, not making eye contact, not looking called by his name, restlessness and disruptive behaviors. All laboratory
investigations were within normal limits. According to DSM-5, the patient was diagnosed with comorbid ASD and ADHD. Patient was
started on tablet short-acting methylphenidate 5 mg once daily and titrated 20 mg twice daily which he tolerated well. After 1 month,
his medication was changed long-acting methylphenidate 27 mg once daily in terms of ease of use. However, on the 2nd day of increase
in dose, he presented with restlessness (more than the past) with constant fidgeting, running around, shouting, increased hyperactivity
and energy, continuous laughing and nonsense talking, unprovoked joy increase, decrease the need for sleep. Then his mother stopped
the medication. After 4 day when he was brought to the outpatient clinic, there was no symptom as described above, so following nonmedication period short-acting methylphenidate started 5 mg/day and increased gradually 20 mg/day in two divided doses. During a
follow-up of 2 years, no further episodes of mania-like symptoms were observed, although he is still being treated with methylphenidate
short-acting tablets, 20 mg/day.
The data regarding the safety of methylphenidate in children with comorbid ADHD and ASD are not enough. Approximately one third of
children with ASD and ADHD are treated with psychostimulants. It is known therapeutic dose of methylphenidate have caused psychosis
or mania in a few cases. One of the common adverse effect of psychostimulant is sleep disturbance also recent studies suggest insomnia
often trigger onset of mood episodes. Clinicians should be heedful during follow up process regarding with adverse effects of long-acting
methylphenidate such as insomnia that may be a premonitory sign of mania.
Keywords: autism spectrum disorder, methylphenidate, mania
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[Abstract:0740] ADHD
Case report: methylphenidate induced pruritus
Canan Yusufoglu, Sebla Gokce, Elif Akin
Department of Child and Adolescent Psychiatry, Erenkoy Training and Research Hospital, Istanbul-Turkey
e-mail address: [email protected]
Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder in childhood, affecting approximately 5%
of children worldwide and persisting into adulthood in a majority of cases. Methylphenidate (MPH) is a psychostimulant medication that
is most commonly used in treatment of Attention-Deficit Hyperactivity Disorder (ADHD). Although the mechanism of action of MPH has
not been fully elucidated, it is thought to block the uptake of norepinephrine and dopamine into the presynaptic neuron and increase
the release of these monoamines into the extraneuronal space in regions of the brain associated with ADHD. Commonly reported adverse
events associated with MPH; 59.6% of caregivers agreed that the drug decreased their child’s appetite and 34.8% agreed that treatment
with methylphenidate made it more difficult for their child to fall asleep at night. Mild to moderate in severity and most commonly
included headache, decreased appetite, insomnia and abdominal pain. Other common adverse reactions in double-blind clinical trials
(>5%) in adult patients were decreased appetite, headache, dry mouth, nausea, insomnia, anxiety, dizziness, weight decreased, irritability,
and hyperhidrosis. There are few case reports about methylphenidate induced skin reactions, like skin color change or skin rash. These
adverse reactions to methylphenidate strongly suggest an allergic basis. The 9 year old boy began treatment with immediate-release (IR)
methylphenidate 5 mg twice daily, which was later switched to suSTAIned-release methylphenidate 27 mg/day. He was admitted 2 weeks
following the switch, reporting pruritus and erythema all over his body. He had no history of pruritus, and allergic reaction. He was advised
to discontinue methylphenidate. The boy’s symptoms of his skin rapidly improved after discontinuation of the treatment.We will discuss
skin reactions after methylphenidate treatment in this case report.
Keywords: attention-deficit/hyperactivity disorder, methylphenidate, pruritus
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[Abstract:0739] ADHD
Suicide attempt with short-acting methylphenidate: a case report
Hamiyet Ipek Toz1, Ali Guven Kilicoglu1, Ayten Erdogan2
Department of Child and Adolescent Psychiatry, Bakirkoy Prof. Dr. Mazhar Osman Training and Research Hospital, Istanbul-Turkey
1
Department of Child and Adolescent Psychiatry, Duzce University, Faculty of Medicine, Duzce-Turkey
2
e-mail address: [email protected]
Methylphenidate is one of the most prescribed psychostimulants that is widely used for the treatment of attention-deficit hyperactivity
disorder (ADHD) all over the world. Although it is accepted as mostly well- tolerated agent in child psychiatry practice, some cardiovascular
side affects have been reported in literature such as tachycardia, hypertension, atrial and ventricular tachydysrhythmias and chest pain.
Although, It is thought that cardiovascular symptoms could be associated with direct adrenergic agonistic effects of methylphenidate,
underlying pathophysiologic mechanism has not been explained clearly yet. There is limited information about suicide attempt with
methylphenidate ingestion in the literature. In this article, we report a case who experienced increase in heart beat rate and blood
pressure without any additional symptom after ingestion of 200 mg short acting methylphenidate for suicide attempt.
A 17 year-old high school girl was referred to child and adolescent psychiatry outpatient clinic of Bakirkoy Mental Health Hospital for
evaluation of her suicidal risk after medical intervention in emergency department. According to information received from her and her
family, she had been diagnosed with ADHD and was taking short acting methylphenidate before admitted to our clinic. Although her
hyperactivity and impulsive symptoms has been improved with treatment, she wasn’t taking the drug regularly. She had problems with
her peers and also had academic difficulties and chaotic family life. She had felt depressive for last one month. Her suicide attempt was
impulsive after an argument with her boyfriend by the ingestion of 200 mg short acting methylphenidate. A few hours after ingestion she
felt palpitation and applied to emergency department.
The use of stimulants prescribed for the treatment of ADHD has been increasing in child and adolescent psychiatry practice during the
period 2001 to 2010. According to literature, the majority of overdoses with methylphenidate in adolescent population associated with
drug abuse and suicide attempt was generally symptomatic. Although methylphenidate associated cardiovascular symptoms show
benign course and respond well to palliative medical intervention, clinicians and families should be aware of possible suicide attempt
with this agent especially in patients with suicidal ideation and impulsive behavior.
Keywords: methylphenidate, overdose, suicide attempt
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S241
[Abstract:0761] ADHD
Osteogenesis imperfecta and attention deficit hyperactivity disorder: a case report
Ali Karayagmurlu1, Cem Gokcen2, Elif Karayagmurlu3
Department of Child and Adolescent Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
1
Department of Child and Adolescent Psychiatry, Gaziantep University, Faculty of Medicine, Gaziantep-Turkey
2
Department of Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
3
e-mail address: [email protected]
Osteogenesis Imperfecta (OI) is a genetic disorder of the connective tissue matrix that rarely seen, autosomal inherited and characterized
by bone fractures, deafness and blue sclera. The impairment of Type 1 collagen production causes frequent fractures, increased bone
fragility and leads to reduced bone mass. Type 1 collagen molecules consist of two α1 chains and one α2 chain. COL1A1 and COL1A2
named genes on chromosome 17 and 7 is responsible for the synthesis of these chains, respectively and mutations in these genes
are one of the important factors that play a role in pathogenesis of OI. Attention Deficit Hyperactivity Disorder (ADHD) is a chronic
neurobehavioral disorders of childhood characterized by inattention, hyperactivity and impulsivity and has higher risk for unintentional
injuries. In this paper, we will discussed a 6-year-old male who were diagnosed with OI, had reccurent traumatic injury and admitted to our
clinic by restlessness, irritability and hyperactivity. A 6 year-old male kindergarten student presented to our clinic with his parents because
of restlessness, irritability and unwillingness to walk although lower extremity fractures were improved after accident. His anamnesis
revealed that the child often talks excessively, interrupt conversations and fidgets with hands or feet or squirms in seat when sitting still is
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expected. The patient was diagnosed with ADHD and NOS Anxiety Disorder. Due to atomoxetine is effective in patients who have ADHD
with comorbid anxiety, atomoxetine was initiated. Six months after medical treatment, ADHD and anxiety symptoms were decreased.
Follow-up with 2-months intervals at outpatient clinic was suggested. This case was presented since this is the first published report
diagnosed with ADHD and OI according to our knowledge. Clinicians must be vigilant for injury-related disorders and should try to keep
in mind that the association of both disorders in order to have chance for early diagnosis and necessary interventions.
Keywords: osteogenesis imperfecta, ADHD, child
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[Abstract:0809] ADHD
Risperidone in treating behavioral disturbances of 11q deletion (Jacobsen syndrome)
Canan Yusufoglu, Sebla Gokce, Elif Akin
Department of Child and Adolescent Psychiatry, Erenkoy Training and Research Hospital, Istanbul-Turkey
e-mail address: [email protected]
Jacobsen syndrome (JS) is a contiguous gene syndrome caused by terminal deletion of chromosome 11 with an estimated prevalence of
1/100.000 births and a female/male ratio of 2:1. This is a rare genetic disorder associated with numerous dysmorphic features. Hallmark
clinical features of JS include pre- and post-natal physical growth retardation, intellectual disability, and characteristic facial dysmorphism.
Many previous studies have shown that adults with 22q11.2. JS have approximately thirty times greater risk for the developing
schizophrenia compared to the general population. Furthermore, studies of children and adolescents with 22q11.2 DS have found high
rates of psychotic symptoms, ADHD and anxiety disorders. Risperidone is known to be efficacious in children and adolescents with ADHD
and is generally safe and well tolerated.
A 7 year old boy with 11q deletion with moderate intellectual and motor disability and ADHD admitted to our clinic. He had 27 month
language, 48 month gross motor development. His family and teachers was suffering from his hyperactivity, agression, irritability and
attention problems. After 0,25 mg/day risperidone treatment for 1 month his symptoms were improved according to teacher and parent
report.
We will discuss the ADHD diagnosis in syndromic cases and treatment in relation with this case report.
Keywords: attention deficit hyperactivity disorder, Jacobsen syndrome, risperidone
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[Abstract:0842] ADHD
Adolescence or isotretinoin or acne or attention deficit/hyperactivity disorder cause adolescent
depression?
Sebla Gokce1, Burcu Ayaz2, Canan Yusufoglu1
Department of Child and Adolescent Psychiatry, Erenkoy Training and Research Hospital, Istanbul-Turkey
1
Department of Child and Adolescent Psychiatry, Marmara University, Istanbul-Turkey
2
e-mail address: [email protected]
Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder in childhood, affecting approximately 5%
of children worldwide and persisting into adulthood in a majority of cases. And it is known that children and adolescents with ADHD
are at increased risk for developing depression. Methylphenidate (MPH) is a psychostimulant medication that is mostly common used in
treatment of ADHD. Depressive side effects like irritability and agitation are commonly seen related with long-acting MPH. In addition
there are few case reports that discuss whether or not long-acting methylphenidate induce suicide attempts in adolescents.
Acne is a common condition among adolescents and has the potential to negatively impact on the psychological well-being of those who
suffer from it. In particular, depression and suicidal ideation are more common in adolescents with acne. Successful treatment of acne can
improve the quality of life and reduce levels of anxiety and depression in these individuals.
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And isotretinoin is a systemic synthetic retinoid used to treat acne vulgaris and some other dermatological diseases. Isotretinoin is
associated with several psychiatric side effects. Since it crosses the blood-brain barrier, isotretinoin affects the expression of a broad
spectrum of genes in the limbic structures, thus affecting the function of the dopaminergic, serotonergic, and noradrenergic neurons
involved in the regulation of mood and emotion. It was suggested that isotretinoin in high concentrations inhibits hippocampal
neurogenesis and induces apoptosis of hippocampal cells. However, some studies do not confirm this pathogenic role, and isotretinoin
was even reported to have a therapeutic effect in acne-associated depression.
However depression itself instead of these risky conditions and comorbidities commonly is seen in adolescents.
We will discuss 16 year-old adolescent who admitted to child and adolescent psychiatry clinic suffering from ADHD, depression and
suicidal thoughts. And she is using isotretinoin for 6 weeks because of her severe acnes, with no improvement yet.
Keywords: acne, isotretinoin, attention deficit/hyperactivity disorder, depression
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[Abstract:0870] ADHD
Attention deficit hyperactivity disorder (ADHD), depression and suicidality in adolescents
Sebla Gokce
Erenkoy Training and Research Hospital, Istanbul-Turkey
e-mail address: [email protected]
Attention deficit hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder that is characterized by hyperactivity
and deficiencies in impulse control, as well as difficulties with sustained attention and distractibility. Endophenotypically, ADHD
frequently involves impairments in executive functioning, such as planning and organizing actions, and in the regulation of emotions
and motivation. The prevalence of ADHD is estimated at about 8-13%. Approximately 70% of children diagnosed with ADHD have
the symptoms in adolescence. Adolescents with attention-deficit/hyperactivity disorder (ADHD) are at increased risk for developing
depression and other comorbid psychiatric conditions such as anxiety disorders, oppositional defiant disorder, conduct disorder,
substance use disorders, eating disorders, and bipolar disorder. A review of studies in community samples has reported that the rate of
depression in youths with ADHD is 5.5 times higher than in youths without ADHD, with rates ranging from 12% to 50%.
In nearly all major life activities, ADHD is associated with considerable functional impairments, which include academic underachievement,
occupational limitations and difficulties with social and family life. Internalizing symptoms and social functioning among young
adolescents with ADHD is nuanced, with social anxiety and anhedonia symptoms associated with lower social skills and social acceptance.
ADHD in females, especially when featuring childhood impulsivity and especially with persistent symptomatology, carries high risk
for self-harm. A high proportion of male adolescents with ADHD are involved in bullying and cyberbullying. There was a significant
association between ADHD and binge eating among adolescents. Tobacco and drug usage and smoking are more common among
adolescents with ADHD.
Adolescents with ADHD reported having more romantic partners than their typically developing (TD) peers. Females with ADHD were
found to have shorter romantic relationships than TD adolescents while males with ADHD reported their age of first intercourse to be nearly
2 years sooner than TD peers. Irrespective of gender, adolescents with ADHD had nearly double the number of lifetime sexual partners.
Symptoms of ADHD, in general, and its comorbidity with other disorders (e.g. depression, phobias, substance abuse, and dysthymia)
can increase probability of performing high risk behaviours. Additionally, people with ADHD are concerned with the anticipated reward
of risk-seeking behavior and prefer these aspects. They also suffer from impairments in executive functions so their “rational-analytical
system” is also disrupted.
A common notion is that the cumulative effects of ADHD-related impairments and the negative environmental circumstances triggered
by these may lead some youths with ADHD to eventually develop depression. Depression or ADHD occurring alone in childhood
is associated with substantial long-term impairment, morbidity, and an increased risk of suicide. However, youths with ADHD and
depression occurring together display even greater levels of psychosocial impairment than youths with either ADHD or depression alone.
Female patients with both depression and co-morbid ADHD have earlier ages of onset of depression, longer durations of depressive
episodes, and higher rates of suicidality and hospitalizations than those with depression alone. We will discuss ADHD in adolescents which
is a common healthcare problem with increasing rates of mortality and morbidity.
Keywords: ADHD, depression, suicidality
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[Abstract:0885] ADHD
Recent advances in ADHD treatment
Ozalp Ekinci
Mersin University, Mersin-Turkey
e-mail address: [email protected]
In the past 10 years, there has been significant research on the treatment of attention-deficit hyperactivity disorder (ADHD). Although
the previously established treatments are not greatly changed, recent developments may be considered as promising. Number of large
sample sized controlled studies have reported the long-term efficacy and tolerability of osmotic-controlled release oral system (OROS)
formulation of MPH, which is currently the first-line medication in ADHD. Newer drugs are also in the market in USA and Europe. The
prodrug lisdexamfetamine dimesylate (LDX) is the first long-acting amphetamine-based ADHD medication to be approved in ADHD. LDX
has been established as an effective and generally well tolerated treatment for children with ADHD. The MPH transdermal patch (MTS)
permits a sustained skin absorption to provide a uniform delivery of MPH. The efficacy and tolerability of the MTS is shown to be similar
to that of OROS MPH. Medikinet retard is a new long acting formulation which provides a 50:50 mixture of immediate and extended
MPH release lasting about 8 hours. Medikinet capsules can be opened and sprinkled on food which may increase treatment compliance
in some children. Given the spesific onset and duration of efficacy of these formulations, patient’s individual needs must be taken into
consideration when selecting the appropriate MPH formulation. The spesific ratio of immediate and extended release in the longacting formulations result in different levels of symptom control throughout the day. Among the other treatment options, guanfacine
extended release (GXR) is a selective α(2A)-adrenoreceptor agonist. FDA approved GXR for the treatment of ADHD as monotherapy and
as adjunctive to psychostimulants in children and adolescents 6-17 years old. Food supplementations were also examined in controlled
trials. Some studies have found Omega-3 fatty acids, particularly with higher doses of EPA, to have modest level of efficacy in ADHD.
Omega-3 fatty supplementation may be considered as an augmentation to traditional pharmacological interventions. Finally, there is
a growing experience on the combination of atomoxetine with MPH in children who previously failed to respond adequately to each
treatment. The available limited evidence suggest that, with close monitorization, drug combination may be effective and tolerable in
selected patients. In conclusion, more comparative and head-to-head studies of OROS MPH, LDX and other long acting MPH formulations
are needed, especially in non-Western countries.
Keywords: ADHD, treatment, attention-deficit hyperactivity disorder
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ANXIETY, STRESS AND ADJUSTMENT DISORDERS
[Abstract:0120] Anxiety, stress and adjustment disorders
A case diagnosed as generalized anxiety disorder responded to valproic acid treatment
Filiz Izci, Sumeyye Yasemin Kurtulus Calli, Yagmur Sever, Rabia Bilici, Murat Yalcin, Medine Gulec
Department of Psychiatry, Erenkoy Training and Research Hospital, Istanbul-Turkey
e-mail address: [email protected]
Generalized Anxiety Disorder (GAD) is an anxiety disorder characterized by chronic anxiety, exaggerated worry and tension and is
treated by medicines as antidepressants, benzodiazepines and buspirone. We report a case diagnosed with GAD that did not respond
antidepressant and benzodiazepine but dramatically responded valproic acid treatment.
V. E., 61 year-old male patient had distress, belief of hearing bad news, sleeplessness and lack of appetite symptoms and did not want to
go outside. He had same symptoms during 25 years, got worsen especially at spring and winter seasons. He got treatment at psychiatry
service only once 16 years ago. He was not treated and controlled regularly. His symptoms got worsen during last 1 year and he had
difficulty even going outside. He had diagnosed with GAD and hospitalized. There was not any feature in medical personal and family
history. His mood and affect were anxious. He had somatic findings of anxiety, anticipation of anxiety, insomnia and anorexia. Psychomotor
activity increased due to anxiety. His insight and judgment were adequate. There weren’t any perception and memory abnormality. The
patient’s routine biochemical results were normal, total blood count and thyroid hormone levels were also normal. HAM-A score was
22. Sertraline 50 mg/day, Alprazolam 0.75 mg/day, mirtazapine 15 mg/day were started. 10 mg Diazepam were given as intravenous
infusion several times due to his anxiety. Sertraline remained same doses and alprazolam increased 1.5 mg/day doses. At fourth week, his
symptoms were same so sertraline increased 100 mg/day doses and due to seasonal features of his symptoms, valproic acid 500 mg/day
was added to treatment. Alprazolam was changed with lorazepam. At the eight week of treatment, HAM-A score decreased to 9. Because
of reduction in degree of symptoms he was discharged with the treatment of sertraline 100 mg/day, mirtazapine 15 mg/day, valproic acid
500 mg/day and lorazepam 0.5 mg/day.
During GAD treatment, antidepressants, benzodiazepines, buspiron, beta-adrenergic antagonists, hydroxilyzin, ondansetrone are used.
Valproic acid is not used in GAD treatment but it is thought that valproic acid shows anxiolytic effect by increasing GABA activity. In this
case, valproic acid treatment solved resistant anxiety symptoms and improved patient’s complaints significantly.
Keywords: generalized anxiety disorder, valproic acid, treatment
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[Abstract: 0371] Anxiety, stress and adjustment disorders
Epistaxis in a girl when she gets angry
Can Sait Sevindik, Mehmet Fatih Yilmaz
Department of Psychiatry, Ardahan State Hospital, Ardahan-Turkey
e-mail address: [email protected]
Epistaxis is a bothersome symptom in all age groups. Local and systemic causes may lead to it. Spontaneous bleeding with psychiatric
symptoms is rare (Ex. Gardner-Diamond Syndrome).
A 19-year-old, female, eldest of 3 sisters, left high school, she got married at 17 without her parents will and divorced after 1 year. She is
living in a village in Cildir district of Ardahan city. She was not working, her family is farmer. She was referred to our clinic with his father
and their core complaint was anger. She was very angry until her adolescents time and she was giving harm to objects around her. She
told us that she was feeling bad for acting like it, she was breaking objects, giving harm to her sister and meanwhile having epistaxis.
She was also feeling dysphoric. Fluoxetine and quetiapine were initiated. Next month we learned that she did not use her treatment and
had argue with his father about it. We persuaded her to stay at hospital for a sometime. Next day we learned that she had argument with
the nurses about visiting the canteen too much, we visited her for a psychiatric interview at her room, she was angry and crying and also
epistaxis was begun. The tension was at normal (110 mmHg-70 mmHg),Active Prothrombin Time was 34.9 sec (20-45), Prothrombin Time
was 16.3 sec (10-15), INR was 1.36 (0.8-1.2) and other biochemical marks were normal. Her anger was eased after some time. We repeated
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the biochemical tests, Active Prothrombin Time was 36 (20-45), Prothrombin Time was 12 (10-15), INR was 0.98 (0.8-1.2). Blood pressure
was (120 mmHg/80 mmHg), Nose examination by the otolaryngologist was normal. There were no ecchymosis on her body and menstrual
cycles were normal. Her IQ was 90, MMPI profile was associated with borderline Attributions. On her next day, she locked her sister and
herself in toilet and beat her up, so we decided to discharge her from our hospital to a better psychiatric hospital. Physical symptoms are
related with emotional feelings. Epistaxis can be seen in hypertensive patients after anger or emotional distress. In our case the patient
has no hypertension and her bleeding diathesis tests were prolonged when she had epistaxis and was normal after that. To the best of our
knowledge this is the first case report of epistaxis with anger. For more knowledge about the ethology and connection between epistaxis
and emotional felling, more cases and better detailed laboratory test are needed
Keywords: epistaxis, anger, psychiatry
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[Abstract:0401] Anxiety, stress and adjustment disorders
Hair regrowth after escitalopram treatment in a patient with alopecia areata: a case report
Kerem Senol Coskun1, Ugur Kocak2, Ahmet Hamdi Alpaslan3, Omer Ozbulut1
Department of Psychiatry, Afyon Kocatepe University, Faculty of Medicine, Afyonkarahisar-Turkey
1
Department of Forensic Medicine, Afyon Kocatepe University, Faculty of Medicine, Afyonkarahisar-Turkey
2
Department of Child and Adolescent Psychiatry, Afyon Kocatepe University, Faculty of Medicine, Afyonkarahisar-Turkey
3
e-mail address: [email protected]
Alopecia areata (AA) is a chronic, recurrent form of nonscarring skin disorder characterized by a sudden loss of hair without inflammation.
Its lifetime incidence varies between 1.7% and 2.1%. Several factors such as genetic predisposition, immunologic and endocrine
abnormalities, environmental factors and infections have been suggested as potential causes for AA. Additionally, stressful events,
environmental stress, high avoidance in attachment relationships, high presence of alexithymic characteristics and poor social support
were found to play an important role both in the onset and aggravation of AA. Depression, anxiety, paranoid disorder, social phobia,
obsessive compulsive disorder, generalized anxiety disorder and alexithymia were found to be comorbid psychiatric conditions in
patients with AA. On the other hand, some studies did not found any difference in anxiety or depression compared to controls.
We present a case of 18 year-old single male patient referred to our Psychiatry Outpatient Clinic for forensic psychiatric evaluation. In
his history, his hair loss began 1.5 months after he started to receive threatening messages (SMS) from an unknown person about 4
years ago. Meanwhile, he started to feel frightened, developed hypervigilance and insomnia. Additionally, he mentioned that he began
to feel anxiety, he could not walk alone, had failure in school performance, lost his appetite and weight and began to cry without any
reason. After the continuation of threatening messages for 20 days, he turned to prosecution. About 1.5 months later, he began to lose
his hair and lost totally within 3 months. One year after the onset of his hair loss, he applied to the outpatient Dermatology Clinic of our
hospital. For about 3 years, he received several dermatological treatments such as intralesional corticosteroid injections, a combination of
psoralen and long-wave ultraviolet radiation (PUVA), oral salazopyrin, topical corticosteroids and immunosuppressive agents. At the time
of admission to our psychiatry clinic, he was receiving oral corticosteroid and PUVA therapy. In the initial psychiatric interview, he stated
that he was thinking his hair loss all the day and was feeling depressed because of his hair loss, he had anxiety attacks and social phobia,
spent most of his spare time on the internet and phone and was always wearing a skullcap when he was outside. Because of depressive
and anxiety symptoms 10 mg/day escitalopram was prescribed in addition to his dermatological treatment. One month later, partial hair
regrowth and two months later, full hair regrowth was observed respectively. Additionally, at the third psychiatric interview he stated that
he felt better, his anxiety attacks disappeared, he gave up wearing skullcap and had better communication with his peers.
Some studies reported that treatment of selective serotonin re-uptake inhibitors (SSRIs) showed a regrowth of hair and an improvement
in psychiatric symptomatology. In a recent study, it was shown that citalopram might help in improving AA in patients with major
depressive disorder. The use of SSRIs might help on the regrowth of hair and might relieve psychiatric symptoms in patients with AA
having comorbid psychiatric disorders, especially depressive and anxiety disorders.
Keywords: alopecia areata, escitalopram, psychiatric symptoms
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[Abstract:0448] Anxiety, stress and adjustment disorders
Sertraline-induced enuresis: a case report
Nuran Ekinci, Ozalp Ekinci, Fevziye Toros
Department of Child and Adolescent Psychiatry, Mersin University, Faculty of Medicine, Mersin-Turkey
e-mail address: [email protected]
Selective serotonin reuptake inhibitors (SSRIs) are the most commonly prescribed antidepressants in child and adolescent psychiatry
clinics. Enuresis, as an adverse reaction due to SSRI use, has been rarely reported. We hereby, report a case of nocturnal enuresis associated
with sertraline use in a child with Separation Anxiety Disorder.
A 8 year-old boy was referred to our clinic by the complaints of fear about loosing his parents and excessive worries about separation from his
mother. He was diagnosed with Separation Anxiety Disorder according to Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV)
criteria. A treatment plan including parent training, behavioral therapy and sertraline in the dose of 25 mg/day were initiated. Sertraline dose was
increased to 50 mg/day at the 1st week. At the 15th day of treatment, there was a marked improvement in his anxiety symptoms. However, his parents
stated that he had been bedwetting every night since sertraline dose was titrated up to 50 mg/day. The case was reported to have no prior history of
enuresis. He was referred to the pediatric urology clinic but all the urologic work-up was in normal range. Since our treatment was effective at target
symptoms, instead of discontinuing the treatment, the daily timing of treatment was switched to morning use. Despite this change, bedwetting
continued with no change in frequency. Finally, medication was discontinued and bedwetting gradually resolved within one week.
Enuresis associated with paroxetine, sertraline and citalopram use in children was reported previously in case studies. To our knowledge,
the present case is the third on sertraline use. Several mechanisms have been proposed on the etiology of this adverse reaction, mainly
on serotonergic 5HT receptors. Serotonin is shown to have a modulatory role on bladder contraction via cholinergic system. Acetylcholine
release is either facilitated or inhibited with 5HT-4, 5HT7 and 5HT 1A receptors. SSRI-induced 5HT-4 receptor activation have been suggested
to be related with acetylcholine release and increased micturition. There is evidence that that this mechanism is dose dependent and
SSRI-induced acetylcholine release is more prominent in higher serotonergic concentrations. Alpha-adrenergic blockade and dopamine
reuptake inhibition properties of sertraline may also be related with enuresis. Adrenergic blockade may cause a decrease in internal bladder
sphincter tone which in turn leads to urinary incontinence. Inhibition of dopamine reuptake may also play a role by suppressing activity
of the urethral sphincter. In light of the available case reports, clinicians should be aware of enuresis as a rare side effect of SSRI treatment.
Keywords: sertraline, enuresis, SSRI
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S247
[Abstract:0593] Anxiety, stress and adjustment disorders
Post-traumatic stress disorder treatment with eye movement desensitization and reprocessing; case report
Cem Oge, Yakup Yilan, Hakan Balibey, Recep Tutuncu, Ayhan Algul, M. Alpay Ates, Cengiz Basoglu
Department of Psychiatry, GATA Haydarpasa Training Hospital, Istanbul-Turkey
e-mail address: [email protected]
EMDR (Eye Movement Desensitization and Reprocessing) (Shapiro 1995) is psychological method which has proven to be effective and it
brings together elements of well-established approaches such as psychodynamic, cognitive, behavioral and client-centered approaches.
EMDR involves activation of information processing capacity of the brain with its bilateral stimulation (eye movement, touch, sound).
Post-traumatic stress disorder (PTSD) is a psychiatric disorder that is characterised with autonomic, dysphoric and cognitive signs together
with affective numbing, distressed re-experiencing and avoidance from previous traumatic events at a person who has encountered, lived
or heard an excessive traumatic event.
In this case report, we discussed 33 year old woman, who shows signs of post-traumatic stress disorder after a car accident. She had
psychiatric medication for a year, although medication symptoms still continued. Treatment process with Eye Movement Desensitization
and Reprocessing (EMDR). She showed rapid recovery by using this psychological method.
Keywords: EMDR, post-traumatic stress disorder (PTSD), traumatic events
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[Abstract:0597] Anxiety, stress and adjustment disorders
Treatment of flight phobia (aviophobia) and specific phobia through the eye movement
desensitization and reprocessing (EMDR) method: two case reports
Cem Oge, Murat Oncu, Hakan Balibey, Recep Tutuncu, Ayhan Algul, M. Alpay Ates, Cengiz Basoglu
Department of Psychiatry, GATA Haydarpasa Training Hospital, Istanbul-Turkey
e-mail address: [email protected]
The presence of traumatic experiences is not necessary in the etiology of phobias. Even though there are many patients don’t have
traumatic experiences in the history. If there is a traumatic event in the history, EMDR therapy seems to be a useful treatment. Also,
although there is not a traumatic event at the beginning, after the formation of phobic fear, every encounter to phobic object, even
the idea, can be seen as traumatic event. EMDR may be a useful treatment of phobias. In this article, a 31-year-old single man working
in military as a sergeant, he didn’t have psychiatric history before. He has experienced a jolt of the aircraft during a flight because of
turbulence and who then developed flight anxiety and could not get on a plane is presented. Within the framework of the protocol
defined by Shapiro, four EMDR sessions, each session, which lasted for about an hour, were applied as treatment. After EMDR sessions
phobic fear and avoidance of the patient were disappeared.
Second case 68-year-old retired officer who didn’t have psychiatric history before. He is suspected bladder cancer; urinary biopsy was
made, after the biopsy anxiety started. He scared of operating room. He had to urinary biopsy again, but he could not have. He had
psychiatric medication for a year. Although the drugs his anxiety continued. After EMDR sessions phobic fear and avoidance of the patient
were disappeared. He had successfully urinary biopsy. EMDR may be useful treatment option in several clinical conditions thought to
occur after the experiences of the past conditioning.
Keywords: eye movement desensitization and reprocessing, specific phobia, flight phobia
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S248
[Abstract:0607] Anxiety, stress and adjustment disorders
Hysterical paralysis after gluteal injection due to conversion disorder: a case report
Cafer Cagri Korucu1, Inci Meltem Atay1, Suleyman Kutluhan2
Department of Psychiatry, Suleyman Demirel University, Faculty of Medicine, Isparta-Turkey
1
Department of Neurology, Suleyman Demirel University, Faculty of Medicine, Isparta-Turkey
2
e-mail address: [email protected]
Conversion disorder is a medical condition in which a person has paralysis, paraesthesia, vision loss, dysphagia or other neurological
symptoms that cannot be clearly explained physiologically. Hysterical paralysis is an uncommon psychogenic, nonorganic loss of motor
function. Allodynia is that, pain elicited by nonpainful stimuli, such as touch-evoked exceptional pain.
A 18-year-old male patient, who was diagnosed to allodynia at the right arm and has been treated for 20 days in neurology and algology
clinics evaluated by psychiatry service. It has been learned that certain medical treatments against allodynia were assigned in neurology
and algology clinics, resulting in no recovery. Results of the laboratory, electromyography (EMG) and electroencephalogram (EEG) and
radiological examination (cranial MRI) showed no pathology. In psychiatric examination; he was cooperative and oriented. His attention
and concentration were reduced. Speech rate and tone were normal. Perceptive pathology was not observed. His affect was anxious.
Intense thought content with respect to the problems experienced with his family was present. Background of the patient has had loss
of motor function (paralysis) in right lower extremities after the gluteal intramuscular penicillin injections, which was two years ago. The
patient didn’t have any benefit with the exercise programs and he wasn’t able to continue high school for two years. After psychiatric
evaluation, medical treatment with sertraline 50 mg/g was initiated due to the diagnosis of conversion disorder. Patient and his family
were informed about the disorder. After three weeks, in the policlinic examination allodynia improved after anti-depressant medication
and supportive psychotherapy. During the polyclinic examinations, interviews were carried out with patient and his family about stress
factors and problems in the family. Amazingly, in two months, the right lower extremity paralysis became significantly less remarkable
and at the end of third month he showed dramatic recovery. The medication treatment and interviews were continued for 8 months. In
this process, medical treatment and psychiatric interviews were concluded because the conversion symptoms did not recur.Hysterical
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allodynia and paralysis are uncommon manifestations in conversion disorder. The most important aim of the treatment is to understand
the need for conversion symptoms. In the psychiatric interviews conducted with patient and his family, interpersonal problems in the
family were identified and these issues were discussed in interviews in examinations. Eventually the patient returned to high school, he
had no problem with his social life. He did not have any active psychiatric complaints again.
Keywords: allodynia, conversion disorder, paralysis
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[Abstract:0714] Anxiety, stress and adjustment disorders
Repetitive transcranial magnetic stimulation in the treatment of depression with a comorbid
diagnosis of auditory hallucinations
Ozer Ozmut, Hakan Balibey, Eda Avcioglu, Recep Tutuncu, Mehmet Alpay Ates, Servet Ebrinc, Ayhan Algul, Mesut Cetin, Cengiz Basoglu
Department of Psychiatry, GATA Haydarpasa Training Hospital, Istanbul-Turkey
e-mail address: [email protected]
Depression patients suffering about sadness, hopelessness, guilt, moodiness, angry outbursts, loss of any interest and their thoughts are
changed it could be trouble of concentrating, trouble making decisions, it’s hard to remember something and hallucinations can also
occur in cases of severe depression. In depression some patients has hallucinations. Hallucination is a perception of objects or experience
of sensations with no real external cause can be auditory, visual. Auditory; is also known as paracusia are the perception of sound without
outside stimulus. We can see it in two conditions, one is elementary and complex. In our case, we report a 31-year-old male patient with
diagnosis of depression with a comorbid diagnosis of auditory hallucinations. He has been a depression’s patient for 9 years who has been
followed up diagnosis of major depressive disorder and has used high dose venlafaxine in depression. The patient was firstly diagnosed
major depressive disorder using the DSM-5 criteria. Transcranial magnetic stimulation was planned for depression of this patient (100%
of motor threshold; 1000 stimuli/day for 20 days).
For one-year-follow-up, significant decreases are observed in scores of Beck (scores 60 to ) and Tinnitus Severity Index (scores 48 to
12). Repetitive transcranial magnetic stimulation treatment may be alternative treatment for depression with a comorbid diagnosis of
auditory hallucinations.
Keywords: repetitive transcranial magnetic stimulation, auditory hallucinations, depression
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[Abstract:0755] Anxiety, stress and adjustment disorders
Ecchymosis related with sertraline
Atakan Yucel1, Mehmet Fatih Ustundag1, Halil Ozcan1, Nermin Yucel2
Department of Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
1
Department of Child and Adolescent Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
2
e-mail address: [email protected]
Sertraline, a selective serotonin reuptake inhibitor, is cornerstone treatment for depression, anxiety, and various other neuropsychiatric
disorders. A bleeding tendency, a serious and rare adverse effect of the serotonin reuptake inhibitor antidepressant, has been observed.
Here we present a cases of sertraline associated with ecchymosis.
A 22 year-old single female, who is a university student, was diagnosed with the first episode of MDD. There were no remarkable results
from the physical and laboratory examinations. The sertraline 25 mg/day was initiated, and the dose was titrated up to 50 mg/day
during the following week. On the 11th day of treatment, the bruising arouse her knees and elbows. The platelet count was observed as
47×109/L. The patient was admitted to internal medicine clinic. There were no noteworthy autoimmune diseases, infections, medication,
food, supplements, and medical history related with bruising without the sertraline. The sertraline was then stopped. After the cessation
of the sertraline, her thrombocytopenia was completely resolved within 17 days. Her platelet count increased to 253×109/L. The
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reboxetine was initiated and titrated up to 8 mg/day from 4 mg/day. It took a total of eight months follow up. At the end of the follow up,
there were no depressive symptoms or thrombocytopenia.
The side effects on the hematological system of the serotonin reuptake inhibitor antidepressants are generally related with aggregation
and a function of the platelets. It is rarely associated with a count of platelets. Furthermore, the cause of the sertraline-induced bleeding
might be sourced by an increased prothrombin time, a prolonged bleeding time, and a partial thromboplastin time. The other mechanism
is the depletion of the serotonin stores by preventing the reuptake of serotonin into the thrombocytes. In our cases, we could not detect
any cause of the thrombocytopenia without the drug-induced thrombocytopenia. Considering these hypotheses, reboxetine, which is
a pure noradrenaline reuptake inhibitor, will have no effect on these mechanisms. Additionally, there have been no reports that relate
reboxetine with the thrombocyte functional disorders and thrombocytopenia. However, it should be supported with further studies.
In conclusion, clinicians should take into account serotonergic drugs related with thrombocytopenia in the subjects treated with these
medications. Reboxetine may be a good, efficient, and safe alternative for the patients with thrombocytopenia and/or with functional
thrombocyte disorders in the treatment of MDD. However, more research is required in order to reach more exact conclusions.
Keywords: ecchymosis, sertraline, thrombocytopenia
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S49-S50
[Abstract:0765] Anxiety, stress and adjustment disorders
Escitalopram aggravates Wolf-Parkinson-White syndrome
Atakan Yucel1, Nermin Yucel2, Oktay Gulcu3, Elif Oral2
Department of Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
1
Department of Child and Adolescent Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
2
Department of Cardiology, Ataturk University, Faculty of Medicine, Erzurum-Turkey
3
e-mail address: [email protected]
Escitalopram is a selective serotonin reuptake inhibitor, which is a safe and effective treatment alternative for depression, anxiety and
obsessive compulsive disorders. The dry mouth, headache, diarrhea, vomiting, sweating, nausea, insomnia, diarrhea, somnolence and
dizziness were frequently observed as an adverse effect. Wolf–Parkinson–White (WPW) syndrome is described as the existence of an
accessory pathway that electrically contact the ventricle to the atrium. The most common symptoms of WPW syndrome are arrhythmia,
dizziness, dyspnea, chest pain and rarely sudden death. In this case, we present escitalopram induced symptoms of WPW case.
A 25 year-old male patient admitted to outpatient clinic with complaints including anxiety, anhedonia, unwillingness, fatigue, and
insomnia. In his psychiatric examination, he was conscious, oriented. His speech was understandable and fluent. Memory and attention
were observed to be normal. Intelligence level was measured within normal limits according to clinical observation. Affect and mood
were anxious. There were no hallucinations or delusions. There were no remarkable results from the physical and laboratory examinations
also medical history. The diagnosis was compatible with major depressive disorder according to the DSM-V. Escitalopram, 5 mg/day, was
initiated and the dose was titrated up to 10 mg/day over four days. On the 21th day of treatment, palpitations, dizziness, tachycardia
and chest pain occurred. The patient was consulted to cardiology department. The diagnosis was compatible with WPW syndrome.
Escitalopram was stopped. After two days, the cardiac symptoms were resolved. Electrophysiology study was applied and the accessory
pathway was ablated. Sertraline, 25 mg/day, was initiated and the dose was titrated up to 50 mg/day over 7 days. The medication had been
tolerated well. At the end of the 9 months, no cardiac symptoms were observed. The depressive symptoms were completely decreased
and sertraline treatment was terminated. The reduction of conduction velocity in atrium to ventricle tends to activate alternative and
accessory pathways in the heart. Escitalopram may cause to increase the QT interval and decrease to conduction velocity in atrium to
ventricle. In case of accessory pathway in heart, these adverse effects of escitalopram may lead to activation of this accessory pathway. In
our case, we emphasize escitalopram exacerbated WPW pathway via repressing the main pathway atrium to ventricle. We therefore urge
the physicians to keep escitalopram as a possible precipitating factor for evaluation of WPW.
Keywords: aggravation, escitalopram, wolf–parkinson–white
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[Abstract:0767] Anxiety, stress and adjustment disorders
Sertraline induced dose dependent euprolactinemic galactorrhea
Atakan Yucel1, Nermin Yucel2, Elif Oral1
Department of Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
1
Department of Child and Adolescent Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
2
e-mail address: [email protected]
Sertraline, a selective serotonin reuptake inhibitor (SSRI), is extensively used for treatment of anxiety disorders and depression. The dry
mouth, diarrhea, vomiting, nausea, insomnia, diarrhea, headache, somnolence, sweating and dizziness may be observed as an adverse
effect. Galactorrhea is a rarely reported adverse effect of the SSRIs. In here, we present a case of sertraline induced galactorrhea.
A 33 year-old woman was admitted to our outpatient clinic complaints with spending excessive time for washing her hands, cleaning
the clothes various time, a fear of contaminations for 3 years. In her psychiatric examination, she was conscious, oriented. Her speech was
understandable and fluent. Memory and attention were observed to be normal. Intelligence level was measured within normal limits
according to clinical observation. Affect and mood were anxious. Obsessions of contamination, compulsions of cleaning and washing
were stated. There were no hallucinations or delusions. There were no remarkable results from the physical and laboratory examinations
also medical history. The diagnosis was compatible with obsessive compulsive disorder (OCD) according to DSM-5. Sertraline, 25 mg/day,
was initiated and the dose was titrated up to 150 mg/day over 1 month. On the 2nd day of sertraline 150 mg/day of treatment, galactorrhea
occurred in both of nipple. There was no any endocrine (especially prolactin levels) and gynecological dysfunction, amenorrhea, nipple
infection or disease and medication without sertraline. Also she had no any pregnancy for the last 6 years. Sertraline 150 mg/day dose was
decreased to 100 mg/day and galactorrhea ceased in a 2 weeks and OCD symptoms were significantly decreased in terms of Yale-Brown
Obsessive Compulsive Scale and clinical observation at the end of the 7th month.
The elevated prolactin levels cause galactorrhea. Serotonin may directly increase the prolactin levels or indirectly via repressing the
inhibitors of prolactin. As our case, the galactorrhea may be observed with euprolactinemic condition. In previous studies, it was stated
that euprolactinemic galactorrhea related with antidepressants. Additionally, in our case, galactorrhea seems to be dose dependent. We
emphasize that physicians need to be aware of sertraline and other antidepressants this side effect during the investigation of galactorrhea
etiology. Further studies is required for explore the exact mechanism of antidepressant-induced euprolactinemic galactorrhea.
Keywords: euprolactinemia, galactorrhea, sertraline
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[Abstract:0769] Anxiety, stress and adjustment disorders
Treatment of chronic urticaria with the agomelatine augmentation
Atakan Yucel1, Nermin Yucel2, Elif Oral1, Zeynep Utlu3
Department of Psychiatry, Ataturk University, Erzurum-Turkey
1
Department of Child and Adolescent Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
2
Department of Dermatology, Ataturk University, Faculty of Medicine, Erzurum-Turkey
3
e-mail address: [email protected]
Chronic urticaria (CU) is a serious common skin diseases which has a profound impact on the quality of life that school and work life, daily
activities, sleep, sexuality and hobbies via demonstrate with a typical, severe itching rash, pruritus and recurrent skin lesions lasting for
more than six weeks. It may persist for years. There are various etiological hypothesis related with CU, one of them is psychological factors
especially emotional distress, severe depression and anxiety. Agomelatine (AG), an antidepressant drug with melatonergic (MT1/MT2)
agonist and 5-HT2C-receptor antagonist features, is approved for depression. In our case, we present a patient with treatment resistantCU, depressive and anxiety symptoms treat with AG.
A 28 year-old, married female was admitted to our outpatient clinic with complaints including anxiety, anhedonia, severe itching rash,
insomnia and 2 years history of CU. In her psychiatric examination, she was conscious, oriented. Her speech was understandable and
fluent. Memory and attention were observed to be normal. Intelligence level was measured within normal limits according to clinical
observation. Affect and mood were anxious. There were no hallucinations or delusions. There were no remarkable results from the
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laboratory examinations also medical history without diagnosis of CU. She declared that the main reason of admission to psychiatry
was complaints of CU because of resistance to dermatological treatment such as ketotifen 2 mg/day, also various antihistamines and
high-dose prednisolone during urticaria attacks. AG 25 mg/day was added to cetirizine 20 mg/day and ketotifen 2 mg/day. The anxiety,
depressive symptoms and itching was decreased within 10 days. The patient has been followed up for 6 months without any CU attacks
and itching. Her social interactions, quality of life, sleep disturbance was improved with this combination of treatment.
In the previous studies, stress, anxiety and depression comorbidity and relationship was reported in dermatological disease as urticaria.
The routine treatment of CU includes the various antihistamines and prednisolone during the severe attacks of CU. In this view, the
physicians should take into account of psychological condition of patient as a predictor of dermatological pathology or comorbid
situations. In our case, we suggested AG to treat the depressive and anxiety symptoms also indirectly CU. The other mechanism of
treatment of CU may be related with improvement effect of AG on the immune mechanism. Furthermore this observation needs to be
supported with further studies whereby the mechanism of this association could be explained.
Keywords: agomelatine, urticaria, resistance
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[Abstract:0833] Anxiety, stress and adjustment disorders
Psychotherapy or medication treatment in anxiety disorder
Medine Yazici Gulec
Erenkoy Research and Training Hospital, Istanbul-Turkey
e-mail address: [email protected]
Anxiety disorders are the most common psychiatric disorders and can lead to a significant disability. Treatment options for anxiety
disorders include psychotherapy and pharmacological treatments. The choice of treatment is affected by many factors such as the
presence of physical illness or psychiatric comorbidity, patient’s preference, motivation, response to previous treatment. There have
been a number of clinical trials and meta-analyses to investigate the efficacy of drugs and psychotherapy in anxiety disorders. Cognitive
behavioral therapy (CBT) was regarded as the psychological treatment with the highest level of evidence. Clinical studies, which compared
the pre and post treatment showed that pharmacological treatments, CBT and CBT-drug combination showed a significant improvement.
However, combination therapy was more effective than pharmacological treatments and psychotherapy alone. German guideline for
anxiety disorders suggests psychotherapy, psychopharmacology and combination of both. CBT is recommended the first step therapy.
Psychodynamic therapy (PDT) is recommended for cases in which CBT is not effective or not available. SSRI and SNRI are recommended
as first choice pharmacological therapy. There are studies showed that the CBT has more advantage about cost-effectiveness in long-term
period. The 24 monthlongitudinal study in panic disorder showed that the mean total societal costs were lower for CBT as compared
to SSRI and CBT+SSRI. When examining the balance between costs and health outcomes, both CBT and CBT+SSRI led to more positive
outcomes than SSRI. The therapeutic relationship which is the one of the predictor of treatment outcome in anxiety disorders is stronger
with the CBT than drug or drug-CBT combination for youth. Non-remission rates to pharmacotherapy for anxiety disorders are related
to higher relapse rates, decreased quality of life and greater functional impairment. A recent studies state that anxiety disorders patients
who didn’t respond to pharmacological treatment had benefit next step CBT. The reducing heart rate and physiological reactivity in
anxiety disorder patients with CBT is showed by the meta-analysis study. While antidepressant drugs reduce anxiety level, psychotherapy
effect on conditioning, avoidance behavior and negative attribution about disease and own personality and improve their coping skills.
Theoretically, antidepressant medication and CBT involve different mechanisms and may be able to treat different components o the
illness.
Keywords: anxiety disorders, psychotherapy, pharmacotherapy
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[Abstract:0854] Anxiety, stress and adjustment disorders
Opioidergic mechanism in alcoholism: Translational studies in rodents and humans
Anita C. Hansson
Heidelberg University, Institute of Psychopharmacology, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim, Heidelberg-Germany
e-mail address: [email protected]
The mu-opioid receptor (OPRM1) is important for alcohol reinforcement and maintenance of alcohol consumption. The OPRM1 antagonist
naltrexone reduces alcohol intake and attenuates alcohol seeking in animal models of relapse and is therefore used as an anti-relapse
therapeutic. However, the treatment seems only effective in a minority of patients. For improving treatment efficacy it is important to
reveal the mechanisms underlying the actions of OPRM1 antagonism in alcohol dependence.
Our data demonstrate a pronounced reduction of OPRM1 expression at both transcriptional and protein level in human postmortem
striatal brain tissue from deceased alcoholics. We further analyzed OPRM1 expression in an animal model, where alcohol dependence
was induced by intermittent alcohol vapor exposure. OPRM1 and opioid peptide expression were analyzed in different rewardrelated brain regions at various time points of abstinence. Three weeks of abstinence resulted in a significant increase of the
preproenkephalin precursor transcript and a simultaneous decrease of OPRM1 binding sites in the nucleus accumbens. Thus, the
profound reduction of striatal OPRM1 receptor availability indicate a dysfunction of the reward system at least in a subpopulation
of alcoholic patients, which may not be amendable to further suppression of OPRM1 function by naltrexone. However, our data
contradict several human positron emission tomography studies using the radioligand carfentanil, showing increased OPRM1
binding potential in alcoholics. Thus, further studies are needed to resolve these discrepancies and to increase our knowledge about
OPRM1 antagonism in alcohol addiction.
Keywords: alcohol use disorder, opioidergic mechanism, mu-opioid receptor
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S253
[Abstract:0884] Anxiety, stress and adjustment disorders
Social anxiety disorder in disfiguring medical conditions: a critical comment on DSM criteria
Yasin Bez
Department of Psychiatry, Marmara University, Faculty of Medicine, Istanbul-Turkey
e-mail address: [email protected]
Social anxiety disorder (SAD) is among the most prevalent psychiatric conditions where treatment seeking of the affected patients
may be delayed usually due to the nature of the disorder itself. Depressive disorder and number of feared social situation are the
most common predictors of treatment seeking in this group of patients (1). Defined criteria for SAD diagnosis in DSM-IV prohibits
the diagnosis if the fear experienced in social settings is related with a general medical condition or another mental disorder. Some
authors argued against the restricting criteria (H criterion) and suggested that applying this criterion strictly for some disfiguring
medical conditions like stuttering, tremor, acne, strabismus, and even obesity would hinder their access to treatment. Oberlander
and colleagues first discussed it in 1994 in their paper and they have shown improvement in social anxiety and avoidance level
of 8 patients after phenelzine treatment (2). Then, in a study conducted with stuttering patients, either suspending H criterion
or using modified DSM criteria that allows the diagnosis if the anxiety level experienced is obviously higher than expected, high
frequencies of SAD have been reported (3). Then, similar results have been shown in the studies that have investigated frequency
of SAD diagnosis or social anxiety level among patients with psoriasis or spasmodic torticollis (4,5). The following studies with
essential tremor patients and also with strabismus patients have shown SAD diagnosis as an independent predictor of disease
related subjective disability (6,7). Moreover, it has been shown to be the only significant predictor of work impairment among
the patients with acne vulgaris (8). In their study, Dalrymple et al. have compared psychosocial characteristics of bariatric surgery
candidates with SAD, modified SAD, and no disorder. They found that both SAD groups have differed from the no disorder group
on social and overall functioning where there were only a few differences between those SAD groups and suggested a change in
the H criterion (9). In line with the suggestions of the above-mentioned literature the restriction posed by H criterion have been
loosened to some extend in DSM-5 and the criterion has been revised to “If another medical condition (e.g., Parkinson’s disease,
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obesity, disfigurement from burns or injury) is present, the fear, anxiety or avoidance is clearly unrelated or is excessive”. However,
it is still unclear whether this revision would be satisfactory and helpful in identifying comorbid SAD in some medical disfiguring
conditions and in increasing their access to treatment or not. Carefully designed future studies are needed to test usefulness of
the revised criteria for SAD diagnosis in DSM-5.
Keywords: social anxiety disorder, SAD, DSM
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AUTISM SPECTRUM DISORDERS
[Abstract:0243] Autism spectrum disorders
Long-acting risperidone treatment for child with autism: a case report
Salih Gencoglan1, Mustafa Erkan2, Leyla Akguc3
Department of Child and Adolescent Psychiatry, Yuzuncu Yil University, Faculty of Medicine, Van-Turkey
1
Department of Child and Adolescent Psychiatry, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul-Turkey
2
Department of Psychiatry, Mardin State Hospital, Mardin-Turkey
3
e-mail address: [email protected]
Autism is a common childhood neurodevelopmental disorder, affecting approximately 1.1 % of children. Autism is defined by severe
impairments in social interaction, communication and behavioral patterns that are restrictive and stereotypical. Here we report a child
patient with autism, who had significant improvement in aggressive behaviors with long-acting risperidone treatment.
The case is a 12 year-old boy, followed in our clinic with autism. His language was delayed, he could set up a simple two-word phrases
and his speech was echolalic. He started using single words at the age of 5 years. He had limited non-verbal communication with poor
eye contact and his response to instructions was inconsistent. He was not able to join his peers or interact with them. He had sexual and
self-mutilative behaviors including masturbation, head banging and finger-biting and aggressive behaviors to his family and teachers.
A routine electroencephalogram revealed no abnormalities and indicated the absence of epileptiform activities. We started 1 mg/day
risperidone solution because of parents reported that he could not use tablets drugs. But he could not use risperidone due to taste of the
solution. We initiated 25 mg of risperidone long-acting injection and continued treatment for 6 consecutive months. Six weeks after the
initiation of treatment, improvement in both sexual and self-mutilative behaviors was noticed. The parents stated that he experienced a
significant improvement of the aggressive behaviors.
Aggressive behaviors in children with autism are the primary cause of residential placement and are associated with greater functional
impairment and more intensive medical interventions. Additionally, aggressive behaviors in children with autism are a frequent source
of parental concern and are known to increase family stress, financial strain, and demands on caregivers. While aggressive behavior in
autism is important due to the detrimental effects on caregiving, it may also be a risk factor for later poor outcomes. For instance, in the
general population, aggressive behavior in childhood is linked to other maladaptive behaviors including conduct problems, emotional
dysregulation, low peer acceptance, and peer rejection. Long-acting risperidone appears relatively safe for use in adolescent autism. This
finding will help guide medication selection in child patients with specific medical vulnerabilities.
Keywords: aggressive behaviors, autism, long-acting risperidone
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S255
[Abstract:0244] Autism spectrum disorders
Atomoxetine treatment for symptoms of ADHD in children with Autism: a case report
Salih Gencoglan1, Mustafa Erkan2, Leyla Akguc3
Department of Child and Adolescent Psychiatry, Yuzuncu Yil University, Faculty of Medicine, Van-Turkey
1
Department of Child and Adolescent Psychiatry, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul-Turkey
2
Department of Psychiatry, Mardin State Hospital, Mardin-Turkey
3
e-mail address: [email protected]
Autistic disorder was described by its three main characteristics, impairment of social interactions, lack of communications, and restricted
and stereotyped pattern of behaviors or interests. Here we report a child patient with autism, who had significant improvement in ADHD
symptoms with atomoxetine treatment.
A 10 year-old boy was referred to our clinic with complaints of impairment in language development, social emotional reciprocity, and
repetitive and sexual behaviors. The patient had also experienced over activity, behavior, and concentration problems since he was
three year-old. A routine electroencephalogram revealed no abnormalities and indicated the absence of epileptiform activities. After
the reevaluation of the history and physical examination, the patient was diagnosed as autism and ADHD using the DSM-IV-TR criteria.
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Methylphenidate 10 mg/day treatment was started and the dose was decreased due to abdominal pain and nervousness. We initiated 40
mg of atomoxetine and continued treatment for 6 consecutive months. Six weeks after the initiation of treatment, improvement in both
sexual behaviors and ADHD symptoms was noticed. The parents stated that he experienced a significant improvement of the oppositional
behaviors.
Atomoxetine appeared to be effective in reducing attention deficit and hyperactive symptoms with high tolerability rates in children with
pervasive developmental disorders. Arnold et al. (2006) Tested the efficacy and safety of atomoxetine in reducing attention deficit and
hyperactive symptoms in children with autistic disorder. Atomoxetine was found to reduce the symptoms of hyperactivity and impulsivity
among the participants. Posey et al. (2006) found that only 13% of the participants withdrew from their study of atomoxetine’s efficacy
due to adverse effects. Atomoxetine is a nonstimulant medication that could be a potential alternative treatment for attention deficit and
hyperactive symptoms with tolerable adverse effects.
Keywords: autism, ADHD, atomoxetine
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[Abstract:0319] Autism spectrum disorders
Aripiprazole use in autistic child with Sturge Weber syndrome
Elif Akin1, Canan Yusufoglu1, Sebla Gokce1, Yasemin Yulaf2
Department of Psychiatry, Erenkoy Training and Research Hospital, Istanbul-Turkey
1
Department of Child and Adolescence Psychiatry, Tekirdag State Hospital, Tekirdag-Turkey
2
e-mail address: [email protected]
Sturge-Weber Syndrome (SWS) is a rare sporadic neurocutaneous syndrome defined by the association of a facial capillary malformation
in the ophthalmic distribution of the trigeminal nerve, with ipsilateral vascular glaucoma and vascular malformation of the eye and a
leptomeningeal angioma. SWS is characterized by a number of significant neurodevelopmental anomalies, including seizure disorders,
cognitive retardation, behavioural difficulties. Autistic Spectrum Disorder is not commonly seen comorbidity in SWS. We reported here a
case of improved behavioral symptoms after the use of aripiprazole in SWS-autism patient.
A 6-year-old boy diagnosed as Sturge Weber Syndrome by child neurologist presented to clinic with behavioural complaints of insisting
and overoccupying with some materials and sometimes just repetitively imparing both child and family‘s daily function. He had echolalia,
limited eye contact and difficulty in joining reciprocal speech. His developmental level was at about 44 months in general, 48 months
in personal-social area, 60 months in fine motor area, 18 months in language area, 48 months in gross motor developmental area. He
had been on special education programme for three years. He was diagnosed as autistic spectrum disorder and risperidone of 0.25 mg
per day was started for behavioural symptoms. But the child‘s symptoms got worse in a few days and risperidone was discontinued and
aripiprazole of 2 ml was given and the child‘s tantrums and repeated behavioral symptoms diminished.
In this case we report a rare condition of comorbidity of Sturge Weber syndrome and autism spectrum disorder and improvement of
behavioural symptoms with aripiprazole use.
Keywords: aripiprazole, autism, sturge weber syndrome
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[Abstract:0330] Autism spectrum disorders
Simultaneous three syndrome in a case
Aslihan Hafo Kiraz1, Veli Yildirim2, Yunus Killi2, Fevziye Toros2
Departmant of Medical Genetics, Kayseri Education and Research Hospital, Kayseri-Turkey
1
Department of Child and Adolescent Psychiatry, Mersin University, Faculty of Medicine, Mersin-Turkey
2
e-mail address: [email protected]
Our purpose in presenting this case is attracting attention to moderate and severe mental retardation which syndromes may be
accompanied. A 6-year-old boy referred to our clinic with atypical dysmorphic face, speech impairment, mental retardation and cardiac
pathology. He was examined in medical genetic department, ophtalmology clinic, pediatric cardiology, pediatric neurology and child
psychiatry clinic. In his background he was born with c/s term delivery, birth weight was 2700 g. Since meconium aspiration he was
stayed in incubator for 2 days. Because of difficulty in swallowing he was fed with bottle for 6 months. He started walking after 4 years
physical therapy support. He started speaking at the age 4.5 and he completed the toilet training at the age of 4. He could not sound ‘r,
l, s, k’ characters for this reason the full speech was scarcely understood. He had bifid uvula, swallowing difficulty and feeding problems.
He does not play with peers, he had limited interests such as knowing the same color, same model cars. The mental level and the
abilities on counting, distinguishing colors was found to be back from his peers. Cocktail party personality characteristics was observed
during the interview. In addition, case was very active and had aggressive behavior. Eye contact was limited and there was difficulty on
communicating the case. On physical examination elfin face, bilateral hypermetropy, strabismus, prominent ears, micrognathia, bifid
uvula, limb anomaly and cryptorchidism was present. Cardiac evaluation of the case consist of focal septal hypertrophy, supravalvular
aort stenosis. Cranial magnetic resonance image was normal. Laboratory testings including CBC, tandem-mass and TORCH-S serology was
normal. The karyotype analyse was 46, XY. On molecular fish analysis with vysis williams region probe - lsi eln spectrumorange/lsi d7s486,
d7s522 spectrumgreen probe, the elastin gene deletion was detected. According to the deletion region the diagnosis was compatible
with the Williams–Beuren Syndrome (WBS).
As a result of his clinical and laboratory researches he was diagnosed with both WBS and Mobius syndrome (MS). Denver test result was
found to be behind their peers in all areas. According to psychiatric results Autism Spectrum Disorder (ASD) and mild mental retardation
was thought to be consistent with the diagnosis.
In literature Bandim et al. (2003) performed the psychiatric examination in 23 children with mobius sequence. And, five (26.1%) met the
diagnostic criteria for infantile autism according DSM-IV such as our patient and two showed autistic-like behavior. Autism is social deficit
and especially characterized symptom limited eye contact. In other hand WBS is hypersocial person. Therefore the conflict may have been
skipped autism diagnosis for WBS patients. Autism displayed less risk awareness and had less social protection; those with WBS were rated
higher on risk factors related to perceived vulnerability and parental independence. Our case has simultaneously three syndrome as ASD,
MS and MS. As a result, ASD and mental retardation cases should be evaluated carefully in terms of the specific syndromes.
Keywords: autism, Mobius syndrome, Williams–Beuren syndrome
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S257
[Abstract:0450] Autism spectrum disorders
Comorbidity of williams-beuren syndrome and a utism spectrum disorder: two case reports with a
review of literature
Evrim Aktepe1, Emel Ozen1, Cafer Cagri Korucu2, Adem Isik1
Suleyman Demirel University Faculty of Medicine Department of Child and Adolescent Psychiatry, Isparta-Turkey
1
Department of Psychiatry,Suleyman Demirel University, Faculty of Medicine, Isparta-Turkey
2
e-mail address: [email protected]
Williams-Beuren syndrome (WBS), a developmental disorder caused by deletion of contiguous genes at 7q11.23, has been characterized
by strengths in socialization and communication. Autism spectrum disorders (ASDs) are a group of neurodevelopmental disorders
characterized by social and communication impairments, repetitive behaviors, and sensory reactivity issues. Given the prevalence of
WBS (1 in 7,500 and 1/25,000 live births) and the recently reported prevalence of ASD placed at 1 in 150. There have been a few reports
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of children diagnosed with both WBS and ASD. In other respects, the two disorders seem to be completely the opposite of each other:
children with Williams-Beuren syndrome are abnormally sociable while children on the autism spectrum disorder are known to have
difficulties in most basic social skills. While some authors describe WBS as the opposite phenotype of ASD, some studies indicate that
both share many common characteristics. In this case report, WBS diagnosed two cases applied to medical board for special education
report. The first case was a 5 year 4 month old boy presented to the department of child and adolescent psychiatry due to intellectual
disability, limited communication, decreased eye contact and stereotyped behaviors. The second case was a 6 year 2 month old girl who
had intellectual disability, decreased eye contact, echolalia, stereotyped behaviors, deficits of social communication and hyperactivity.
These two cases will be discussed in the light of literature.
Keywords: autism spectrum disorder, developmental disability, williams-beuren syndrome
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S257-S8
[Abstract:0491] Autism spectrum disorders
Aripiprazole in children with autistic spectrum disorders: treatment and 16-week follow-up period
of a 23 month-old boy patient
Ipek Percinel1, Kemal Utku Yazici2
Department of Child and Adolescent Psychiatry, Osmaniye State Hospital, Osmaniye-Turkey
1
Department of Child and Adolescent Psychiatry, Firat University, Faculty of Medicine, Elazig-Turkey
2
e-mail address: [email protected]
This report discusses the aripiprazole treatment and follow-up period of a 23 month-old boy patient with autism spectrum disorder (ASD)
presented with severe irritability and hyperactivity.
The patient, who was diagnosed with ASD at an external center and included in special education and rehabilitation program when he
was 20 months old, was admitted to our clinic with irritability and hyperactivity, which were also notable before. He was 23 months old,
when he was admitted to our clinic. Pharmacological treatment was suggested based on risk-benefit assessment. The patient with a body
weight of 13.2 kg was started on risperidone 0.25 mg/day (0.019 mg/kg), and a controlled dose increase was planned. The patient had
contractions in the chin, neck and the back on the third day of treatment, and was examined in cooperation with pediatric neurology
department. Findings were read as an extrapyramidal side effect, which was considered to be associated with risperidone, and treatment
was ceased. The patient was then started on aripiprazole 1 mg/day (0.08 mg/kg). The dose was gradually increased every two weeks up
to 3 mg/day (0.22 mg/kg). The patient was evaluated every two weeks during the follow-up. The patient’s clinical assessment was made
using Childhood Autism Rating Scale (CARS), Aberrant Behavior Checklist (ABC) - Irritability and Hyperactivity subscales, Clinical Global
Impression-Severity Scale (CGI-S), Clinical Global Impression-Improvement Scale (CGI-I), and Clinical Global Impression-Side Effects Scale
(CGI-SE). The CGI assessment was based on behavioral symptoms such as irritability and hyperactivity.
The patient’s CARS score was 39; ABC-Irritability score was 30; ABC-Hyperactivity score was 39; and CGI-S score was 5 (markedly ill) at
admission. After 16 weeks of treatment, a notable improvement was observed in his irritability and hyperactivity symptoms. In addition,
a decrease was observed in his CARS score. The patient well tolerated aripiprazole 3 mg/day. No side effect was observed except for mild
sedation. At the end of 16 weeks, the patient’s CARS score was 31; ABC İrritability score was 9; ABS Hyperactivity score was 17; CGI-S score
was 3 (mildly ill); CGI-I score was 2 (much improved); and CGI-SE score was 2 (do not significantly interfere with patient’s functioning).
This report aimed to discuss 16-week clinical follow-up of a 23 month-old boy with ASD, whose irritability and hyperactivity symptoms
were treated with aripiprazole. Aripiprazole is one of the two drugs approved by FDA for the treatment of irritability in children and
adolescents with autistic disorder aged 6–17 years. There are studies and case reports in literature on the use of aripiprazole in children
with ASD. Results of these studies generally report that aripiprazole is effective on irritability and hyperactivity symptoms and well
tolerated by the patients. Similar to these studies, we have observed a notable improvement in irritability and hyperactivity symptoms in
our case, as well. As far as we are aware, our case report presents the youngest patient with ASD in literature, who showed improvement
with aripiprazole treatment. Our report is considered to be of importance in this regard.
Keywords: aripiprazole, autism spectrum disorders, irritability
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[Abstract:0521] Autism spectrum disorders
Moebius syndrome associated with autism spectrum disorder: a case report
Mahmoud AlmBAIdheen, Koray Kara
Department of Child and Adolescent Psychiatry, Gulhane Military Medical Academy, Facultyof Medicine, Ankara-Turkey
e-mail address: [email protected]
Moebius syndrome, a rare congenital disorder of varying severity, has an incidence of 0.0002-0.002, equal in both genders, involves
multiple cranial nerves and is characterized predominantly with bilateral or unilateral paralysis of the facial (VII) and abducens (V) nerves.
Clinical signs and symptoms of the syndrome usually appear during the neonatal period. Moebius syndrome is frequently associated with
abnormalities of other systems. Of these, abnormalities of the musculoskeletal system (unilateral agenesis or hypoplasia of the pectoral
muscles, pes equinovarus and pectus excavatum), oculomotor system abnormalities (strabismus), swallowing difficulties, and orofacial or
craniofacial anomalies. Mental retardation seen in about 10-15% in patients with moebius syndrome.
In the studies the incidence of OSB associated with Moebius syndrome is controversial. The awareness of this comorbidity has been
reported to be important for the diagnosis and treatment of patients with Moebius syndrome. This report presents a male patient with
Moebius syndrome, which was associated with Autism Spectrum disorder.
Case: A 26-month-old boy known case of Moebius syndrome, brought by his family to our outpatient clinic due to difficulties in speech
and low eye to eye contact. According to information received from the family, patient was born at term to a G2P1 mother via C/S delivery.
The patient weighed 4.41 kg at birth and was 51 cm long. No history of drug usage or infection during the pregnancy. No family history of
medical or psychiatric illness.Physical examination revealed bilateral epicantus, anteverted nares, hypertrichosis in both ears and simian
crease in left hand. The left eye does not close and the corner of the mouth lifts involuntarily to the right. During psychiatric evaluation
the patient had low level of joint attention and eye-eye contact, no speech, extremely insensitive to voice stimuli, had no imitation skills,
stereotyped movements (hand flapping), and low levels of participation in the peer games.
Ankara Developmental Screening Inventory (ADSI) was performed; retardation has been shown in all areas of development. Childhood
autism rating scale (CARS) was 42. According to the DSM V criteria our patient was evaluated as a case of autism spectrum disorder. Our
patient started to get clinical follow-ups and intensive applied behavior analysis.There are some research findings suggesting higher
prevalence of autism among patients with Moebius syndrome. Typical facial expressions (mask like face) due to facial palsy, speech delay,
possible mental retardation and other clinical features of Moebius syndrome comprise difficulties in making diagnosis of autism. Long
term follow-up of larger number of cases are necessary to understand whether the presence of both autism and Moebius syndrome in a
patient represents comorbidity or only a coincidental condition.
Keywords: autism, comorbidity, Moebius syndrome
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S259
[Abstract:0529] Autism spectrum disorders
A mucopolysaccharidosis type 3b case having hypoactivity and autism-like characteristics
Hilal Aydemir1, Cagatay Ugur2, Ozden Sukran Uneri3
Department of Child Psychiatry, Ankara Pediatric Hematology Oncology Training and Research Hospital, Ankara-Turkey .
1
Department of Child Psychiatry, Ankara Pediatric Hematology Oncology Training and Research Hospital, Ankara-Turkey
2
Department of Child Psychiatry, Ankara Pediatric Hematology Oncology Training and Research Hospital, Ankara-Turkey
3
e-mail address: [email protected]
Autism is a developmental disorder characterized with qualitative impairment in social interaction and communication, and stereotypical,
repetitive, and restrictive interest and activity patterns. There is no detectable etiological reason in 10-25% of ASD cases. Majority of
these are composed of chromosome abnormalities and other genetic syndromes. Mucopolysaccharidosis type III (MPS Type 3, Sanfilippo
syndrome) is a metabolic, autosomal recessive disorder characterized with deficiency of lysosomal enzyme playing a role in breakdown
of heparan sulphate. Its incidence is 1 in 100.000 births. It may be accompanied with coarse face, mental retardation, and growth
and developmental delays. Cases having MPS Type 3 may present to the clinic with progressive mental breakdown, speech delay and
some behavioral problems, and may sometimes diagnosed with attention deficit, hyperactivity disorder, autism, idiopathic speech/
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developmental delay. Here, we present a case having both autism and mucopolysaccharidosis, which is a rarely reported condition in the
literature.
A 3-year and 2-month-old boy patient was first brought to our polyclinic with complaints of having no speech, being in his own world
and having no contact with his peers. The patient looking younger than his age had dysmorphic findings. His motor development was
considerably delayed and he was not able to walk. He had no meaningful words. His eye contact was limited, was not responding when
his name was called, and he showed no joint attention. He had hand flapping stereotypes and was interested in ice-cream boxes. He was
diagnosed with “mucopolysaccharidosis type 3B” as a result of the clinical and genetic evaluations performed when he applied to the
neurology clinic for developmental delay at the age of 2.5.
Mucopolysaccharidos type 3B or Sanfilippo syndrome develop as a result of lysosomal alpha-N-Acetyl-glucosaminidase (NAGLU) enzyme
deficiency and is characterized with degeneration, progressive destruction in the central nerve system, and hyperactive and aggressive
behaviors. Mucopolysaccharidosis type 3 has 4 sub-types as A, B, C and D. Severe behavior problems characterized with hyperactive
behavior are the dominant symptoms observed in most of the patients. Behavioral problems usually start at the age of 3-5. Disturbance
and anxious, destructive, chaotic and sometimes aggressive behaviors can be observed. Severe aggressive behavior is observed especially
in MPS type 3B. Contrary to this, our patient had autism-like behaviors accompanied with hypoactivity without any behavioral problems.
The frequency of autism-like behavior is increased at the ages of 3-4 in children diagnosed with early-onset MPS type 3. As in our patient,
new-onset autistic-like symptoms in Sanfillippo syndrome can be explained with “acquired” autistic behavior model. For example, having
restricted eye contact with non-verbal behaviors, not responding to name, limited area of interest and repetitive behaviors can be
observed. Clinicians should be alert to differential diagnosis including MPS Type 3 in children having autism-like behaviors at the age of
3-4. Indeed, MPS diagnosis can be made between the ages of 2-6 at the earliest. In order to contribute to the literature, we present this
case diagnosed with MPS type 3B and showing autism-like features with prominent hypoactive behavior.
Keywords: MPS IIIB, Sanfilippo, autistic symptom
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[Abstract:0582] Autism spectrum disorders
Atypical autism and early onset schizophrenia; a case report
Nukhet Yigitbasi1, Ebru Kanmaz Findikli1, Hacer Altun2, Selcuk Kardas1
Department of Psychiatry, Sutcu Imam University, Faculty of Medicine, Kahramanmaras-Turkey
1
Department of Child and Adolescent Psychiatry, Sutcu Imam University, Faculty of Medicine, Kahramanmaras-Turkey
2
e-mail address: [email protected]
Atypical autism is the term used when the person’s behavior pattern fits most but not all the criteria for typical Autism. Atypical autism
is likely to become manifest only after 3 years of age and it is a type of autism that may go undiagnosed for years. Children with atypical
autism have a greatly increased risk of schizophrenia.
A 19-year-old female patient. She had long and recurrent introversion periods, enuresis, encopresis and mutism and were regularly
navigating for one or two days in recent year. In this term she had not communication with others. She was looking long time to a single
point, feeling full of fear, shouting as “birds coming” and removing the same sounds. The patient was admitted our clinic because of these
symptoms.
In the story of child development; she had had normal birth story, she had began to walk and talk timely. She had had strange behaviors
since childhood. She had been a cranky, so crying child, and asking for what she want to happen consistently. In primary school she had
been failing to conduct long-term dialogues. Her family had referred her to child psychiatry clinic in 8 year-old because of signs as not
to have eye contact, as spelling same words, clapping her hands and playing with her nose stereotypically, as not to communicate with
her friends and not to have any friends. The patient had been diagnosed as Atypical Autism. She had been treated with risperidone and
fluoxetine for 6-7 years. She had left school at 13 year-old and she had started to school again after one year. She had began to see a
number of animal images and hear voices that giving orders. Thesuspectful thoughts about people that they would hurt herself had been
added as psychotic symptoms. Olanzapine 20 mg/day had been added gradually by 4 years. In the last few months her treatment was as
olanzapine 20 mg/day, 12 mg/day risperidone, 6 mg/day biperiden, 800 mg/day carbamazepine, haloperidol decanoate 50 mg/month.
In our clinic the patient’s laboratory values were as AST 51, ALT 77, GGT: 478. We tapered the drug doses slowly and stopped olanzapine
and carbamazepine. EEG and CT were normal. In the end, her treatment was as risperidone 6 mg/day and lorazepam 4 mg/day, biperiden
6 mg/day. Her liver enzymes became normal levels, hallucinations and abnormalbehaviors stopped.
Today, schizophrenia is beginning before 17-18 years called early onset schizophrenia (EOS). EOS has an insidious onset. Poor school
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performance, social withdrawal, disorganized behavior, reduced personal hygiene are the most common prodromal symptoms. While, the
diagnosis of autism and schizophrenia comorbidity an uncommon occurrence in the literature, children with pervasive developmental
disorders seem to be more risky in this regard. In this respect, we believe that the definition of VEOS-EOS should be kept in mind while
cinical follow-up of children with atypical autism as seen in our patient.
Keywords: atypical autism, early onset schizophrenia, childhood
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S260-S1
[Abstract:0789] Autism spectrum disorders
Case report: aripiprazole induced bullae on the plantar surface of foot in a child with autism and
albinism
Sebla Gokce, Canan Yusufoglu, Elif Akin
Department of Child and Adolescent Psychiatry, Erenkoy Training and Research Hospital, Istanbul-Turkey
e-mail address: [email protected]
Autism spectrum disorders (ASDs) are childhood onset developmental disorders characterized by impairment of social skills and
repetitive behavior, and also for classic autistic disorder, a significant impairment of communication. In addition to these core symptom
domains, persons with ASDs frequently exhibit interfering behavioral symptoms, including irritability marked by aggression, selfinjurious behavior, and severe tantrums. Aripiprazole is an atypical or newer generation antipsychotic with a unique mechanism of
action impacting dopaminergic and serotonergic neurotransmission. This drug is efficacious in children and adolescents with irritability
associated with autistic disorder and was generally safe and well tolerated. And it has FDA permission for autism for a while. Common
adverse events included weight increase, vomiting, nasopharyngitis, increased appetite, pyrexia, upper respiratory tract infection, and
insomnia. Discontinuation of the treatment usually occurs due to weight gain and agression.
Albinism is a rare genetic condition globally characterized by a number of specific deficits in the visual system, resulting in poor vision, in
association with a variable hypopigmentation phenotype. This lack or reduction in pigment might affect the eyes, skin, and hair.
We will discuss a 8 year-old boy, who had the diagnosis of autism spectrum disorder since the age of 3, and known to have oculocutenous
albinism. He was admitted to our clinic because of irritability, severe tantrums, stereotypes, hyperactivity and self-injurious behaviors.
We began with aripiprazole treatment 2,5 mg/day and increased to 5 mg/day at the end of 1 week. After two weeks of treatment the
boy came with bullae on his solE. Family was advised discontinue the drug and after discontinuation of the treatment, the bullae was
disappeared.
Keywords: albinism, autism, aripiprazole
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S261
[Abstract:0795] Autism spectrum disorders
Treatment of self injury behavior due to autism spectrum disorder with methylphenidate: a case
report
Emine Demirbas Cakir1, Halime Harmanci1, Nuran Demir2, Zehra Topal2, Ali Evren Tufan2
Abant Izzet Baysal University, Faculty of Medicine, Training and Research Hospital, Bolu-Turkey
1
Department of Child and Adolescent Mental Health and Diseases, Abant Izzet Baysal University, Faculty of Medicine, Bolu-Turkey
2
e-mail address: [email protected]
Autism spectrum disorder (ASD) begins in early childhood and characterized with deficits in social communication, social interaction and
restricted repetitive behaviors, interests, and activities. Irritability, anger and self-injury behavior are frequently present symptoms among
children with ASD. Although there are many pharmacological agents being tried for treatment of self-injury behavior, only risperidone
and aripiprazole have been approved for treatment of irritability, aggression and self-injury behavior due to ASD. However it is also
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reported that self-injury behavior due to ASD may be resistant to treatment with both risperidone and aripiprazole and in these cases it
may be necessary use of several pharmacological agents combined. In this paper it has been aimed to report a case with ASD with selfinjury behavior treated with methylphenidate.
A second grade and nine year two months old girl presented outpatient clinic with complaints of self-biting, chewing her own tongue,
hitting her head to the floor, tear her hair, jumping off, hyperactivity and reduce in sleep. She has been followed by several clinics with
autism diagnosis since she was 4 year-old. Her symptoms first started when she was 3 year-old as irritability, hitting her head to the
wall and hyperactivity then severity of her symptoms have increased within following years. She has been treated with risperidone,
aripiprazole, haloperidol, chlorpromazine, clozapine, carbamazepine, valproic acid however she didn’t give desirable response to any of
them. When she presented to our clinic she was on chlorpromazine 200 mg/day, risperidone 1 mg/day and aripiprazole 5 mg/day. Physical
examination showed, there were scars on her both upper extremities due to new and old bites and also on her tongue due to chewing,
ecchymotic lesions on her face because of hitting self-harm and jumping off. She has score of 56.5 on childhood autism rating scale.
Her final treatment determined as chlorpromazine 200 mg/day, risperidone 1 mg/day and short acting methylphenidate 20mg/day (in
divided doses). One month after, there was a dramatically decrease in frequency and severity of self-injury behaviors. Ecchymotic lesions
on her face were diminished, and scars on her arms and tongue were about to heal. She had more eye contact and started to smile and
her ability to imitate increased. Autism Rating Scale score was 41.5.
In this paper a case with ASD with severe self-injury behavior resistant to commonly used pharmacological agents, treated with
methylphenidate has been reported. It has been reported clozapine and naltrexone may be considered in treatment of self in treatment
of treatment resistance self-injury behavior. Our experience has showed that methylphenidate also may be an option in treatment of
treatment resistance self-injury behavior.
Keywords: autism, self-injury, methylphenidate
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S261-S2
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BIOLOGICAL PSYCHIATRY AND NEUROSCIENCE
[Abstract:0264] Biological psychiatry and neuroscience
Mortality and morbidity due to neuroleptic malignant syndrome: two case reports
Halil Ibrahim Guzel1, Hasan Mayda2, Erol Baspinar3, Yasemin Gorucu3, Erman Bagcioglu3
Department of Psychiatry, Konya Aksehir State Hospital, Konya-Turkey
1
Department of Psychiatry, Mardin Kiziltepe State Hospital, Mardin-Turkey
2
Department of Psychiatry, Afyon Kocatepe University, Faculty of Medicine, Afyonkarahisar-Turkey
3
e-mail address: [email protected]
Neuroleptic malignant syndrome (NMS) is a serious, rarely encountered, and fatal condition which is observed due to antipsychotics
and drugs affecting dopamine transmission. It is presented with high fever, muscle rigidity, autonomic function disorders, changes in
blood pressure and consciousness levels. Although it is commonly encountered with classical antipsychotics, it may develop during
atypical antipsychotic use. Previous NMS experience, some characteristics related to patients and treatments, presence of organic
causes, and affective disease may be listed among risk factors. Many treatment approaches including hydration, fever control, supportive
interventions for respiration, dopamine agonist use, muscle relaxants, and electroconvulsive therapy (ECT) may be beneficial. If untreated,
approximately 10% of NMS patients may die, and approximately 3% of patients may develop persistent complications such as cognitive
function loss, and flexion contracture.
In this article we present a 36-year-old female patient who has been followed up for psychosis and mental retardation for 2 years, and
applied with NMS symptoms (fever, autonomic function deterioration, muscle rigidity, high creatinine kinase) after a single parenteral
dose of zuclopentixol. Despite all interventions, she was dead 1 week later due to Acute Respiratory Distress Syndrome (ARDS). The second
case is a 42-year old female patient with schizophrenia who is followed for 5 years, and whose flexion contracture is partially treated after
NMS by ECT.
The patient survives with persistent squeal. Although significant improvements are present in psychiatric patient treatment, NMS is still
an imminent condition because of its mortality and morbidity.
Keywords: neuroleptic malignant syndrome, mortality, squeal
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S263
[Abstract:0418] Biological psychiatry and neuroscience
Chiari malformation-type I in a patient with atypical psychosis
Elvan Ciftci1, Filiz İzci2, Salime Gursoy1, Medine Yazici Gulec1
Department of Psychiatry, Erenkoy Training and Research Hospital, Istanbul-Turkey
1
Department of Psychiatry, Istanbul Bilim University, Sisli Florence Nightingale Hospital, Istanbul-Turkey
2
e-mail address: [email protected]
Here, we aimed to discuss a case which is a patient with atypical psychosis which has Chiari malformation type 1.
A 25-year-male patient. His first symptoms began as hallucination of seeing people who directing him and giving information about the
future five years ago. He had been followed with antidepressant and antipsychotic treatment with different diagnosis. The patient was
admitted to our clinic for evaluation of the need for appointment of custody. He had complaints of occasionally occurring headache,
forgetfulness and sense of a weighted head for 15 years. Except giving short and inadequate answers to some questions and his affect
was irritable any other positive parameters did not determined in his mental state examination. In his cognitive examination, weakness in
the calling memory, visuospatial ability and executive functioning were observed. His physical and neurologic examination were normal.
Roscharsch and MMPİ test protocols were invalid due to defensive attitude and inadequate answers. After about ten day of follow-up
without treatment, olanzapine dose was increased up to 15 mg for stabilization of the starting symptoms of visual hallucination of two
people and anticipation. The patient underwent neuroimaging with cranial MRI scans demonstrating a Chiari Malformation type I (CM-I)
with cerebellar tonsils laying down approximately 9 mm, right occipital condyl hypoplasia and normal neural parenchyma. The patient
was consulted to neurology and neurosurgery and detailed examination and follow-up were recommended for the operation. His
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neurologic complaints described was thought to occur due to CM-I. His electroencephalogram was evaluated as normal. Neurocognitive
battery of the patient whom in some parts of cognitive functions impairments were seen, resulted in moderate verbal and mild
to moderate non-verbal memory impairment, difficulty in focusing and sustainability of attention, visuospatial and constructional
functioning difficulty related with frontal axis. In verbal memory, beyond impairment of learning and recall processing, loss in the ability
of recognition was observed. When all clinical observation and symptoms were evaluated together, the case needed to be follow-up
for cognitive impairment probably secondarily related to CM-I. The patient was discharged with diagnosis of atypical psychosis and the
treatment of olanzapine 15 mg/d.
CM-I is a congenital anomaly that occurs when there is a displacement of one or both cerebellar tonsils extending more than 5 mm
below the foramen magnum. Among symptomatic patient headache is the most command complaint, followed by weakness and
altered sensation according to a study. However, a paucity of research exists with regard to neuropsychological function in CM-I.
Subjective cognitive complaints appear common to CM-I. Neuropsychological evaluation of two cases of CM-I patient demonstrated
preserved general cognitive functioning but had varying patterns of performance on measures of visuospatial, executive functioning and
processing speed. In terms of affective functioning, both endorsed significant depressive symptomatology, but had varying patterns of
severity on other estimates of psychiatric symptomatology.
When all results are taken account, there is not one pattern of cognitive and affective functioning associated with CM-I. During evaluation
of these cases with CM-I, enviromental and psychological rather than neurological should be considered and neuropsychological
evaluation in CM-I will provide guidance for psychoeducation and psychotherapy
Keywords: chiary malformation, psychosis, atypical
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S263-S4
[Abstract:0428] Biological psychiatry and neuroscience
Phantom limb pain treated successfully with duloxetine-a case series
Mihriban Dalkiran Varkal1, Abdullah Genc1, Ilknur Yildirim2, Besir Dikmen3
Department of Psychiatry, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul-Turkey
1
Department of Anesthesia and Reanimation, Istanbul University, Institute of Oncology, Istanbul-Turkey
2
Department of Orthopedics, Necip Fazil City HospitaL, Kahramanmaras-Turkey
3
e-mail address: [email protected]
Phantom limb pain (PLP) is a general complaint after amputation which is usually described as ‘burning, tingling, shooting and cramping’.
The pathophysiology of PLP is still uncertain. Althouh several medications have been studied in the treatment of phantom pain, there is
already elusiveness in the appropriate pharmacologic management of PLP. Here we present three cases of PLP, treated with duloxetine.
Various therapeutic approaches have been used in the treatment for PLP. The serotonin-norepinephrine reuptake inhibitors (SNRIs) are
popular for neuropathic pain, migraines, and
fibromyalgia due to fewer side effects and efficacy.
Cases:
Sex
Age Reason of
Form of
Time after
Treatment
amputation Amputation amputationregimen
Male
19
Traffic accident Below-knee
2 months
Duloxetine
30 mg/day
Male
20
Bomb exposure Trans tibial
2 months
Duloxetine
30 mg/day
Male
55
Embolism
Below-knee
1 month
Duloxetine
30 mg/day
Female 15
Combat woundingBelow-knee
1 month
Duloxetine
30 mg/day
Duration of
VAS*-before
treatment teatment
1 month
9/10
VAS-after
treatment
1/10
2 months
8/10
3/10
3 months
10/10
2/10
15 days
9/10
6/10
Four cases of phantom limb pain treated with duloxetine is summarized at the table. *VAS: visual analog scale
Various therapeutic approaches have been used in the treatment for PLP. The serotonin-norepinephrine reuptake inhibitors (SNRIs) are
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popular for neuropathic pain, migraines, and fibromyalgia due to fewer side effects and efficacy.
In literature there are case reports of successful use of milnacipran .and mirtazapine in PLP. Additionally there is a case report of duloxetine
and pregabalin combination. We propose that duloxetine could have beneficial effects in treating PLP.
Keywords: phantom limb pain, duloxetine, neuropharmacology
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S264-S5
[Abstract:0546] Biological psychiatry and neuroscience
Unknown face of posttraumatic stress disorder: traumatic brain injury
Taner Oznur
Department of Psychiatry, Gulhane Military Medical Academy, Ankara-Turkey
e-mail address: [email protected]
In daily psychiatric practice, trauma is mostly handled with psychological consequences caused by itself. Diagnosis and treatments of
damages occurring related to the physical dimension of the trauma are frequently performed by medical branches such as neurology,
neurosurgery and general surgery. However, if the symptoms that occur in patients exposed to physical trauma can not sufficiently
understood or elucidated by these branches, they are taken into consideration as psychiatric symptoms and patients are referred to a
psychiatrist. On the other hand, the emergence of psychiatric symptoms after the damage in the brain tissue caused by trauma is not
uncommon. Cognitive or behavioral changes are observed with the effects of environmental factors on brain tissue in the patients with
traumatic brain injury (TBI). Different clinical manifestations can be observed depending on the affected brain region and potency of
the trauma. The severity of the emerging clinical appearance as can vary from mild to severe, also it can be short term, long term or
permanent. Status of the patients with the symptoms lasting more than one year are considered to be permanent. Changes in level of
consciousness, memory loss, deterioration in cognitive function, and neurological defects emerge after to the exposure to traumatic
factors. Falling down, motor vehicle accidents, collision of foreign objects and being attacked are the major traumatic factors in the
etiology of TBI. Falling down is the most common cause of TBI in childhood. A increase in emergency services applications due to TBI is
seen over the years. Incidence of TBI was found to be higher in males. These patients refer to the psychiatric outpatient clinic because
psychiatric symptoms are observed very often in TBI patients and TBI is a potential risk factor for Post Traumatic Stress Disorder. Also
unusual clinical manifestations in TBI are mistakenly described as conversion disorder by clinicians. For these reasons, biological and
psychological aspects of trauma need to be addressed in a holistic way.
Keywords: traumatic brain injury, posttraumatic stress disorder, neurological defects
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S265
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CHILD AND ADOLESCENT MENTAL AND BEHAVIORAL DISORDERS
[Abstract:0171] Child and adolescent mental and behavioral disorders
Effectiveness of low dose aripiprazole as monotherapy on obsessive compulsive disorder and tic
disorder co-morbidity: a case report
Omer Faruk Akca, Savas Yilmaz
Department of Child and Adolescent Psychiatry, Necmettin Erbakan University, Meram Faculty of Medicine, Konya-Turkey
e-mail address: [email protected]
Pediatric Obsessive-Compulsive Disorder (OCD) is a common and debilitating disorder which can cause substantial impairment in
academic, social, and family functioning. Tourette Syndrome or tic disorders can be seen together with OCD and this co-occurrence is
defined as a specific subtype of early onset OCD, with higher male prevalence. First line interventions in OCD treatment include Cognitive
Behavioral Therapy, Selective Serotonin Reuptake Inhibitors, and the combination of both these treatments. Atypical Antipsychotics
can be used in addition to antidepressant treatment in resistant cases. Aripiprazole, which is a partial dopamine agonist, can be used in
both tic disorder treatment and augmentation of OCD treatment. It is reported to be as effective as Risperidone in treatment of resistant
OCD cases co-morbid with tic disorders. Because of less side effects, aripiprazole is a safe and well tolerated medication compared to
Risperidone. Despite effectiveness of aripiprazole in combination with Selective Serotonin Reuptake Inhibitors in resistant OCD cases is
known, effectiveness of single Aripiprazole treatment on OCD symptoms was not reported before. This case report presents a 14 year
old boy admitted to our clinic with diagnoses of OCD and tic disorder and his both OCD and tic symptoms completely disappeared two
months after administration of low dose aripiprazole treatment. Also, the possible mechanisms of action related to the effectiveness of
aripiprazole on OCD will be discussed.
The patient was admitted to our clinic with complaints of multiple motor tics including blinking, jumping and touching to his head with
his hand. Additionally, mild obsessive thoughts and compulsive behaviors including worries about hurting other people, doubts about
actions he has committed, and checking activities were determined in the psychiatric examination. Aripiprazole 5 mg/d was started for
his motor tics at the admission. At the second visit 40 days after the admission, both tics and OCD symptoms were disappeared and no
tics or OCD symptoms were seen during the 5 months of follow-up.
Keywords: aripiprazole, obsessive compulsive disorder, tic disorder
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S266
[Abstract:0227] Child and adolescent mental and behavioral disorders
Factitious disorder in a 10 year old mentally retarded girl
Elif Akin, Canan Yusufoglu, Sebla Gokce, Ibrahim Adak
Department of Child and Adolescent Psychiatry, Erenkoy Training and Research Hospital, Istanbul-Turkey
e-mail address: [email protected]
A factitious disorder is a condition in which a person acts as if they have an illness by deliberately producing, feigning, or exaggerating
symptoms. In literature, there are not many child cases. In this case, we emphasized considering factitious disorder in differential diagnosis
in children and in accompanying with disabilities in developmental issues.
A 10-year-old girl referred to clinic with her mother with the complaints of stomachache, vomiting of blood. Mother also told child
was showing the stones she’s vomiting. They said they went to many doctors but nothing was found. In addition, the child presented
to psychiatry clinic before for two times because of academic failure and learning problems and had been diagnosed as mild mental
retardation with total IQ score of 63. And for about one year child was told having anhedonia, sadness and unwillingness by her mother.
In detailed examination, it was realized that the child was showing the stones she was picking up from outside and she was biting her
inner lips. She was consulted to psychiatry after all medical evaluations (including abdominal ultrasonography, gastroscopy) have been
completed and nothing found.
Fluoxetine and risperidone treatment was began with diagnosis of Munchausen syndrome. In conclusion, we would like to remind
factitious disorder in differential diagnosis in children and with developmental disabilities cases where there are physical and mental
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symptoms, many hospital referrals, inconsistent history, examination and laboratory findings in order to prevent unnecessary
interventions having damaging risk to patient by using the advantage of early diagnosis and treatment.
Keywords: factitious disorder, fluoxetine, mental retardation
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S266-S7
[Abstract:0230] Child and adolescent mental and behavioral disorders
Oversleepiness with sertraline in depressed adolescent under corticosteroid treatment
Canan Yusufoglu1, Elif Akin1, Sebla Gokce1, Yasemin Yulaf2
Department of Psychiatry, Erenkoy Training and Research Hospital, Istanbul-Turkey
1
Department of Child and Adolescence Psychiatry, Tekirdag-Turkey
2
e-mail address: [email protected]
Psychiatric adverse effects during systemic corticosteroid therapy are common. Disturbances of mood, cognition, sleep, and behavior
as well as frank delirium or even psychosis are possible, the most common adverse effects of short-term corticosteroid therapy are
euphoria and hypomania. Conversely, long-term therapy tends to induce depressive symptoms. Corticosteroid-induced symptoms
frequently present early in a treatment cycle and typically resolve with dosage reduction or discontinuation of corticosteroids. In severe
cases or situations in which the dose cannot be reduced, antipsychotics or mood stabilizers may be required. We report here a depressed
adolescent girl, who is under chronic treatment of corticosteroıd, developing oversleepy state after use of sertraline.
A 12 year old girl presented to clinic with complaints of sadness, anhedonia, increased susceptibility, fatigue for four months. Because
she had juvenile rheumatoid arthritis, she was on treatment of corticosteroid and methotrexate for one year. For depressive symptoms,
sertraline 25 mg/day was given. Two months later on child’s arrival, it was told that corticosteroid treatment was stopped before one
month and the child‘s complaints were diminished after discontinuation of steroid drug. In addition the child and family said they gave
up sertraline after a few day use because of Oversleepiness during day time.
In this case we emphasize that we should be aware of psychiatric side effects of steroid therapy considering age of patient, duration and
dose of treatment and also much more increased probability of antidepressant drugs maybe due to increased susceptibility at receptor
level.
Keywords: corticosteroid, oversleepiness, sertraline
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S267
[Abstract:0245] Child and adolescent mental and behavioral disorders
Frontal lobe syndrome: a case report
Salih Gencoglan1, Mustafa Erkan2, Leyla Akguc3
Department of Child and Adolescent Psychiatry, Yuzuncu Yil University, Faculty of Medicine, Van-Turkey
1
Department of Child and Adolescent Psychiatry, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul-Turkey
2
Department of Psychiatry, Mardin State Hospital, Mardin-Turkey
3
e-mail address: [email protected]
Brain pathologies such as cerebrovascular disease, head trauma, brain tumors, brain infections, neurodegenerative diseases that damage
the frontal lobes can also result in profound changes in personality and social adjustment. Dysfunctions of the frontal lobes result a
relatively specific clinical syndromes. We purposed to report a case with Frontal Lobe Syndrome diagnosed.
A 16 year-old female was referred to our clinic due to aggressive behaviors, impulsiveness, sexual disinhibition, loudly speech and
changes in personality. The symptoms started after she had a traffic accident 2 years ago. He was not able to join her peers or interact with
them. Therefore she could not return to her school again. Neurological examination was normal. The Brain Magnetic Resonance lmaging
(MRI) showed that encephalomalacic changes and atrophy secondary to trauma in the both frontal and temporal lobes bilaterally. In
the Electroencephalography (EEG) potentially epileptiform paroxysmal disorder were detected. We initiated 1 mg/day of risperidone.
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After three weeks, due to insufficient improvement, 1000 mg/day valproic acid was added on the patient’s medications and continued
treatment for 6 consecutive months. Six weeks after the initiation of treatment, improvement in both sexual and aggressive behaviors was
noticed. The parents stated that he experienced a significant improvement of aggressive behaviors.
Case reports and imaging studies have implicated that the patients with lateral prefrontal damage may show apathy, indifference, speech
poverty, and poor executive abilities. On the other hand, damage to the ventromedial prefrontal cortex may lead to poor impulse control,
puerility, euphoria, increased energy, aggression, violence and sociopathy. The frontal lobe is the largest lobe in the brain, yet it is often
not specifically evaluated in routine neurologic examinations. When a patients history suggests frontal lobe dysfunction, a detailed
neurobehavioral evaluation is necessary to probe frontal lobe functions.
Keywords: frontal lobe syndrome, risperidone, valproic acid
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S267-S8
[Abstract:0257] Child and adolescent mental and behavioral disorders
Aripiprazole use in autistic child with Sturge Weber syndrome
Elif Akin, Canan Yusufoglu
Department of Psychiatry, Erenkoy Training and Research Hospital, Istanbul-Turkey
e-mail address: [email protected]
Sturge-Weber Syndrome (SWS) is a rare sporadic neurocutaneous syndrome defined by the association of a facial capillary malformation
in the ophthalmic distribution of the trigeminal nerve, with ipsilateral vascular glaucoma and vascular malformation of the eye and a
leptomeningeal angioma. SWS is characterized by a number of significant neurodevelopmental anomalies, including seizure disorders,
cognitive retardation, behavioral difficulties. Autistic Spectrum Disorder is not commonly seen comorbidity in SWS. We reported here a
case of improved behavioral symptoms after the use of aripiprazole in SWS-autism patient.A six year old boy diagnosed as Sturge Weber
Syndrome by child neurologist presented to clinic with behavioral complaints of insisting and overoccupying with some materials and
sometimes just repetitively impairing both child and family‘s daily function. He had echolalia, limited eye contact and difficulty in joining
reciprocal speech. His developmental level was at about 44 months in general, 48 months in personal-social area, 60 months in fine motor
area, 18 months in language area, 48 months in gross motor developmental area. He had been on special education program for three
years. He was diagnosed as autistic spectrum disorder and risperidone of 0.25 mg per day was started for behavioral symptoms. But the
child‘s symptoms got worse in a few days and risperidone was discontinued and aripiprazole of 2 ml was given and the child‘s tantrums
and repeated behavioral symptoms diminished.
In this case we report a rare condition of comorbidity of Sturge Weber Syndrome and Autism Spectrum Disorder and improvement of
behavioral symptoms with aripiprazole use.
Keywords: aripiprazole, autism, Sturge Weber syndrome
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S268
[Abstract:0266] Child and adolescent mental and behavioral disorders
Pimozide induced cardiovascular side effects: a case report
Hicran Dogru1, Gizem Mujdecioglu Demir1, Aziz Kara2, Esin Ozatalay1
Department of Child and Adolescent Psychiatry, Akdeniz University, Faculty of Medicine, Antalya-Turkey
1
Department of Child and Adolescent Psychiatry, Erciyes University, Faculty of Medicine, Kayseri-Turkey
2
e-mail address: [email protected]
Tourette syndrome is a chronic neuropsychiatric disorder with onset in childhood, characterized by multiple motor tics and at least
one vocal tics that leads to severe psychosocial disability. The prevalence of tic disorders varies between 10 and 15% for transient tics,
about 3-4% for chronic motor or chronic vocal/phonic tics to 1% for TS. There are many pharmacotherapeutic agents considered in the
treatment of Tourette syndrome, the main treatment for tics has been neuroleptic drugs with potent D2 receptor-blocking properties,
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such as haloperidol and pimozide.The classes of medication with the most proven efficacy in treating tics Pimozide can have long-term
and short-term adverse effects. Along with its needed effects, pimozide may cause some unwanted effects. Although not all of these side
effects may occur, if they do occur they may need medical attention. One of these, seen rarely but needs treatment, when once occurred
are cardiac adverse effects such as. Here we report a child patient with severe TS, who had significant side effects with pimozide treatment.
The case is a 12-year-old male. Disease onset occurred 3 years ago with involuntary, repetitive muscle movements and vocalizations like
coprolalia. He was treated with risperidone, aripiprazole and haloperidol in sequence between 2010 and 2013. These drugs produced
either mild improvement or no effect. We initiated pimozide at 1 mg/d and then escalated to 2mg/d. Two months after the initiation
of treatment, improvement in both the involuntary muscle movements and the vocalizations was noticed. On the control visit after
four month, the patient described a serious side effect, arrhythmia. After consultation to the pediatric cardiology the QT interval was
significantly prolonged (QT:0.50).
Two antipsychotic medications, haloperidol and pimozide, are the only two FDA approved treatments for tics, although they are not
currently recommended as the first-line pharmacotherapy because of their adverse side-effect profile. Managing symptoms of Tourette’s
syndrome with pharmacotherapy can be seriously Challenging for clinicians in some cases. Pimozide is a well-known agent for tic
management in Tourette’s Syndrome. In a placebo-controlled metaanalysis comparing pimozide with other antipsychotics in Tourette
syndrome, pimozide was found to be more effective than placebo and Haloperidol. Extrapyramidal effects along with ECG changes and
endocrine effects as seen with other neuroleptic agents occur with pimozide as well. However autonomic effects of the drug are weaker.
Rarely, sudden death and cardiac arrest as well as ventricular tachycardia and ventricular fibrillation with fatal outcome have been
reported. Cardiac functions of patients taking more than 16 mg per day of pimozide should be checked periodically, focusing primarily
on the ECG changes. If repolarization changes (prolongation of the QT interval, T-wave changes or U-wave development) appears or
arrhythmIAS occur, pimozide should be reassessed to determine the need for continued treatment and the appropriate dose. In our case,
the medication was discontinued after such an evaluation. These patients should be closely monitored and the dose of pimozide should
be reduced preferably. Pimozide can prolong the QTc interval, suggesting that ECG monitoring prior to and after initiating therapy is
appropriate.
Keywords: child, pimozide, prolonged QT
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S268-S9
[Abstract:0270] Child and adolescent mental and behavioral disorders
Need for holistic approach to assessment in child psychiatry outpatient clinic: a case report
Ozlem Kahraman, Ayse Irmak, Didem Behice Oztop
Department of Psychiatry, Erciyes University, Faculty of Medicine, Kayseri-Turkey
e-mail address: [email protected]
The fact that clinical assessment of children is challenging and complex requires access to several sources of information. While
information is obtained from child, parents and teachers, and by observing interactions between family members, assessment tools can
be used.
A 6-year-old girl was referred to outpatient clinic with complaint of “decreased success in the class, behavioral changes” by her mother.
Her mother stated that she began not listening to her teacher and jumping imaginary rope a few months after beginning first class,
disrupting concert of class. The mother also stated that her handwriting worsened with unwillingness for reading; that she was publicly
telling discussions between parents; and that she was behaving peevishly and raising her voice to everyone within prior a few months.
In the interview, she was a very active, talkative child who tells problems in their family without asking. According to child, circumstances
were bad in the house and her father was limiting everything to her. In the prenatal history, it was found out that her mother experienced
psychological problems during pregnancy. In her history, she had breath holding spells until 5 years of age and EEG and cardiologic
examination was found to be normal. In her family history, it was found out that her mother received SSRI with a diagnosis of conversion
disorder and then she stopped drug use due to recovery of symptoms. In addition it was also found out that her father had psychological
problems but didn’t refer to psychiatry department. Teacher Information Sheet and Conner’s Rating Scales which would be completed by
parents and teacher were given to mother in order to assess in the next interview. In addition, a family interview was scheduled. In the
family interview, it was found that the father had intensive anxiety which disrupts functionality in home and work, affecting his attitudes
against mother and child. It was also revealed that the mother had increased frequency of conversions with decreased tolerance. The
father was examined in adult psychiatry department. He was diagnosed as generalized anxiety disorder, and treatment was initiated at
same day. The mother was referred to psychiatry outpatient clinic to maintain treatment. It was thought that adjustment disorder was
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developed in the child due to reflection of psychopathologies of parent to family environment. The child was diagnosed as attention
deficit hyperactivity disorder based on history and results of scales. The patient was prescribed atomoxetine after routine laboratory
evaluations. In control visit, it was seen that parents were maintaining psychiatric treatments and that child became less irritable as
problems in family environment were decreased. It was found out that her teacher reported near-normal activity with improved attention
by ADHD treatment. The child is still attending to follow-up examinations in our clinic.
For the purposes of clinician, it is important to find answers of questions such as “Does child have a real psychiatric problem or does
symptom of child reflect problems related family or school” or “Are there stressors that may cause problems in child”.
Keywords: assessment, child, holistic approach
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Abstract:0299] Child and adolescent mental and behavioral disorders
Psychiatric disorders related childhood epilepsy: case report
Fatma Betul Ayvaz, Pinar Yurtbasi
Department of Child and Adolescent Psychiatry, Turgut Ozal University, Faculty of Medicine, Ankara-Turkey.
e-mail address: [email protected]
There is a strong association between epilepsy and psychiatric disorders, especially in childhood. We describe a 11-year-old boy who
presented with extreme mood swings, anger outbursts, insomnia in addition to his long-term epilepsy, and discuss the diagnostic and
treatment challanges of this case. He was described as hyperactive, irritable in preschool years, and was followed only by pediatric
neurologist with epilepsy and attention deficit hyperactivity disorder diagnosis, and was being treated with valproat (20mg/kg/
day), oxcarbazepine (15 mg/kg/day) and risperidone (1 mg/day). The neurological diagnosis was atypical childhood epilepsy with
centrotemporal spikes. His epilepsy had never been controlled completely His WISC-R score was normal intellectual capacity, while he was
seven. At age 8, after learning a family financial crises and sad mood in the pateint, pediatric neurologist decided to change risperidone
to fluoxetine. One month later, while taking fluoxetine (10 mg/day) and same anticonvulsants, he exhibited manic symptoms (grandiosity,
irritable and elevated mood, increased speech and agressiveness, decreased sleep and bizaar behaviors like playing with his soil). He was
hospitalised and treated in an inpatient child psychiatry clinic. In the four years leading up to our evaluation, he never had experienced
manic or psychotic symptoms again. But his emotional lability, anger outbursts persisted along with his agressive behaviors. Many drug
trials (including haloperidol, quetiapine, olanzapin, aripirasole, clonazepam) had been applied, and mostly they switched each other
inappropriately by different physicians. He was brought to our clinic by his parents for his agressive and he has frequent severe tantrums
(shouting, cursing, crying, hitting), usually in response to limits on his behavior or not getting his way. His parents and teachers had
observed progressive personality and behavioral changes in the form of mood swings, anxiety, agression, and in his cognitive detoriation.
We started zuclopenthicsol acetate and followed two months at 8 mg/day doses, while he was also taking his anticonvulsant medications.
Compliance were not good at oral zuclopentichsol and parents wanted to swithced his medication again. At this point, we suggested
monthly depot injections of zuclopentichsole decanoate. Then, the agressive outbursts and irritable mood gradually subsided. After
a year, he was still described as more compliant, and his family was impressed with his less agressive attitudes. The use of the depot
zuclopentixole provided a substantial improvement. Also, no additonal neurological or mental side effects were detected at follow-up. A
collaborative approach of neurology and psychiatry is necessary in pediatric epileptic cases, both to avoid misdiagnosis the psychiatric
problems before they get more complicated and to identify most effective drug combinations earlier. This report also emphasize the need
for considering depot antipsychotics in the treatment of severe mood and behavior dysregulation related with epilepsy.
Keywords: depot antipsychotic, epilepsy, mood dysregulation
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[Abstract:0322] Child and adolescent mental and behavioral disorders
Disruptive mood dysregulation disorder; a case report
Taha Can Tuman, Ugur Cakir, Ugur Savci
Department of Psychiatry, Abant Izzet Baysal Training and Research Hospital, Bolu-Turkey
e-mail address: [email protected]
Disruptive mood dysregulation disorder appears repetative verbal or behavioral anger outbursts as unproportional with situation and
development. Except this anger outbursts, mood is irritable almost every day. Therefore this disorder often be confused with bipolar
disorder as manic episodes. In this case report, we discussed an adolescent who followed wrongly diagnosed bipolar disorder and
admitted to the psychiatry unit twice in a year and finally with detailed history and assessments diagnosed disruptive mood dysregulation
disorder.
A-17-year-old man one year ago after leaving his girlfriend he get angry and started shouting with everything. Occasionally he is applying
physical violence. To appease the anger, he was damaging himself with razor. Last year, he admitted to the psychiatry unit with the
diagnosis of bipolar affective disorder for anger behavior problems and damage the equipments at home. It was learned that ın hospital
the patient was started valproic acid 1000 mg per day and quetiapine 600 mg per day. Despite the treatment, the patient’s irritability and
anger continued and he didnt use hid drugs regularly due to the side effects of sedation and concentration problems. In his psychiatric
history, it was learned that since childhood he was constantly angry and furious, he was often get anger outbusts. But there was no
manic episode. Family history was unremarkable. On mental status examination, mood was irritable, İn thought content there was hostile
opinions to his girlfriend and his parents. There was no delusion or hallucination. There was no history of substance abuse. We diagnosed
“disruptive mood disregulation disorder” to the patient. We stopped valproic acid and quetiapine and we started sertraline 50 mg per
day for anger management and methylphenidate for attention deficit. Anger management training was given. Outpatient follow-up was
planned to be invited to social skills training.
Patient have disruptive mood dysregulation disorder, often misdiagnosed as bipolar affective disorder. Differential diagnosis with bipolar
affective disorder is made with a detailed history. The correct diagnosis is important for treatment. While irritability is episodic in bipolar
affective disorder, in disruptive mood dysregulation disorder irritability is continious. Mood stabilizers often using in bipolar affective
disorder but stimulants, behavioral interventions and atypical antipsychotics often used in this disorder. Lithium treatment in bipolar
affective disorder is essential but lithium is not superior to placebo in placebo controlled study for disruptive mood dysregulation
disorder. It is generally avoided SSRI in bipolar affective disorder for induced mania but there is no risk of triggering mania in disruptive
mood disregulation disorder so SSRI drugs can use and be useful. Also, stimulants commonly used in disruptive mood dysregulation
disorder because of comorbid ADHD is often. Social skills training, attitude suggestions is useful.
Keywords: bipolar, differential diagnosis, disruptive mood
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S271
[Abstract:0341] Child and adolescent mental and behavioral disorders
Risperidone induced thrombocytopenia: a case report
Esra Ozhan Ibis1, Mutlu Karakus2, Ali Ibis1, Nermin Yucel1
Department of Child and Adolescent Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
1
Department of Child and Adolescent Psychiatry, Agri State Hospital, Agri-Turkey
2
e-mail address: [email protected]
Conduct disorder manifests with aggression towards human and animals, destructive behavior, fraud, stealing and violating rules.
Conduct disorder is a more serious condition than ADHD, which is concomitantly seen in 25% of conduct disorder cases, leading to
various conditions prospectively such as anti-social personality disorder and alcohol addiction; in this respect, early diagnosis and
treatment are essentially important in this disorder. An atypical anti-psychotic, risperidone, is effectively used in treatment of conduct
disorder. Thrombocytopenia secondary to anti-psychotic use is rare, but an extremely dangerous side effect. This article is a case report
regarding thrombocytopenia secondary to risperidone use in a patient with ADHD accompanied by conduct disorder.
A 13 year-old boy was brought to our out-patient clinic with his family with complaints of hyperactivity, inability to concentrate, getting
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bored quickly, frequent fights with friends, physical harming to his friends, taking money from his father’s workplace without permission,
and escaping from school ongoing since first grade. Development stages were normal according to his history. Psychiatric examination
revealed criticizing approach and refusal to doctor visit, increased psychomotor activity, distractibility and intermittent impulsivity.
Patient was diagnosed with attention deficit hyperactivity disorder combined type and conduct disorder childhood-onset type according
to DSM-V diagnostic criteria following clinical evaluation and visits with his family and teacher. CBC (HGB: 14.5 g/dl, WBC: 6.6 X 103/
PLT: 210 X 103/mm3), biochemistry values and electrocardiography were within normal limits. 0.5 mg/kg/day atomoxetine was started.
Dose was increased to 1mg/kg/day 1 week later. His psychomotor hyperactivity, distractibility, forgetfulness and complaint of easily
getting bored were improved in control visit after 6 weeks; however, complaints like fighting with friends, harming friends physically
and violating rules persisted. CBC (HGB: 13.8 g/dl, WBC: 7.4 X 103/ PLT: 221 X 103/mm3), biochemistry results and electrocardiography
were within normal limits. Risperidone 0.5 mg/day was started. Physical examination, performed during the control visit after 1 week,
revealed 6 ecchymotic lesions in anterior surface of right and left legs and volar surface of left forearm, the largest and smallest measuring
3x2 cm and 1x0.5 cm, respectively. CBC, PT, aPTT, İNR and biochemistry results were only remarkable for PLT value of 58 X 103/mm3. He
was consulted with Pediatric Hematology for evaluation of thrombocytopenia etiology. Following necessary tests, thrombocytopenia
secondary to risperidone use was considered and risperidone 0.5 mg/ day treatment was stopped. PLT increased to 155 X 103/mm3
during control visit 1 week later. Thrombocyte levels remained within normal limits after risperidone withdrawal. He was followed-up with
aripiprazole 5mg/day added to ongoing atomoxetine treatment. Drug-induced thrombocytopenia generally develops 5-15 days after the
onset of treatment and disappear approx. 1 week after drug withdrawal. In our case, thrombocytopenia developed 1 week after the onset
of risperidone treatment and CBC values returned to normal 1 week after withdrawal. Development of findings after treatment onset and
total remission after withdrawal suggested risperidone-induced thrombocytopenia. Risperidone-induced thrombocytopenia is rare, but
a serious side effect that always requires attention, and CBC follow-up should be performed when necessary.
Keywords: risperidone, side effect, thrombocytopenia
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[Abstract:0392] Child and adolescent mental and behavioral disorders
Therapy for stereotypic movement disorder in typically developing children
Sahin Bodur
Department of Child and Adolescent Psychiatry, Dr. Sami Ulus Maternity and Children’s Health and Diseases Training and Research Hospital, Ankara-Turkey
e-mail address: [email protected]
Stereotypic movement disorder are defined in this manuscript as involuntary, rhythmic, repetitive, fixed (fashion, form, amplitude, and
location) movements that appear purposeful, but are purposeless (serve no obvious adaptive function, or purpose), and stop with
distraction. Stereotypies can present in those with normal development and without neurological disorder. Motor stereotypies are
commonly seen in children with autism spectrum disorder but can also be seen in those with sensory impairment, social isolation and
or learning disability. They are divided into two subgroups dependent on the presence of other developmental problems: ‘primary’
(development is otherwise typical) or ‘secondary’ (associated with autism, intellectual disability, or sensory deficits).
Management for stereotypies is mostly behavioral. The role of medications for treatment of motor stereotypy disorders in typically
developing children is not clear and behavioral therapy can be beneficial Positive outcomes were usually reported after behavioral
interventions such as “mechanical restraints alone or with other intervention variables”, “response blocking alone or with other
intervention variables”, “non‐contingent stimulation”, “various contingency manipulations”, and “microswitch clusters”.
Habit reversal and differential reinforcement of other behavior improve stereotypic behaviors in non‐autistic children.
Keywords: therapy, stereotypic movement disorder, children
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[Abstract:0411] Child and adolescent mental and behavioral disorders
Mania symptoms while decrease in dose of fluoxetine: a case report
Ozge Gizli Coban
Department of Child and Adolescent Psychiatry, Akdeniz University, Faculty of Medicine, Antalya-Turkey
e-mail address: [email protected]
A 6-year-old girl was referred with complaint of “fear of school” by her parents. The patient didn’t allow their parents to leave room during
interview. In the history it was found that the patient didn’t attend preschool education and began elementary school last year. When
she began school, she had problem to separate from her mother; thus, the mother stayed in the classroom over 15 days. The parents
made several attempts to send her school; even they beat her, which made the situation worse. The parents cited that she avoids from
unfamiliar persons and generally doesn’t like talking. She also didn’t speak during interview but completed the tests given. The patient
was considered as “separation anxiety disorder”; thus, fluoxetine (20 mg) and risperidone (0.5 mg) was prescribed to the patient. In the
next visit, it was seen that her anxiety was decreased but she didn’t let her mother to leave room. She was more convenient, more talkative
and joyful. She agreed to allow her mother staying in waiting room in the next visit. The mother reported that she expressed herself better
and became more energetic. The patient received this regimen for 3 months didn’t raise difficulties in terms of attending school. Thus,
fluoxetine dose was reduced to 15 mg. In the next control visit, it was found that her mother took her school where the patient didn’t want
her to wait at the school. In the next control visit, the mother reported that there was increased activity and she was walking on school
bench at class as well as jumping on seats at home. Fluoxetine dose was reduced to 10 mg by consideration of increased activity due to
fluoxetine. Meanwhile, her elder sister aged 11 years was referred to our outpatient clinic with “crying episodes, suicidal thought” over
1-2 months. She was prescribed fluoxetine 20 mg which controlled symptoms. It was found out that there was no history of psychiatric
disorder in the family. In the next visit, it was found out that there was increased activity in S.K including beating her sister and throwing
objects to all family members. There was also excessive spending. She spent 50 TL for junk food which was given her to deliver teacher.
However, she was a sparing child previously. During this period, she attempted to leave home by picking up her belongings and cited that
“I don’t want to be your child, I will be child of other people” when she was stopped by her mother on the street. Fluoxetine was withdrawn
by consideration of “manic switch” and risperidone dose was titrated to 1 mg/day (twice daily). The mother reported that she was forcing
her peers to apologize even they touch her. She also acted same way to her teacher and threatened by sending from school. She had got
on top of her friend and cited that “I will kill you today”. Urgent EEG was ordered to exclude organic pathology which was interpreted as
normal. Risperidone was maintained at the same dose. Two weeks later manic symptoms disappeared.
Keywords: decrease, fluoxetine, mania
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[Abstract:0435] Child and adolescent mental and behavioral disorders
A Case of severe long-term selective mutism in a child with intellectual disability
Ahmet Hamdi Alpaslan1, Ugur Kocak2, Kerem Senol Coskun3, Cansu Cobanoglu1
1Department of Child and Adolescent Psychiatry, Afyon Kocatepe University, Faculty of Medicine, Afyonkarahisar-Turkey
2Department of Forensic Medicine, Afyon Kocatepe University, Faculty of Medicine, Afyonkarahisar, Turkey
3Department of Psychiatry, Afyon Kocatepe University, Faculty of Medicine, Afyonkarahisar-Turkey
e-mail address: [email protected]
Here, we report a rare case of an adolescent male with ID presenting continuous mutism for about two years. The case is discussed in
light of the related literature.
The client, “Kerem” (not his real name), is a 13-year-old boy referred by his teacher to a tertiary outpatient child and adolescent psychiatry
clinic. Kerem was born in a rural area in the eastern Turkey. He is the older of two siblings in a two-parent low-middle-income household.
At the time, he was in the seventh grade in middle school. He was diagnosed with ID at the age of 8 after WISC-R testing. His mother
reported that Kerem did not speak to his teacher or his peers or participate in school activities. And he performed academically far
below his classmates. Last year, he completely stopped talking at school. He spoke mostly to his mother and very minimally to his sister;
however, outside the home and with any other relatives, including his biological father, he was completely mute, only communicating
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with non-verbal gestures. Positive findings in the mental status examination were that the patient was following commands given
to him, he responded in a non-verbal manner or by writing, his eyes were open and movements were normal, and his psychomotor
activity decreased. He was mute throughout the interview. He was very close to his mother, who appeared very protective. His cognitive
ability was evaluated with the Stanford-binet test. SB, is a widely used assessment instrument with sound psychometric properties. He
received a score of 55 on the Stanford-Binet. According to the Stanford-Binet, he had a mild ID (IQ = 55–70). Using The Peabody Picture
Vocabulary Test, we tried to test receptive language in the client, but he did not cooperate with the psychologist. Kerem and his parents
were interviewed by a child and adolescent psychiatrist to diagnose primary and possible comorbid psychiatric disorders. The psychiatric
diagnosis was made according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition, (DSM-5). He did not
appear to demonstrate signs or symptoms of an autism spectrum disorder, such as stereotyped or restricted interest or poor eye contact.
Our case fulfilled the diagnostic criteria for SM, and a diagnosis of comorbid occurrence of SM and ID was made. After the diagnosis
process, Kerem was started on fluoxetine at 10 mg per day. Additionally we applied psycho-educational and behavioral interventions
(including information about SM and how to use defocused communication, role playing). About four months later after the beginning
of the therapy, his mother reported that Kerem was now talking to his father and his sister at home. Overall, he appeared very sociable
and well-liked by his classmates.
In conclusion, longitudinal data and long-term follow-up data regarding this population are needed. Diagnosis and treatment for many
cases of ID with SM can be delayed for several years. Thus, early screening for SM in an era when many children attend day care or
preschool would seem to be a useful practice.
Keywords: adolescent, intellectual disability, selective mutism
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[Abstract:0449] Child and adolescent mental and behavioral disorders
Risperidone treatment in very young children: four cases before 30 months of age
Ozalp Ekinci, Nuran Ekinci
Department of Child and Adolescent Psychiatry, Mersin University, Faculty of Medicine, Mersin-Turkey
e-mail address: [email protected]
Psychiatric symptoms in very young children is challenging for clinicians since empirical data on the efficacy and tolerability of medications
is lacking. Behavioral approaches, including parent training and behavioral therapy, are generally effective in mild to moderate cases.
However, for the severe and refractory cases, medications must be taken into consideration. This report describes the safe and effective
use of risperidone in the treatment of four very young children.
Four cases before 30 months of age were included to the study. Case one, a 24-month-old boy, was admitted to our clinic with the
primary complaints of sleeplessness and aggressive behaviors. The parents stated that, since she was born, she had difficulty on initiation
sleep. Case two, a 23-month-old boy, was admitted to our clinic by the complaints of hyperactivity, aggressive behaviors at nursery and
sleep problems. Parents reported that he was too active both at home and kindergarten school. He frequently had accidents because
of his impulsivity. Case three, a 26-month-old girl, had the complaints of hyperactivity and rigid sensitivity on daily clothing. Her
parents reported that she was too active since she started to walk. She was also reported to cry or yell when her clothing rituals are not
completed according to her wish. Case four, a 26-month-old boy, was admitted to our clinic by the complaints of self injurious behavior,
sleep problems and food refusal. He was reported to cry and hit his head to the wall when her wishes are not done instantly. He had
difficulty on initiation sleep and had frequent awakenings in the night. At the first evaluation, behavioral treatment and hydroxyzine HCL
were recommended in all cases. However, after 3 weeks, no efficacy was observed on primary complaints. Before risperidone treatment,
a routine pediatric examination and medical tests including complete blood counts, blood biochemistry and ECGs were performed.
Risperidone was started in the dose of 0.125 mg/day and gradually increased to 0.25 mg/day at the 1st week. After 1 month, all of the
cases had significant improvement in target symptoms, including sleep and food intake. None of patients reported impairing adverse
reactions and post-treatment medical tests were in normal range. Problematic weight gain was not reported in any patient.
Our positive results in 4 children before 30 months of age may be considered as promising for the safe and tolerable use of risperidone in
very young children. However, large sample sized short-term and long-term controlled studies are needed to confirm our findings. Pretreatment medical evaluation, careful motorization and slow dose titration may be the keys of high tolerability.
Keywords: risperidone, very young children, ADHD
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[Abstract:0470] Child and adolescent mental and behavioral disorders
Acute psychosis in a adolescent with neurobrucellosis: a case report
Salih Gencoglan1, Mustafa Erkan2, Leyla Akguc3
1Department of Child and Adolescent Psychiatry, Yuzuncu Yil University, Faculty of Medicine, Van-Turkey
2Department of Gastroenterology, Sisli Hamidiye Etfal Taining and Research Hospital, Istanbul-Turkey
3Department of Psychiatry, Mardin State Hospital, Mardin-Turkey
e-mail address: [email protected]
Brucellosis is a multisystem zoonotic disease with varied manifestations. Neurobrucellosis is an uncommon complication of brucellosis
and can present as meningitis, meningoencephalitis, myelit, radiculoneuritis, peripheral neuropathy, intracranial hypertension and
cranial nerve palsy. It has been reported that neurobrucellosis may mimic insidious psychiatric diseases and present with psychotic
manifestations and complications. We purposed to report a case with acute psychosis due to neurobrucellosis.
A 13-year-old adolescent who was followed up due to Brucella infection in outpatient pediatric infectious diseases as outpatients.
Adolescent was consulted to our clinic due to talking nonsense, hallucinations, laughing to oneself, detrimental behavior towards people,
nervousness, insomnia and lack of appetite. He experienced increased psychomotor activity and had occasional aggressions in terms of
behavior. Patient was initiated on olanzapine treatment with a dose of 10 mg/day and the dose was gradually increased up to 20 mg/
day. In the follow-up visits of the patient a significant decline was noted in complaints and such complaints as insomnia, lack of appetite,
auditory and visual hallucinations, delusions, agitation and disorganized behavior were eliminated.
The diagnosis of neurobrucellosis may be missed as this infection can imitate various diseases. Patients may be admitted with neurological
and psychiatric disorders. The presence of obscure or unexplained neurological and psychiatric disorders should alert the clinician to
the possibility of neurobrucellosis in endemic regions. Neurobrucellosis should be ruled out in all patients who develop unexplained
neurological symptoms, especially in those who live in endemic areas.
Keywords: adolescent, neurobrucellosis, acute psychosis
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[Abstract:0489] Child and adolescent mental and behavioral disorders
Aripiprazole induced severe weight loss: a case report
Nilfer Sahin1, Bedia Ince Tasdelen2
Department of Child and Adolescent Psychiatry, Mugla Sitki Kocman University, Faculty of Medicine, Mugla-Turkey
1
Department of Child and Adolescent Psychiatry, Elazig Mental Health Hospital, Elazig-Turkey
2
e-mail address: [email protected]
Autism spectrum disorders (ASDs) is characterized by impairment in social interaction, abnormalities in language development, restricted
interest and/or repetitive behaviors. Children with autism and ASDs have a high rate of irritability and aggressive symptoms. In a study, up
to 30% of children with autism have symptoms of irritability, including aggression (24.5%), severe tantrums (30.2%), and deliberate selfinjurious behavior (SIB) (16%). The treatment of irritability in ASDs is multimodal and includes the use of behavioral and pharmacologic
approaches. Aripiprazole is a quinolone derivative, which has higher affinity to dopamine D2, and D3 receptors as well as 5-HT1A, 5-HT2A
and 5-HT2B receptors. Aripiprazole has been recently approved to treat irritability associated with autistic disorder in children and
adolescents 5–16 years of age. Here, we present a case of aripiprazole-induced severe weight loss in a child with autistic disorder.
Case: A 6-year-old nonverbal male with prior psychiatric diagnoses of autism, mental retardation, and attention-deficit/hyperactivity
disorder. He was admitted to our outpatient policlinic due to an increase in aggression and self-injurious behavior. His behavior included
head banging and scratching himself until he bled. When patient come to the examination he was using risperidone 1 mg/day for 2 years.
Risperidone escalated to a dose of 1.5 mg per day to cope with his behavioral problems. In the control visit on the second week, there
was no improvement in aggression and self-injurious behavior. Thus, risperidone was withdrawn while 1 mg per day aripiprazole was
initiated, which then escalated to a dose of 4 mg per day. In the control visit on the second week, it was found that aggression and selfinjurious behavior was greatly reduced. However, his mother complained significantly decreased appetite for 2 weeks. His body weight
was 19 kgs with a height of 110 centimeters. Although decreased appetite side effects, treatment continued and recommended to arrive
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after 2 weeks. 2 months later he was admitted to our outpatient policlinic due to severe weight loss (4 kgs in 2 months). His body weight
was 15 kgs. No abnormal finding was detected in physical and neurological examinations as well as blood tests including complete blood
count and biochemistry and thyroid function tests. We eliminated organic conditions that can cause weight loss. Then we discontinued
medication, to observe weight loss is whether due to aripiprazole or not. After discontinuation the aripiprazole treatment, appetite has
returned to normal and the patient received 2 kgs in a month.
Aripiprazole is reported to cause fewer side effects e.g., weight gain, elevation in glucose and lipid levels, prolactin elevation, QTc
prolongation, and onset of diabetes mellitus compared to other atypical antipsychotics. Other side effects include headache, somnolence,
nausea, vomiting, insomnia, lightheadedness, constipation, increased appetite and dyspepsia. However, in over-weight children and
adolescents with ASD, who receive atypical antipsychotics for long periods, switching to aripiprazole may be beneficial for metabolic
parameters; thus, our case report shows that aripiprazole-induced severe weight loss should be born in mind when using this drug.
Keywords: aripiprazole, autism, weight loss
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[Abstract:0532] Child and adolescent mental and behavioral disorders
Risperidone induced Pisa syndrome in a male adolescent
Serkan Gunes1, Meltem Cobanogullari Direk2, Veli Yildirim1, Cetin Okuyaz2, Fevziye Toros1
Department of Child and Adolescent Psychiatry, Mersin University, Faculty of Medicine, Mersin-Turkey
1
Department of Pediatric Neurology, Mersin University, Faculty of Medicine, Mersin-Turkey
2
e-mail address: [email protected]
Pisa syndrome (PS) or pleurothotonus is a rare condition of acute or tardive dystonia. PS is characterized by an abnormal posture with
tonic lateral flexion and slight rotation of the trunk. This abnormal posture resembles the Leaning Tower of Pisa. In this case report, a male
adolescent who developed Pisa syndrome with risperidone treatment will be presented.
A 15-year-old boy was admitted to pediatric neurology clinic for the complaint of abnormal posturing. Interviewing with the family, it was
learned that he had been diagnosed with attention deficit hyperactivity disorder, conduct disorder and mental retardation by a child and
adolescent psychiatrist and risperidone 2 mg/day therapy was commenced to control behavioral problems. Risperidone 2 mg/day therapy
has continued for the last four years and one month ago the patient developed tonic flexion of trunk and head toward left. History taken
from his relatives suggested no additional medication use. No movement and neurodegenerative disorders were reported in family history.
Neurologic examinations showed that the patient had clear consciousness, no cranial nerve problems and no abnormalities in sensation
of the extremities, muscular strength and deep tendon reflexes. Tonic flexion of trunk and head to the left and shift of the center of gravity
toward the left were observed. No evidence of other extrapyramidal symptoms was found. No abnormalities in common blood and
biochemical tests were seen. Magnetic resonance imaging of the head detected global cortical atrophy, agenesis of the corpus callosum
and no abnormality in basal ganglia.
The diagnosis of PS was suspected, because abnormal standing posture occurred after long-term risperidone use and possible
neurological diseases were excluded by family history and neurological examinations. After consultation with a child and adolescent
psychiatrist, the daily dose of risperidone was decreased from 2 mg to 1 mg. Approximately 2 weeks after reducing the dose, abnormal
posture gradually improved and flexion of trunk and head resolved.
PS can be defined as a special type of extrapyramidal side effects, commonly associated with prolonged use of typical antipsychotics. It
was also reported with atypical antipsychotics clozapine, olanzapine, risperidone, aripiprazole and quetiapine. In our case, the patient
developed PS four years after using risperidone.
A dysfunction of cerebral dopaminergic pathways which are important for regulation of axial muscle tone is a possible causative factor
in the pathophysiology of PS. Risperidone is a new generation antipsychotic drug with a high affinity for dopaminergic D2 receptors.
Blockade of D2 receptors in cerebral dopaminergic pathways with risperidone could be associated with PS in our case.
Risk factors of PS include old age, female gender, previous treatment with typical antipsychotics, combined pharmacologic treatment and
the presence of organic brain disorder. Our case is a 15-year old male with organic brain changes.
In conclusion, the present case was reported as a reminder of PS and to emphasize that this motor complication can be seen in young
males who are receiving antipsychotic medication.
Keywords: adolescent, Pisa syndrome, risperidone
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[Abstract:0540] Child and adolescent mental and behavioral disorders
New developments in psychopharmacological treatments of childhood anxiety disorders
Ayhan Bilgic
Department of Child and Adolescent Psychiatry, Necmettin Erbakan University, Meram Faculty of Medicine, Konya-Turkey
e-mail address: [email protected]
Anxiety disorders are the most common type of psychiatric disorders diagnosed in childhood, with a prevalence rate of between
6 and 20%. They adversely affect social and family relationships as well as school performance of children. Advances in pediatric
psychopharmacology raise a number of opportunities to potentially decrease morbidity in children with anxiety disorders. Growing body
of data suggests that selective serotonin reuptake inhibitors (SSRI) and cognitive–behavioral therapy (CBT) are effective for the treatment
of pediatric anxiety disorders. Moreover, the majority of acute responders to the SSRIs or CBT maintained positive response during to
long-term treatment. However, especially for youth with moderate to severe anxiety symptoms, multimodal treatment is recommended,
including medication in combination with cognitive behavioral therapy. While considering pharmacologic treatment, selection should
be guided by the evidence base and clinical guidelines. Side-effect profiles of the pharmacologic agents, the presence of coexisting
psychiatric disorders and unique clinical characteristics of the patients should also be taken into account. Nowadays, limited information
is available on the pharmacologic treatment approach for partial and nonresponders to first-line treatments in children. Further studies
is needed to determine the use of second- and third-line treatments or augmentation strategies. In this panel novel development in the
treatment of pediatric anxiety disorders will be discussed in detail.
Keywords: anxiety disorders, children, psychopharmacology
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[Abstract:0631] Child and adolescent mental and behavioral disorders
Beneficial effects of lithium on severe irritability in a patient with Rett syndrome
Duygu Kinay1, Ilyas Kaya1, Ahmet Zihni Soyata2, Ayse Kilincaslan1
Department of Child And Adolescent Psychiatry, Istanbul University, Cerrahpasa Faculty of Medicine, Istanbul-Turkey
1
Department of Psychiatry, Istanbul University, Cerrahpasa Faculty of Medicine, Istanbul-Turkey
2
e-mail address: [email protected]
Rett syndrome (RS) is a neurodevelopmental disorder that causes severe cognitive and physical impairment. Its predominant features
include social withdrawal, loss of previously acquired skills (e.g. loss of acquired motor skills and speech), and gait ataxia. Currently, there
are no specific treatment options for RS and the treatment is predominantly symptomatic. Here, we present a case of RS with severe
irritability that improved with lithium.
A 20-month-old girl had been first brought to our clinic by her parents with symptoms of speech delay, social withdrawal, repetitive
hand stereotypies (hand washing, clapping, or twisting), shouting, feeding problems, insomnia and bruxism. Diminished eye contact had
been observed. Her psychomotor development had been considered to be normal till eight months, however, significant delay had been
observed in communication and social interaction on the admission examination. From 3 to 8 years, the patient had gone to a different
clinic. When she had been brought again at age 8, MECP2 gene mutation was detected and the patient was diagnosed as having RS.
Daily doses of melatonin 3 mg, valproic acid 200 mg, and risperidone 0.75 mg. were initiated for insomnia and impulsivity. Melatonin
had minimal benefit and risperidone had to be stopped due to severe weight gain. After a relatively stable period, severe irritability and
agitation emerged at the age of 10. The patient also had increased energy, decreased need for sleep, self-mutilative behaviors such as
arm-biting, disruptive and aggressive behaviors such as hitting people, breaking objects and shouting. Zuclopenthixole, haloperidol and
quetiapine did not improve these symptoms. Subsequently, lithium was initiated and titrated up to 1200 mg. All symptoms disappeared
in 2 weeks and did not reemerge at the 6-month follow-up.
Lithium has been used in psychiatry for more than 60 years in the treatment of bipolar disorders. It has also been associated with reduction
in aggressive behavior in youth with conduct disorder and other neurodevelopmental disorders. In the present case, the beneficial effects
of lithium on both mood and aggression might have caused improvement in the symptoms. Additionally, brain-derived neurotropic
factor (BDNF) has been recently implicated in the pathophysiology of RS. It has been proposed that lithium and antidepressants might be
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useful in RS via enhancing the BDNF release. In conclusion, lithium may be an effective treatment choice for patients with RS and severe
irritability. Beneficial effects of lithium in RS should be evaluated in larger series to confirm our observations.
Keywords: lithium, neurodevelopmental disorders, Rett syndrome
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[Abstract:0633] Child and adolescent mental and behavioral disorders
Antipsychotics’ side effects to treatment compliance in adolescents: a case report
Evrim Aktepe, Emel Ozen, Funda Ozyay Eroglu, Orhan Kocaman
Department of Child and Adolescent Psychiatry, Suleyman Demirel University, Faculty of Medicine Isparta-Turkey
e-mail address: [email protected]
For general health and psychiatric morbidity, weight gain is one of the major problem in adolescants. Antipsychotic-induced weight gain
is main reason of treatment noncompliance that increases the risk of relapse. Weight gain also affects the psychological well-being. One of
the side effects of antipsychotic drugs in the endocrine system is the increase prolactin level and clinical manifestations of prolactin such
as galactorrhea, amenorrhea and irregular periods in women. Noncompliance is an important problem that affects all areas of medicine
and may be worse for psychiatric disorders, especially for psychosis. The side effects have played a major role in compliance. In this case
report, adolescent patient with non-adherence to antipsychotic medication due to side effects was presented.
A 16-year-old female patient admitted to the outpatient clinic with complaints of irritability, aggression and tantrums. At the initial
evaluation; truancy from school, lying, arguing with adults, bullying, substance abuse, self-mutilation, suicide attempt, impulsivity were
detected for a year. Risperidone 1 mg/day was prescribed with the prediagnosis of conduct disorder. The first months of treatment was
observed decrease in symptoms. In the fourth month, she reported amenorrhea, galactorrhea, increased appetite and weight gain (9 kg).
Her prolactin level was found to be minimal elevated (27 ng/mL, normal range: 3.34-26.72 ng/mL). Gynecologic assessment was normal.
She was started on aripiprazole 2.5 mg/day, which was gradually increased to 5 mg/day over the next 4 weeks and simultaneously,
risperidone was tapered off 0.5 mg less every other week and stopped. She resumed normal menstruation after 4 weeks and galactorrhea
stopped. In the third month of aripiprazole treatment; a sense of loss of control on eating behavior, postprandial regret, make excessive
exercise symptoms were determined without weight gain. But she refused the treatment and dropped out because of side effects.
Usage of antipsychotics is widespread in many psychiatric disorders in pediatric groups. Antipsychotic-induced weight gain is becoming
one of the topics that most complaints of patients. Adolescents may be more sensitive to the weight gain effects of antipsychotic. In
adolescents; weight gain can lead to aggression, loss of confidence, negative self-concept and low self-esteem. Elevated dieting, pressure
to be thin, appearance overvaluation, body dissatisfaction, body mass, and low self-esteem and social support are predictor for eating
disorders. Bulimia nervosa is an eating disorder characterized by binge eating (large amount of food in a short time) and purging, typically
by vomiting, taking a laxative, diuretic and/or excessive exercise, because of an extensive concern for body weight. In this case, she
reported a sense of loss of control on eating behavior, postprandial regret, make excessive exercise, extensive concern for body weigh
symptoms and prediagnosis of bulimia nervosa non purging subtype was excluded due to lack of binding episodes.
Keywords: adolescent, antipsychotics, compliance
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[Abstract:0645] Child and adolescent mental and behavioral disorders
Management of aggression in children with psychiatric disorders
Serhat Turkoglu1, Tumer Turkbay2, Ayhan Bilgic3, Dursun Karaman2
Selcuk University, Faculty of Medicine, Konya-Turkey
1
Gulhane Military Medical Academy, Ankara-Turkey
2
Necmettin Erbakan University, Meram Faculty of Medicine, Konya-Turkey
3
e-mail address: [email protected]
Aggression can be characterized as behaviors with the immediate purpose of causing harm to another individuals. Aggression is
considered as a crucial component of human behavior. Although aggressive behaviors can serve an adaptive function in particular
situations, maladaptive aggression can have a serious impact on the individuals and their society. Aggression in childhood may be linked
with short- and long-term costs, such as low academic performance, peer victimization and rejection, disruptive behaviors. Furthermore,
aggression in childhood, seems to be a predictor of life time aggressive behaviors, criminality and related public health concern.
Aggression in children and adolescents is associated with multiple factors. It is clear that both the genetic and environmental parameters
show an effect in the development of aggression, but how they interact in the existence of the behavior is not well known. Demographic,
temperamental, parental and familial factors, and cultural differences were found to be associated with aggression in children. Otherwise,
it has been proposed that early-life environment, including prenatal/postnatal stress, may play a critical role in the development of
aggression in children. According to this aspect, early difficulty produces acute and long-lasting epigenetic alterations, therefore these
alterations may influence brain development and the ability to learn to control aggressive behavior.
Former knowledge suggests that family factors, such as socioeconomic status and parenting style, are associated more mightily with
aggressive behaviors in children. Many studies showed that for aggression in children, both parenting skills training and training for
the child aimed at improving peer relationship, problem-solving skills, academic skills and compliance with demands from authority
figures are effective treatment strategies. Currently, the most effective treatment for aggression is a combination of behavior therapy and
pharmacological treatment. In this workshop novel development in the treatment of aggression in children will be discussed in detail.
Keywords: child, aggression, psychiatric disorder
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[Abstract:0651] Child and adolescent mental and behavioral disorders
Urinary retention associated with atomoxetine use: a case report
Nilfer Sahin1, Hatice Altun2
Department of Child and Adolescent Psychiatry, Mugla Sitki Kocman University, Faculty of Medicine, Mugla-Turkey
1
Department of Child and Adolescent Psychiatry, Sutcu Imam University, Faculty of Medicine, Kahramanmaras-Turkey
2
e-mail address: [email protected]
Atomoxetine is the first non-stimulant drug approved by the United States Food and Drug Administration for the treatment of Attention
Deficit Hyperactivity Disorder (ADHD). By inhibiting the presynaptic reuptake of norepinephrine, atomoxetine leads to an increase in the
level of norepinephrine. Atomoxetine has a limited effect on the reuptake of serotonin, and minimal affinity to the receptors of other
neurotransmitters and carriers. The most common side effects are stomachache, decreased appetite, vomiting, somnolence, nervousness,
asthenia, vertigo and dyspepsia. In this manuscript, we present a 12-year-old male case that developed acute urinary retention in the
period following atomoxetine treatment. A 12-year-old male came to our outpatient clinic due to the following complaints: “unwillingness
to study at home, attention deficit, low performance in class, forgetfulness, hyperactivity, constant and excessive talking, disorderly
behavior in class “. It was determined that the child had been hyperactive ever since he learned to walk. After being referred to the child
psychiatry outpatient clinic while in 2nd grade, the child was diagnosed with ADHD and started on short-acting methylphenidate 5 mg
three times a day. However, methylphenidate led to complaints of excessive palpitations, after which the child’s family discontinued the
treatment and did not take their children to another psychiatric examination.
During the psychiatric evaluation, it was observed that his level of psychomotor activity had increased, that he had difficulty in focusing
his attention, and that his level of impulsivity was very pronounced. Based on the psychiatric assessment, ADHD - Combined Type was
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diagnosed. The physical examination and ECG findings of the patient were within normal limits. Taking into account the complaint of
palpitation triggered by methylphenidate in the patient’s medical history, the patient was started on atomoxetine. Based on the case’s
weight (55 kg), plans were made to begin atomoxetine treatment at a dose of 25 mg/day, and to raise the dose to 50 mg/day two weeks
later; however, the case experienced a decrease in the frequency and quantity of urination on the first day, and urinary retention on the
second day following the beginning of the treatment. The case was not taking any medication other than atomoxetine, and had no history
of trauma, or any previous complaints of burning sensation during urination or urinary retention. The urology department was consulted.
Examination, biochemical parameters and ultrasonography performed by the Urology clinic suggested acute urinary retention associated
with atomoxetine. Atomoxetine was discontinued and during this control visit performed one day later, it was learned that the patient’s
urination frequency had returned to normal. The urinary storage and discharge processes are regulated by the balanced between the
sympathetic and the parasympathetic pathways. However, the excessive activation of the sympathetic system may lead to urinary
retention through the inhibition of the parasympathetic pathway. Urinary retention caused by the use of atomoxetine, a noradrenergic
agent, can be explained by the disruption of the sympathetic-parasympathetic balance involved in the process of urination due to the
excessive activation of the sympathetic system.
Keywords: atomoxetine, side effects, urinary retention
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[Abstract:0664] Child and adolescent mental and behavioral disorders
Major depression with catatonic features in an adolescent remitted with olanzapine and alprazolam
Yagmur Gunduz1, Ayse Kilincaslan1, Hamza Ayaydin2, Ilyas Kaya1
Department of Child and Adolescent Psychiatry, Istanbul University, Cerrahpasa Faculty of Medicine, Istanbul-Turkey
1
Edirne Public Hospital, Edirne-Turkey
2
e-mail address: [email protected]
Catatonia is a disorder defined primarily by a cluster of signs including immobility, mutism, and withdrawal or refusal of food and water,
no reaction to sensory stimuli, sometimes with the symptom of waxy flexibility. Here, we present a 13 year-old boy diagnosed with major
depressive disorder with catatonic features, which remitted following treatment with olanzapine and alprazolam.
The patient was brought to the child and adolescent psychiatry outpatient clinic by his parents with symptoms of loss of interest in
enjoyment activities, crying, withdrawal, sleeplessness, declining appetite that had resulted 11 lbs weight loss, irritability and depressive
mood that started 2 months ago. His parents described progressive psychomotor retardation, loss of spontaneous speech, staying in the
same posture for hours, refusal of food in the last 20 days. The patient was not hospitalized, was started 10 mg/day olanzapine and 1
mg/day alprazolam and followed with weekly visits. At the second visit, his parents reported that his reduced movement and movement
speed was improved but he still had no spontaneous speech. Olanzapine was increased to 20 mg/day. At the third visit his parents
reported improvement in appetite and sleep but he was still depressed. Citalopram 10mg/day was initiated. At the fourth visit, he was
talking spontaneously. With remission of the catatonic symptoms, alprazolam was decreased to 0.5mg/day and stopped in two weeks.
After six weeks of his admission, he is currently on olanzapine 10 mg/day plus citalopram 20 mg/day regimen and clinically showed
remarkable improvement in his depressive symptoms without any residual catatonic symptoms.
Catatonia is a severe psychomotor syndrome with an excellent prognosis if recognized and treated appropriately. The treatment of
catatonia in children and adolescents should follow the same principles as in adults. Catatonia can accompany many different psychiatric
illnesses and somatic diseases. A minority of catatonic patients suffers from schizophrenia (30%), while a majority has a bipolar disorder
(43%). In a recently study, 20% of depressed patients met the DSM-IV criteria for catatonia. Benzodiazepines are the first-choice treatment
for catatonia, regardless of the underlying condition. Emerging data from the literature emphasize the frequent and successful use of
atypical antipsychotics, including olanzapine, in various clinical forms of benign catatonia. However, use of antipsychotics in the presence
of catatonia should be evaluated in any individual case because of the possibility of aggravating the catatonic symptoms.
Keywords: alprazolam, catatonia, depression
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[Abstract:0691] Child and adolescent mental and behavioral disorders
Biotidinase deficiency and attention deficit hyperactivity disorder
Elif Akin, Canan Yusufoglu, Sebla Gokce
Erenkoy Training and Research Hospital, Istanbul-Turkey
e-mail address: [email protected]
Biotinidase deficiency is a genetic autosomal recessive metabolic disorder in which biotin is not released from proteins in the diet
during digestion or from normal protein turnover in the cell with the primary defect in most individuals with late-onset multiple
carboxylase deficiency If untreated, young children exhibit clinical features of seizures, hypotonia, ataxia, hearing loss, optic atrophy,
and developmental delay, skin rash and alopecia. In literature, there are mostly reports about mental retardation and autism comorbidly
seen with biotidinase deficiency, but not about attention deficient and hyperactivity disorder (ADHD). On the other hand there are some
studies linking ADHD with nutritional deficiencies of coenzymes (B3, B6, biotin, zinc, magnesium) roled in central nervous system.
A 7-year-old boy presented to clinic with inattentiveness, difficulty in learning, excess motor activity, talking too much. He could read and
write, but had a lower academic performance comparing to his grade. He was on special education program for one year as mild mental
retardation with IQ score 62. His medical history included biotidinase deficiency diagnosed early at 3 months of age with seizures and
had been on biotin supplement treatment thereafter. DSM-5 diagnosis of ADHD was made and a very good response in symptoms was
acquired with methylphenidate treatment.
We would like to discuss this case from two separate views. One is, biotidinase deficiency and ADHD are both disorders of genes, not well
known common or not. The other point is that, biotin is one of the cofactors roled in neurotransmitter functioning so also in ADHD but
the effects on symptoms and treatment are questionable.
Keywords: attention deficient and hyperactivity disorder, biotidinase deficiency, biotin
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[Abstract:0692] Child and adolescent mental and behavioral disorders
Factor VII deficiency and methylphenidate use in an attention deficient and hyperactivity disorder twin
Canan Yusufoglu, Elif Akin, Sebla Gokce
Erenkoy Training and Research Hospital, Istanbul-Turkey
e-mail address: [email protected]
Factor VII (FVII) deficiency is a rare congenital coagulation disorder, transmitted with autosomal recessive inheritance, with clinical
phenotypes range from asymptomatic condition, even in homozygotes, to severe disease characterized by life-threatening and disabling
symptoms (central nervous system and gastrointestinal bleeding and hemarthrosis). Methylphenidate is a central nervous system
stimulant drug widely used in Attention Deficit Hyperactivity Disorder (ADHD). Methylphenidate hematologic side effects have rarely
included leukopenia, anemia, pancytopenia, thrombocytopenic purpura, and thrombocytopenia; however, causality has not been
established.
6 year old age twin boys were presented to clinic with attention and learning difficulties, hyperactivity, distractiveness, willingness
in reading and writing. They had WISC-R scores of verbal score: 64, performance score: 82, total score: 71 in one and verbal score: 90,
performance score: 90, total score: 89 in the other. Twin boys were diagnosed clinically as ADHD. Their medical history included FVII
deficiency, with the presentation with stomach bleeding three times at about five in one of boys. They had no drug treatment history.
Hematological laboratory blood counts checked before stimulant drug treatment for ADHD symptoms were in normal range. The boys
treated with short acting methylphenidate at average dose of 10 mg per day with improvement in ADHD symptoms and on follow up
regular blood counts were made with no significant change and no clinical symptoms of bleeding or any other related.
In this twin case with FVII deficiency, a genetic coagulation disorder with the possible bleeding symptoms, we point the good results with
a safe and effective use of methylphenidate.
Keywords: attention deficient and hyperactivity disorder, factor VII deficiency, methylphenidate
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[Abstract:0697] Child and adolescent mental and behavioral disorders
A case of attention deficit hyperactivity disorder and an X de novo structural chromosome
abnormality
Elif Akin1, Canan Yusufoglu1, Yasemin Yulaf2
Erenkoy Training and Research Hospital, Istanbul-Turkey
1
Tekirdag Child and Adolescence Mental Health Clinic, Tekirdag-Turkey
2
e-mail address: [email protected]
All human behavior is the result of both genetic and environmental factors. Genetic vulnerability underlies a number of child psychiatric
disorders. There have been a number of case reports of child psychiatric patients with a variety of abnormal chromosomes and many
researchers have studied the relationship between chromosomal abnormalities and child psychiatric conditions such as autistic disorder
or mental retardation. Attention deficit hyperactivity disorder (ADHD) is a common, heritable disorder of childhood. Sex chromosome
abnormalities are relatively rare conditions that are sometimes associated with behavioral disorders.
A 14-year-old boy was referred to clinic with failure in academic abilities with no reading and writing, inability in learning in special
education with difficult in sitting and focusing attention during the lesson time. He could not have much activity as he had depended
on someone else for self care. In physical examination he had microcephaly and his developmental history included delay in walking
and language at nearly five, had on special education program for seven years. He had ASD cardiac operation at six. His medical history
revealed de novo structural chromosome anomaly (7q 36-7q ter monozomy, Xp22.13-Xp ter trizomy). His IQ score was 43, clinically
diagnosed as moderate mental retardation and ADHD.
Chromosome anomalies can be inherited from a parent or be “de novo”. This is why chromosome studies are often performed on parents
when a child is found to have an anomaly. If the parents do not possess the abnormality it was not initially inherited; however it may be
transmitted to subsequent generations. Considering this case and considering ADHD, the authors propose that the sex chromosomes
may contain risk genes for ADHD and not only the inherited gene genes may also play a role in ADHD.
Keywords: attention deficit hyperactivity disorder, chromosome abnormality, genetic
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[Abstract:0699] Child and adolescent mental and behavioral disorders
Learning disability in a child with congenital adrenal hyperplasia
Canan Yusufoglu1, Elif Akin1, Yasemin Yulaf2
Erenkoy Training and Research Hospital, Istanbul-Turkey
1
Tekirdag Child and Adolescence Mental Health Clinic, Tekirdag-Turkey
2
e-mail address: [email protected]
Congenital adrenal hyperplasia (CAH) is a syndrome of prenatal and/or postnatal androgen excess secondary to genetic deficits in the
cytochrome p450 enzymes of the cortisol synthesis pathway. Individuals with CAH may suffer from different degrees of androgenization.
Psychosocial factors, endocrinal causes, chronic hypocortisolism and compensatory changes of corticotrophin releasing hormone may
have important clinical implications for psychiatric manifestations. Early exposure to androgens increasesrisk of learning disabilities.
A 12-year-old girl was referred to clinic because of anhedonia, willingness to go to school, nervousness, consulted from endocrinology as
she had just got the diagnosis of diabetes mellitus and had difficult in adapting. She had been diagnosed CAH with the genetic result of
q318x heterozygosity and was under treatment. In addition for later period consequences of CAH, she as using metformin for diabetes
and oral contraceptive for regular menstruations. Before referral to clinic, she had been assessed in another clinic and started sertraline
50 mg/ day and using for two months. History about academic performance revealed poor grades and difficulties in learning from the
beginning of school. She had limited verbal expression and low academic abilities. She had WISC-R scores of verbal score 87, performance
score 116 and total score 101. Learning disability was diagnosed clinically and with educational support and with the therapy of
adaptation problems, she had improvements in academic performance, self esteem, social relationships.
Diagnosis of psychiatric disorders in presence of the diseases with neuroendocrinological effects on central nervous system may be
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sometimes complex in manner. Although CAH itself or as a consequence or sometimes drugs used in treatment of it may cause adaptation
problems with for example depressive symptoms, other psychiatric manifestations- especially learning disabilities- other than the stress
effect should be considered either.
Keywords: androgen, congenital adrenal hyperplasia, learning disability
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[Abstract:0715] Child and adolescent mental and behavioral disorders
Disruptive mood dysregulation disorder and chronic irritability
Sevay Alsen
Dr. Behcet Uz Children’s Diseases and Surgery Education and Research Hospital, Child Protection Center, Izmir-Turkey
e-mail address: [email protected]
As one of the most common symptoms in youth, irritability, is part of the clinical presentation of several psychiatric disorders and their
psychopathology. Irritability is defined as a low threshold to experience anger in response to frustration. Irritability can present early in life
and is a predictor of long-term psychosocial adversity; yet, the diagnostic status of irritability is a matter of intense debate.
Irritability is considered as a deficit in emotional regulation. Developmentally appropriate anger-related behaviors tend to reflect
frustration in expectable contexts, whereas chronic irritability is inappropriate to the situation. Stimuli that could be manageable elicit
intense responses manifested by reactive verbal and/or physical aggression towards the perceived object of threat or frustration. Deficits
in emotional regulation are highly associated with psychopathology and one of the most important predictors of mental disorders in
cross-sectional and longitudinal studies.
Irritability has been surrounded by controversy in child and adolescent psychiatry. First, the debate was driven by the boundaries between
chronic irritability and bipolar disorder (BD) diagnosis. Once the boundaries with BD were clarified, the debate turned to the proposal of a
new diagnosis category called Disruptive Mood Dysregulation Disorder, whose main symptom is emotional dysregulation with behavioral
problems and another prominent feature is nonepisodic (or chronic) irritability. Evidence from both community and clinical longitudinal
studies suggest that such irritability is associated with later unipolar, but not bipolar, mood disorders. Disruptive mood dysregulation
occurs at relatively low rates in the community, and it most often occurs in combination with other psychiatric disorders. This propensity
toward comorbidity is extended to all common psychiatric disorders but is strongest for oppositional defiant disorder and depressive
disorders. Overall, disruptive mood dysregulation disorder is associated with high levels of social impairment, school suspension, all types
of service use, and family poverty. The presentation of irritability - chronic or episodic - is crucial for understanding its psychopathological
meaning, particularly because the constructs of episodic and chronic irritability are separable and remain stable over time. For instance,
the correlation of episodic irritability between early and late adolescence is 0.79, whereas that of chronic irritability, is 0.56. However, the
correlation between episodic and chronic irritability is much lower, 0.34 in early and 0.26 in late adolescence. Thus, chronic and episodic
irritability seldom overlap but are each relatively stable over time. Furthermore, the two constructs present different associations with age:
episodic irritability has a linear association, whereas chronic irritability presents a curvilinear trajectory, with a peak in mid-adolescence.
In addition, longitudinal associations are also diverse between the two phenotypes: episodic irritability in early adolescence is associated
with generalized anxiety disorder, simple phobia, and mania in late adolescence and only mania in early adulthood, whereas chronic
irritability in early adolescence is associated with disruptive disorders in late adolescence and only with major depressive disorder in early
adulthood.
In this article it has been aimed to discuss the association between chronic irritability, DMDD and it’s developmental course in the
perspective of childhood psychiatric disorders.
Keywords: chronic irritability, disruptive mood dysregulation disorder, emotional dysregulation
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[Abstract:0728] Child and adolescent mental and behavioral disorders
Ventricular asymmetry in autism spectrum disorder comorbid attention deficit hyperactivity
disorder and treatment with atomoxetine
Nermin Yucel1, Atakan Yucel2, Mutlu Karakus3
Department of Child and Adolescent Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
1
Department of Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
2
Department of Psychiatry, Agri State Hospital, Agri, Turkey
3
e-mail address: [email protected]
Autism spectrum disorders (ASD) and attention deficit hyperactivity disorder (ADHD) are neurodevelopmental disorders. ADHD, the most
common psychiatric disorder in childhood, is defined by inattention, hyperactivity, and impulsivity, while ASD is characterized by social
dysfunction and restricted, repetitive behaviors/interests. In our case we reported a child with ventricular asymmetry who diagnosed ASD
comorbid ADHD and had treated with atomoxetine.
A 10 years-old boy referred our outpatient clinic with complaints including hyperactivity, inattention, aggression, difficulty in keeping
the rules, poor peer relations, interest to the technological tools, twirling around and lack of reciprocal conversation. Concerning his
neurodevelopmental history he started to walk at 3 year-old, he talked with two words at 5 year-old and he obtained sphincter control at
6 year-old. There was no psychiatric history in his family. In his psychiatric examination; he was cooperated and oriented. The hyperactivity,
short attention span, poor eye contact, difficulty maintaining conversations, echolalia and restricted/stereotyped behaviors were observed.
His physical and neurological examination was unremarkable. His blood pressure was 110/60 mm/Hg, heart rate was 96 bpm and weight
was 36 kg. Laboratory tests including thyroid function tests, complete blood count, electrolytes, liver function tests, kidney function tests
were normal. The cerebral ventricular asymmetry was detected in MRI however no intervention was recommended by neurosurgery. The
diagnosis was compatible with ASD accompanied by ADHD according to DSM-5. Childhood Autism Rating Scale (CARS) score was 35,
Autism Behavior Checklist (ABC) score was 102 and Conner’s Parent Rating Scale- Short Form(CPRS-SF) score was 49 and Conner’s Teacher
Rating Scale- Short Form (CTRS-SF) score was 38. Methylphenidate was applied at 0.5 mg/kg dose initially and was titrated up to 1mg/
kg in following two weeks. In the 3rd week of follow-up, his grandmother reported that he was angry, nervous, restless and irritable. He
suffered insomnia additionally he attempted to jump from the window repeatedly and cyanosis appeared on his face and extremities.
Methylphenidate treatment was terminated. Then atomoxetine applied 0.5 mg/kg at first and increased 1.1 mg/kg dose after a week. In
the 3rd week of atomoxetine treatment, his symptoms such as hyperactivity, inattention, impulsivity, irritability, stereotyped behaviors,
technological interests were reduced. Atomoxetine was well tolerated. At the 5th weeks from the initiation of atomoxetine treatment CARS,
ABC, CPRS-SF, CTRS-SF were scored as 29, 87, 34, and 26, respectively. There was no any cyanotic body section, insomnia, suicidal attempt.
In clinical practice, 30–85 % of children with ASD manifest hyperactivity, inattention and impulsivity symptoms, which are core symptoms of
ADHD. Cerebral asymmetry is a common feature in both disorders. Additionally, cerebellar changes and asymmetry demonstrated to be linked
with ASD, also a reversal of cerebral asymmetry has existed from anatomical and functional neuroimaging studies in subjects with ADHD.
Pharmacological treatments for ADHD, methylphenidate and atomoxetine, have used in ASD with ADHD symptoms. Atomoxetine has a better
tolerability than stimulant medications because of safe side effect profile in co-occurring ADHD and ASD. The conclusion of the current trials
suggests that treatment with atomoxetine reduced ADHD symptoms and may improve restricted/stereotyped behaviors and communication.
Keywords: attention deficit hyperactivity disorder, atomoxetine, autism spectrum disorder
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S284
[Abstract:0738] Child and adolescent mental and behavioral disorders
Nicotine and alcohol addiction in adolescents
Gul Karacetin
Department of Child and Adolescent Psychiatry, Bakirkoy Training and Research Hospital, Istanbul-Turkey
e-mail address: [email protected]
Adolescence is a critical period that involves pubertal changes, continuation of brain development, formation of identity and an increase
in risk-taking behaviors. Because of these developmental features, adolescence is one of the periods in human life that carry the greatest
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risk for onset of nicotine and alcohol use. Also, adolescents are reported to have lower sensitivity to the sedative effect of alcohol; which
is a risk factor for continuation of its use. Nicotine and alcohol use, once initiated, may turn into repeated use and addiction with time. In
addition, the sequence of initiation to substance use generally begins with alcohol and nicotine, which is followed by other substances.
Nicotine and alcohol addiction has many negative consequences for psychological and physical health of adolescents. Thus, prevention
of nicotine and alcohol use is very important in terms of prevention of use of other substances and health-related risks of nicotine and
alcohol. Effective strategies for the prevention of nicotine and alcohol addiction depend on control of risk factors and protective factors.
Risk factors can be divided into individual, familial and community factors. Many adolescents are able to avoid addictive use of nicotine
and alcohol despite their exposure to risk. This led to the investigation of protective factors. Prevalence, clinical characteristics, prevention
and treatment of nicotine and alcohol addiction in adolescents will be summarized in this presentation.
Keywords: nicotine, alcohol, addiction
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S284-S5
[Abstract:0749] Child and adolescent mental and behavioral disorders
Postpartum depression mothers and their children
Serhat Nasiroglu
Sakarya University, Training and Research Hospital, Sakarya-Turkey
e-mail address: [email protected]
There is a very strong evidence that parental psychiatric disorders are damaging child development. Maternal depression is associated as
a risk factor for the socioemotional and cognitive development of the children. According to the standard diagnostic criteria; Postpartum
depression seen in mothers can be explained and defined as a part of non-psychotic depression within a one year of childbirth.Studies
have shown that 13%-40% of pregnant women have shown maternal depression symptoms, which make it the most common prenatal
complication.
During the postnatal period the incidence of depression in mothers is around 9.8% and 4.8% in fathers according to a recent metaanalysis report.Turn-taking skills and many others are thought to be the ones learned via mother-infant interactions, which are the
“playing field” of these infants. The amount of these behaviors shown to be decreased in depressed mothers and their infants, which
eventually contribute their interaction breakdown. Behavioral disorders seen in children may stem from from these parental psychiatric
breakdowns and disturbances.Externalizingbehaviors and low social competence in adolescent boys were independently associated with
early exposure to maternal depression, which is including the prenatal one as well. Significantly increased risk of externalizingbehaviors
and significant lower verbal intelligence was associated to prenatal depression but not anxiety neither postpartum depression according
to a study by Barker et al.
Different number of studies have questioned the basal cortisol secretion levels in at risk groups including the children of depressed parents
given the anticipated roles of HPA axis dysfunction in depressive disorders. Change in cortisol stress reactivity in the children of depressed
parents are also seen in some studies at least as tested in young infants and children. Cross-sectional studies of young infants are suggesting
the increased cortisol reactivity. Even though there is not so much studies examining the cortisol reactivity in youth or adults at risk for
depressive disorders. Results are showing that boys of PPD mothers gave significantly more poorly on the perceptual, motor and verbal
subscales of the McCarthy Scales of Children’s Abilities (McCarthy 1972) compared to the girls or children of non PPD mothersMurray’s
cohort also examined behaviors of a child at 5 years postpartum. Strong effect of PPD have been seen in maternal reports explaining the
child’s behavior at home: those who had been depressed. Maternal reports of the child’s behavior at home showed a strong effect of PPD:
Significantly higher levels of disturbance than well mothers are seen in those who had been reported as depressed.In special case child
neurotic and antisocial behavior were higher. Controlling the attachment security, gender of child, parental conflicts and socioeconomic
status remained.The relationship of postpartum mood to maternal report of infant crying and activity level were evaluated by a study of
88 expectant mothers. Activity level was evaluated by actometers (i.e., small wristwatches modified to detect motion) at each 6 weeks.
Keywords: children, maternal depression, postpartum depression
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[Abstract:0825] Child and adolescent mental and behavioral disorders
Psychotic disorder due to Lafora disease: a case report
Safak Taktak
Department of Psychiatry, Ahi Evran University, Education and Research Hospital, Kirsehir-Turkey
e-mail address: [email protected]
Lafora disease is a type of progressive myoclonic epilepsy with poor prognosis, characterized by myoclonus, seizures, cerebellar ataxia
and mental disorder. Lafora disease frequently develops 10-18 years of age and transmission is autosomal recessive. Epilepsy in children
and adolescents with depression, anxiety disorders, attention deficit hyperactivity disorder can be seen relatively frequently. More rarely,
these people can be seen in psychotic disorders. In this paper, we aimed to draw attention to diagnosis of fatal treatment-resistant and
diagnosis of Lafora developing psychotic symptoms in children. In this case, there is a 12 year-old daughter. The girl’s father followed with
diagnosis of schizophrenia, there are mothers and grandmothers in the history of epilepsy. This girl, after returning from school in the
seventh grade asleep in the room, could not be awakened up in the morning, was recognized uriner incontinence and taken to hospital.
EEG in the upper brain stem and primary generalized epileptiform from midline structures determined that an abnormality.
Despite of the fact that he increasing doses of valproic acid 3000 mg/day Carbamazepine 800 mg/day have been use, it were not associated
with an improvement in the disease. The first three years passed at least three times a week, asleep in the arms and legs as jerking
described by mother seizures have been learned over the last year through every day. After the first attack irritability, suspiciousness,
mobility, obedience to, patient with aggressionattempted suicide by drinking a year after their heart medications at home. It was found
the last three years in a psychiatric ward 9 times briefly at admission was made. Routine biochemistry, complete blood count, thyroid
hormones, and the vitamin levels were within normal limits. When psychiatry files examined, generally being willing to communicate,
psychomotor activity from time to time increased, which is properly association, affects the variable it is, sexual content and paranoid
delusions of thought content, auditory and visual hallucinations, orientation, being sufficient attention and memory was found. Although
in the treatment of patient, Amisulpride, trifluperazine, quetiapine, chlorpromazine, haloperidol were used, constantly running away from
home, the exit in front of the speeding car has been determined. This patient was found to jump from the third floor of home. MRI did
not reveal any pathology in the brain a year before she died, Made in genetic analysis; EPM2 the gene was determined that the deletion.
Also, mutation was not found in the indicated exon scanned. The diagnosis was Lafora and Clobazam 30 mg/day was added to treatment,
but it was indicated that these drugs do reduce irritability outside of a clinical correction. Especially over the last year in order to reduce
psychotic relapse in emergency service at least once a week, haloperidol has to be done 10 mg of haloperidol and biperidene 5 mg IM.
She died at the age of 16, had not awakened up when she last seizure, due to come foaming at the mouth and bruising was admitted to
intensive care. Two days later it was learned that the patient died with pneumonia aspiration
Keywords: clobazam, lafora, psychotic disorders
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S286
[Abstract:0859] Child and adolescent mental and behavioral disorders
Trichotillomania and habit reverse training
Didem Behice Oztop
Department of Child and Adolescent Psychiatry, Erciyes University, Faculty of Medicine, Kayseri, Turkey
e-mail address: [email protected]
Trichotillomania (TTM) has been known for a long time, but it has attracted less attention according to other psychiatric disorders. It
is characterized as significant hair loss due to individuals’ repetitive self-pulling of hair and is classified as Obsessive-Compulsive and
Related Disorders in DSM-5. Hairpulling is the trademark symptom of the disorder. Children with TTM pull their hair from anywhere it
grows, including (but not limited to) the scalp; eyebrows; eyelashes; and, among older children and adolescents, pubic regions. Children
also experience clinically significant impairment in 1 or more areas of daily functioning (eg, interpersonal relationships, academics) as a
result of hairpulling. The prevalence of TTM is approximately 1.2% in the general population and more prevalent in children than in adults.
Empirical evidence suggests that the average age of onset is approximately 9 to 10 years and about 70% of children with TTM may
also meet the diagnostic criteria for other psychiatric diagnoses (Anxiety disorders, OCD, ADHD, and oppositional defiant disorder).
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Evolutional, genetic, neurophysiological and neurocognitive factors are related to its ethiology.
It leads to significant distress and functional impairment and is often difficult to treat. The treatments recommended for TTM are CBT,
waiting-list condition, pharmacotherapy, and supportive therapy. Although clear evidence is not available, clomipramine, selective
serotonin reuptake inhibitors and antipsychotics are recommending for medication. Although CBT is superior and a comprehensive
approach to treatment that includes a variety of therapeutic techniques awareness training, function-based interventions, selfmonitoring, aversion, massed practice, relaxation training, social support, and stimulus control, the core component of CBT protocols for
TTM is the habit reverse training (HRT).
HRT was a comprehensive procedure consisting of several steps. Self-monitoring (eg, asking patients to follow their hairpulling and
motor/vocal tics), awareness training (the therapist asks the child to describe in great detail and reenact the repetitive behavior (such as
hairpulling, motor or vocal tics), competing response training, stimulus control procedures (ie, modifying the environment to reduce cues
for hairpulling), and social support were the most frequently endorsed elements of HRT used for the treatment of TTM. The social support
component of simplified HRT consists of identifying a family member (most typical) or friend to provide encouragement and support in
the children’s use of their competing response.
TTM has not fully been recognized yet. This under-recognition has contributed to deficits in funding, delays in the necessary research, and
has limited the timely advancement of treatment options. Although CBT with HRT is considered by many to be the best treatment option,
improvements are needed. As a result, a series of multicentered, coordinated large scale studies are needed to explore the etiology of the
disorder, reach an agreement its classification and defining the best approach and algorithms for the treatment.
Keywords: trichotillomania, habit reverse training, TTM, HRT
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S286-S7
[Abstract:0871] Child and adolescent mental and behavioral disorders
Catatonic clinical manifestations and treatments in children and adolescents
Seher Akbas
Department of Child and Adolescent Psychiatry, Ondokuz Mayıs University, Samsun-Turkey
e-mail address: [email protected]
Systematic controlled studies of catatonia in childhood and adolescence are lacking in modern literature. Findings in this area are based on
case reports and smaller studies. Supporting the occurrence of catatonia in children and adolescents diagnosed with affective, psychotic,
autistic, developmental, drug-induced, and medical-neurologic disorders. Recent reports contradict the rarity of pediatric catatonia.
The prevalence of catatonia among psychiatric adult patients ranges between 7.6% and 38%. It is more prevalent in mood disorder
than psychosis. It was reported that 20-30% of patients with bipolar affective disorder develop catatonia once in their course of disease
and 20% of patients with catatonia develop mania. Approximately 33% of children with schizophrenia have catatonic signs and 17%
of patients with catatonia admitted to children and adolescent polyclinics are diagnosed as psychotic disorder. Catatonia has been
increasingly rec¬ognized as an additional disease accompanying the autism. Two systematic studies show catatonia to occur in 12% to
17% of adolescents and young adults with autism. Mutism, stereotypic speech, echolalia, stereotypic and repetitive behaviors, posturing,
grimas, rigidity, mannerisms and agitation have been defined as common symptoms of autism and catatonia. Repetitive self-injurious
behavior in autism is particularly emphasized and considered as a variant of catatonia. Association of catatonia with mental retardation
was emphasized in the studies. Nevertheless there are small number of studies on the treatment of catatonia among children and
adolescents, it is considered similar with adult catatonia treatment. It is reported that benzodiazepine and electroconvulsive therapy used
for the treatment of adult catatonia are also reliable and effective for the treatment of children and adolescents catatonia.
Keywords: child, adolescent, catatonia
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DEMENTIA, DELIRIUM AND RELATED COGNITIVE DISORDERS
[Abstract:0259] Dementia, delirium and related cognitive disorders
Frontotemporal dementia: a case report
Hasan Mayda1, Halil Ibrahim Guzel2, Yasemin Gorucu3, Fatima Karakaya Colak4, Erman Bagcioglu3
Department of Psychiatry, Mardin Kiziltepe State Hospital, Mardin-Turkey
1
Department of Psychiatry, Konya Aksehir State Hospital, Konya-Turkey
2
Department of Psychiatry, Afyon Kocatepe University, Faculty of Medicine, Afyon-Turkey
3
Department of Neurology, Isparta State Hospital, Isparta-Turkey
4
e-mail address: [email protected]
Frontotemporal Dementia (FTD) is the second most commonly encountered dementia type in middle aged subjects. It is characterized
by behavioral changes, executive function disorders, and language problems. Clinical anamnesis not required for the diagnosis. It is
disease, which may present itself with personality and behavioral changes, disinhibition, emotional indifference, deterioration in social
relationships, insight loss, speech deterioration, compulsive collecting, and hyperorality. Neurological examination is generally normal,
and there are focal abnormalities in frontotemporal areas in cranial imaging examinations. There is no effective treatment, and serotonin
reuptake inhibitors may be helpful in controlling behavioral symptoms.
In the present article, a 62-year-old-male patient who had complaints of personality and behavioral changes for the last 2 years, decreased
personal care and talking, excessive walking and eating behavior, compulsive change and sock collections, is described. The patient had
no marked forgetfulness or speech disorder, and he could continue his daily living activities except behavioral problems. Neurological
examination was normal. In cranial imaging, there was a marked atrophy in frontotemporal areas. After sertraline and trazodone
treatment, his complaints were partially improved. The patient had positive family history for FTD. The patient was dead due to high blood
glucose level, which was developed because of hyperorality. We aimed to present this frontotemporal dementia case.
Keywords: frontotemporal dementia, demantia, middle age
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S288
[Abstract:0304] Dementia, delirium and related cognitive disorders
Primary progressive aphasia: a case report
Hatice Bayraktar
Department of Psychiatry, Gumushane State Hospital, Gumushane-Turkey
e-mail address: [email protected]
Primary progressive aphasia (PPA) is a rare progressive neurodegenerative dementia characterized by progressive worsening of language
with relative preservation of the daily life activities, memory, visuospatial functions. The disease starts with word-finding disturbances
(anomia) and frequently proceeds to impair the grammatical structure (syntax) and comprehension (semantics) of language. PPA was
firstly defined by Mesulam in 1982.
A 63-years-old rigth-handed female patient who was presented with a progressive word finding and grammatical structure disturbances.
Other cognitive functions, personality traits and daily life activities were relatively preserved. Neurological and medical findings were
within normal range, except anomia and fluent aphasia. Comprehension, repetition were relatively intact. Her cranial MR imaging
displayed a focal asymmetric left temporal lobe atrophy and the left Sylvian cistern was enlarged.
The case was diagnosed as PPA because of the progressive language impairments with relative preserved memory, personality, daily
life activities and visual processing. The diagnose was supported by MRI findings. This rare clinical entity is presented with clinical and
laboratory features.
Keywords: asymmetric left temporal lobe atrophy, fluent aphasia, primary progressive aphasia
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[Abstract:0520] Dementia, delirium and related cognitive disorders
Blackening of the teeth with high doses of memantine: a case report
Merve Sahin Can, Hayriye Baykan, Tunay Karlidere
Department of Psychiatry, Balikesir University, Faculty of Medicine, Balikesir-Turkey
e-mail address: [email protected]
Alzheimer’s disease (AD) is a chronic neurodegenerative disorder which is the most common cause of dementia. Memantine is an
uncompetitive N-methyl-D-aspartate (NMDA) receptor antagonist which was approved for the treatment of AD. In this case report we
aimed to define the blackening of teeth with memantine 40 mg/day dose used and discuss the possible causes.
A 58-year-old woman admitted to our outpatient clinic with the complaints of insomnia, amnesia (forgetfulness), anxiety of to be lost
outside, and irritability for 6 years. She was operated for sphenoid sinus fungal infection and there was no sign of active illness. Her mother
had the treatment of AD. In mental examination; she had anxious temperament and future concerns and anxiety of being lost. She had
avoidance behavior of going out alone. She had difficulties in falling asleep.
Escitalopram 10 mg/day was given for anxiety disorder. Symptoms of anxiety decreased but amnesia progressively increased. She started
to have difficulties finding the places that she knew before. For amnesia etiology; anemia, vitamin B12 deficiency, folic acid deficiency
was not detected. Cranial MR was normal. The patient was diagnosed early onset dementia; and memantine 20 mg/day was added to
the treatment. During controls it was noticed that she took memantine 40 mg. daily dose in the last 2 months. Patient complained about
the blackening of the upper and lower teeth in the last month. Coagulation tests, kidney and liver function tests, thyroid function tests,
hemogram was normal. She had no gingival disorders and no change in eating habits. The dose of memantine was reduced to 20 mg/day
and 2 weeks later the level of blackening was decreased and 6 weeks later she had the normal color of teeth and blackening had been
completely lost.
Rarely, memantine was associated bruising or gingival bleeding. In the patient’s diet, we found no change in last two months, also
she did not use any drug accumulating in enamel and causing blackening, like tetracycline or ferrous preparations. Effervescent
form of memantine contains; citric acid, maltodextrin, polyethylene glycol, sodium bicarbonate, sorbitol, aspartame, a raspberry and
betacarotene. It was considered that to exposure these ingredients overdose might have a side effect like this.
To our knowledge, in literature blackening in the teeth with memantine was not defined. However, oral health is closely associated with
AD. Patients begin to forget the routine functions to be performed for oral health. In the last stages of disease patients forget the necessity
of oral care. In this case change in the color of teeth can be an unexpected side effect with memantine, so further studies will help us to
understand the mechanisms underlying this effect.
Keywords: Alzheimer’s disease, memantine, side effect
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S289
[Abstract:0635] Dementia, delirium and related cognitive disorders
Frontal lob syndrome after a seizure: a case report
Merve Sahin1, Hamza Sahin2, Ebru Findikli1, Selcuk Kardas1
Department of Psychiatry, Sutcu Imam University, Faculty of Medicine, Kahramanmaras-Turkey
1
Department of Neurology, Sutcu Imam University, Faculty of Medicine, Kahramanmaras-Turkey
2
e-mail address: [email protected]
Frontal lobe syndrome (FLS) occurs when the damage to the prefrontal regions. It is characterized by changes in personality and behavior
in individuals. In here, we presented a patient who was admitted to emergencey room cause of a seizure and diagnosed of a frontal lobe
syndrome secondary to cerebrovascular disease during the follow up.
A 68-year-old, diabetic male patient were admitted to the emergency room cause of status epilepticus. He was admitted to the neurology
intensive care unit in post-ictal confusion state. In his neurological examination, he was confused and seemed lethargic. He had no focal
deficits. Valproate 1000 mg/day and phenytoin 300 mg/day were started. Brain CT was performed. In the right frontal lobe, a hypointense
area, which was in 2.5x3 cm diameter, was found. During the hospitalization in intensive care unit, he became agitated and began to
ask for eating foods much more than normal. During follow-up; his blood sugar was regulated, there were no seizures and his vital signs
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were normal. After eight days, he was taken into the neurology service. According to information received from the family, the patient
hadn’t recognized his family members, had run away from home and began to present strange behaviors since the last month. He
kept on exhibiting inconvenient behaviors and having excessive food cravings in the neurology service. He was consulted to our clinic
for these complaints. He was getting quickly anger; having excessive eating and drinking request; trying to escape from home during
the last month. In his psychiatric assessment; he was conscious, his cooperation and orientation was limited, his self-care was poor,
he had difficulty making eye relationship. His psychomotor activity was increased; he was agitated and aggressive; he had nonsense
conversation. Attention and memory assessment could not be made. Routine blood tests and thyroid function tests were normal. There
was no significant pathology in the EEG study. In light of these findings, preliminary diagnosis of frontal lobe syndrome was diagnosed.
Paroxetine and quetiapine were started. His agitation and aggression were reduced. He hadn’t have any seizures recurrences. Finally, he
was discharged with follow-up recommendations of neurology and psychiatry control.
FLS is occurred by various reasons (such as trauma, tumors, cerebrovascular diseases, infections), which damage the prefrontal regions.
The symptoms vary according to the localization of the lesion in the frontal lobe. If the lesions are seen in convexity part of the frontal
lobe, pseudo-depressive clinic findings (such as lack of interest, unresponsiveness, apathy) reveal out in the course of the disease. As
in our patient; if the lesion is in the orbitofrontal region, pseudopsychopathic personality disorders (disinhibition, aggression, sexually
inappropriate behavior and social discordance) can occur.
Like in here, frontal lobe damages, which occurred as a result of cerebrovascular disease, can cause symptoms of frontal lobe syndrome
and seizures. Keeping in mind, this association is important to avoid delays in diagnosis and treatment.
Keywords: frontal lob, seizure, syndrome
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[Abstract:0672] Dementia, delirium and related cognitive disorders
Variable symptomatology of catatonia: a case report
Omer Asan, Baise Tikir, Ozlem Citak, Erol Goka
Ankara Numune Training and Research Hospital, Ankara-Turkey
e-mail address: [email protected]
Catatonia was originally described in 1874 by Kahlbaum as a unique clinical presentation of motor, vocal and behavioral abnormalities.
It was incorporated as a type of dementia praecox by Kraepelin in 1896. In DSM-5 catatonia has conceptualized as an independent
syndrome.
In DSM-5 catatonia has conceptualized as an independent syndrome. The creation of a separate diagnostic class for catatonia in future
classification seems the safest approach of this syndrome in patients of all ages and the best approach to promote research. A 19-year-old
boy presented our emergency service with a complaint of increase in sleep (15-18 h/day, food intake, irritability, mutism for one week
period. After the tests and consultations in the emergency service the patient has been taken to psychiatry service. In the neurologic
examination: the conscious; stupor, motor examination; not cooperative, rigidity, sense and cerebellar tests; not cooperative. In the first
week he slept for 18-21 h/day, he was usually waking up for eating, he was eating much and compulsively. When he awakened he was
conscious, but apathic and negativist. When conversation ended he was falling asleep. He was bringing his hands above his penis often
(hypersexuality?). He was talking about something not happened (confabulation). Fever, pulse and blood pressure has been checked 8
times per day and were normal. The laboratory tests, electroencephalography and cranial MRI were normal. For differential diagnosis
lumber punction has been made, the microbiological and pathological results were normal. At the first week the symptoms were
hyperphagia, increase in sleep, apathy, cognitive problems, hypersexuality? Our pre-diagnose was Klein-Levine syndrome. At the 8th day
the patient stop eating and speaking. The mutism, not eating and drinking, negativism, waxy flexibility and sometimes rigidity symptoms
continued for 4 days. Glob vesicale happened because he was not urinating. The diagnose was catatonia. The patient has been prepared
for electroconvulsive therapy (ECT). But after four days he started eating and drinking; the mutism, waxy flexibility, rigidity symptoms
has passed without treatment. The food intake, hyperphagia and compulsive eating, negativism, apathy, hypersexuality? symptoms have
started again. After 25th day the sleeping time started to reduce, he was giving more results at conversations, affektif participation was
better, he was more interesting with his around. At the 30. day he was sleeping 8 h/day, he was eating 3 times/day and he was not eating
compulsive. Also his cognitive behaviors were better. At 31. day he has been discharged from hospital.
The last studies are warranted to test the hypotheses that NMS is a drug-induced form of malignant catatonia, that PWS is a GABAergic
genetic-endocrine model of catatonia, that KLS represents a periodic form of adolescent catatonia, and that anti-NMDA receptor
encephalitis is an autoimmune type of catatonia. The etiopathogenesis of catatonia remains unclear. Several models are available to guide
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future research but are limited because of our lack of understanding of brain-behavior relations. In our case there is different symptoms
like food intake, increase in sleep and hypersexuality before and after the classic symptoms of catatonia, so this shows us catatonia may
include variable different symptomatology.
Keywords: catatonia, food intake, syndrome
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[Abstract:0709] Dementia, delirium and related cognitive disorders
A case of herpes encephalitis presenting as hypomanic attack
Yasemin Akkoca1, Ozlem Ozel2
Department of Psychiatry, Ankara Training and Research Hospital, Ankara-Turkey
1
Department of Infectious Diseases, Ankara Training and Research Hospital, Ankara-Turkey
2
e-mail address: [email protected]
Herpes simplex virus (HSV) encephalitis has a high mortality rate and it has to hurry treatment. Typically patients with herpes simplex
encephalitis (HSE) will have fever plus at least one of a series of neurological deficits. The initial presentation of HSE may consist of marked
behavioral abnormalities like restless hyperactivity, hallucinations, anosmia, Kluver-Bucy Syndrome, and acute manic or hypomanic
symptoms. The association of psychiatric symptoms can be traced to the involvement of basal frontal and temporal lobes in the disease.
The purpose of this case report is emphasize that a psychiatric disorder may indicate an organic brain disease. A 45-year-old female
has applied to a center with the complaints of excessive talkativeness, obsessions, absurd behaviors, fever and headache for ten days.
MRI brain showed left temporal lobe, inferoposterior frontal lobe, insular cortex, lentiform nucleus, hypocampal and parahypocampal
regions hyperintensities. The patient was hospitalized with encephalitis prediagnosis to the infection service for further examination and
treatment. The patient was evaluated with psychiatric consultation in the clinic. She had perseveration, psychomotor agitation, excessive
talkativeness, flight of ideas, and visual hallucinations. Her affect was euphoric and irritable. There was no family history of psychiatric
disorders. We prescribed quetiapine (50 mg-100 mg/day) with diagnosis of hypomanic attack related HSV encephalitis. After HSV-2
detected positive on CSF PCR study, acyclovir was started. Despite the rapid improvement on the encephalitis findings with the acyclovir;
in out patient follow-ups it was observed that the hypomanic symptoms continued descending. After 8 months in the patient’s control
was completely improved her hypomanic symptoms. Due to the risk of recurrence of the attacks, quetiapine 100 mg was continued. HSE
has often been related with marked psychological symptoms in the acute phase. The psychiatric symptoms caused by brain damage can
be complex and atypical. Right or left hemisphere lesions may result either a bipolar disorder or a unipolar mania. Despite the normal
central biochemical markers and imaging results, their psychological-behavioral profile continued to show significant abnormality in the
long term follow up. Atypical psychological or physical examination finding on patients who applied for psychiatric examination, may
indicate a disease associated with brain damage. It is vital for recovery without sequelae of a brain disease that requires detection in the
early stages and immediate treatment, such as HSE.
Keywords: herpes simplex encephalitis, seconder hypomanic attack, organic mood disorders
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DISSOCIATIVE, SOMATIZATION AND FACTITIOUS DISORDERS
[Abstract:0122] Dissociative, somatization and factitious disorders
Treatment of a patient diagnosed with premenstrual dysphoric disorder whose dissosiative episodes
are seen during premenstural periods: a case report
Yagmur Sever, Filiz Izci, Rabia Bilici, Sumeyye Yasemin Kurtulus Calli, Merve Setenay Iris Koc, Murat Yalcin
Department of Psychiatry, Erenkoy Training and Resarch Hospital, Istanbul-Turkey
e-mail address: [email protected]
Premenstrual Syndrome is a collection of emotional symptoms such as depressive mood, irritability, nervousness, with or without
physical symptoms such as swelling of breasts, headache, weakness and gainin waigth, related to a woman’s menstrual cycle. These
symptoms start at late luteal phase and end with the begining of mensturation. Premenstrual Dysphoric Disorder (PMDD) is a severe
form of premenstrual syndrome. PMDD causes serious clinical and social problems. we aim to report a case diagnosed with PMDD whose
dissosiative episodes are seen during luteal phase.
24 year-old, female patient. She hospitalized due to severe irritability, self mutilative actions, crying crisises which were persisting up to
10 days before mensturation. These symptoms had persisted since adolesence but symptoms had worsened during 1 year after marriage.
An unknown medicine was prescribed when she was adolesent and she benefited partially. It is learned that there were half hour periods
during last few months that she couldn’t remember, and during these periods she was crying, shouting, self-mutilating and being
excited. Except these periods, she was compatible, quiet and had good relationships with others. Psychiatricly, her self-care was normal,
she was willing to negotiate. She was normal except the symptoms of irritability, impulsivity, self-mutilative behaviours, aggression and
dissosiative amnesia which were seen during luteal phase. Her insigth and judgement were adequate. Her gynecological examination
was also normal. There was no any feature in medical personal and family history. She was diagnosed with PMDD and fluoksetine 20 mg/
day was started. Also, during 10 days before mensturation, haloperidol 1 mg/day usage was suggested. Troughout her outpatient clinical
follow-up, there was no any dissosiative episods, and her seymptoms decreased.
PMDD is characterized by psychical and physical symptoms. Clinically, these symptoms range irritability, nervousness to explosion of anger
and self mutilation. In the treatment, combined oral contraseptives, serotonine reuptake inhibitors (SSRI), magnesium, calcium and vitamine
B combinations are used. There are some studies showing benefits of SSRIs usage at premenstural period or during menstural cycle. In
our case, not only crying, agression sypmtoms but also explosion of anger, even self mutilation symptoms were noted in the course of
dissosiative episods. PMDD symptoms show difference between patients and its severity can disrupt social and interpersonal relationships.
Keywords: premenstrual dysphoric disorder, dissosiative episodes, treatment
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S292
[Abstract:0127] Dissociative, somatization and factitious disorders
Depersonalization associated with kallman’s syndrome: a case report
Ahmet Ozturk, Alperen Kilic, Ali Emre Dursun, Erdem Deveci, Ismet Kirpinar
Department of Psychiatry, Bezmialem University, Istanbul-Turkey
e-mail address: [email protected]
Kallman’s Syndrome (KS) is a hereditary disease characterized by hypogonadotropic hypogonadism accompanied either by anosmia or
hyposmia. In KS the main problem is the lack of GnRH production or secretion. According to literature findings, mutation in the GNRHR
gene which is related with hypophysis and hypothalamus, may be involved in the pathogenesis.
Depersonalization disorder mentioned as one of the dissociative disorders in DSM-5 and it basically is a process that involves dissociation
from the body or the person himself continuously and repetitively. Depersonalization is a process that may accompany other psychiatric
disorders and it may also accompany some other medical processes. In this piece we aimed to represent a case of Kallman’s syndrome,
which is a rare hereditary disorder, accompanied by depersonalization syndrome.
Patient E. P is a 36 year-old male patient. The patient applied to our outpatient clinic in 2014, September. In his history he claims that he
was diagnosed as Kallman’s syndrome after he had applied to a hospital with the complaint of short penis and inability to smell. Patient
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told that he experiences a sensation that his body and soul is separated since he was 7. The patient started to be treated for anxiety and
depression 10 years ago. He revealed that he received treatment periodically and most of his symptoms were relieved but he sometimes
experiences episodes of anxiety and he was on fluoxetine 20 mg (day and aripiprazole 5 mg/day for almost a year. Despite different
treatments he received so far, he still claims that he experiences depersonalization episodes almost every day and he has the sensation
that he watches his body as an outsider and feels that his body is changing and therefore he feels anxious. The patient did not have active
psychotic findings. He did not have a history of drug abuse. Since he had hypogonadotropic hypogonadism he was using testosterone
intermittently. His testosterone level was 0.1 mg/dl (reference range: 2.4-8). The patient did not have a severe stressor. We diagnosed
the patient as depersonalization syndrome according to DSM 5. His treatment was continued.Depersonalization syndrome may be seen
in psychiatric disorders such as schizophrenia, anxiety disorders (panic disorders etc.), as well as in stress and drug abuse. Furthermore,
it may accompany some neurological disorders such as Alzheimer’s, ALS and MS. In our case since the patient did not have an active
psychiatric problem which depersonalization may accompany and since the Kallman’s is the chronic process in the case, we thought the
findings may be related with the Kallman’s syndrome. Although the etiology is unclear, depersonalization disorder may be associated with
dysregulation of the hypothalamic-pituitary-adrenal axis. Consistent with our findings, there are cases of schizophrenia accompanied by
depersonalization in some Kallman’s cases in the literature, and also both the disorders have the similar etiologies. These facts lead us to
the idea that our approach may be right. The complex etiology of the depersonalization disorder in this case, needs to be enlightened
with further research.
Keywords: Kallman’s syndrome, depersonalization, hypothalamic-pituitary-adrenal axis
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S292-S3
[Abstract:0188] Dissociative, somatization and factitious disorders
Paroxetine induced hypertension: a case report
Merve Setenay Iris Koc1, Filiz Izci1, Servet Izci2, Rabia Bilici1, Yagmur Sever1, Sumeyye Yasemin Kurtulus Calli1, Engin Emrem Bestepe1
Department of Psychiatry, Erenkoy Training and Research Hospital, Istanbul-Turkey
1
Department of Cardiology, Kartal Kosuyolu High Specialized Education and Research Hospital, Istanbul-Turkey
2
e-mail address: [email protected]
Selective serotonin reuptake inhibitors (SSRI) are antidepressants preferred for their wide safety range and low side effect profile. Here we
aimed to discuss hypertension in a case after paroxetine treatment was initiated.
A 56-year-old female patient was admitted to outpatient psychiatry clinic with unwillingness, wanting to cry, lack of energy. Her
complaints were started after psychiatric her son started on a psychiatric treatment and hopelessness, anhedonia and insomnia was
added to her complaints during the last 2 months. The patient indicated no previous history of any organic or psychiatric disease or
treatment. The patient was conscious, oriented, cooperated. Her fever was 37 °C, blood pressure 110/80 mmHg and pulse was 75 per
minute. No pathological findings were detected in biochemistry, complete blood count, urinalysis or ECG. In the psychiatric examination,
self care was moderate, she was establishing eye contact, communicative and cooperative. Spontaneity and intonation of the speech
and psychomotor activity was diminished. Her mood and affect were depressed and anxious. The patient’s thought content included
hopelessness and inadequacy. No perception or memory deficit was found. Paroxetine 10mg/day treatment was initiated and the patient
was recommended to increase the dose to 20 mg/day in the second week of treatment. The patient was called for control after 15 days.
The patient noted that in the 7th day of the treatment after paroxetine dose was increased to 20 mg/day her blood pressure was increased
up to 155/110 mm/hg. A cardiology consultation was requested. The patient’s cardiological examination and ECHO findings were normal.
However, during 24 hour arterial blood pressure holter monitoring her blood pressure recordings were between 155/110 mm/Hg and
135/85 mm/Hg. Because the patient had no previous history of hypertension, concurrent rise in blood pressure after paroxetine therapy
suggested drug-induced hypertension. After the patient’s current treatment was stopped her 7-day blood pressure measurements that
were obtained 4 times a day were stable. Treatment was planned to continue with mirtazapine 7.5 mg/day.
SSRIs may cause side effects such as anxiety, sleep disorders, tremor, sexual dysfunction and headache by posSIBly increasing 5-HT in the
central nervous system. Also, cardiovascular side effects may occur rarely. Mostly pulmonary hypertension is observed with SSRIs and
there are reports about fluoxetine and paroxetine induced hypertension. Here we report a case with hypertension after paroxetine 20 mg/
day therapy who had no previous history of hypertension before.
Keywords: hypertension, side paroxetine, effect
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[Abstract:0321] Dissociative, somatization and factitious disorders
Munchausen syndrome by proxy presented as multiple bone fractures
Mehmet Fatih Ustundag, Gokhan Ozpolat, Halil Ozcan, Elif Ozcan
Department of Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
e-mail address: [email protected]
Munchausen syndrome by proxy (MSBP) is a clinical issue and special form of child abuse. In MSBP the abuser is generally the mother, who
fabricates, exaggerates and/or induces physical, psychological, behavioral and/or mental health problems in the child. The perpetrators
are willing to fulfill their need for positive attention by hurting their own child. Signs, symptoms, physical and laboratory findings are
highly unusual, discrepant with the patient’s presentation or history. Symptoms usually disappear in the absence of the perpetrator. We
aimed to reconsider this rare and important syndrome by presenting an interesting case.
Married, mother of 6 children, 34-year-old woman had brought her 5-year-old son to the emergency department because of pain in his
right leg. She said that her son had fallen off the broken stairs at home. Right tibia fracture was detected by X-ray imaging. The broken
bone was reduced, cast was applied by an orthopedist and the boy was sent home. After two weeks, she brought her 7-year-old son to
the emergency department because of pain in his both legs. She said that her 7-year-old son felt from the same broken stairs too. Both
tibia fracture was shown in X-ray imaging. The child was admitted to the orthopedic clinic. After a very short time from his discharge,
she brought her 12-year-old son to the emergency department with similar complaints. Whereupon orthopedist suspected child abuse,
requested a psychiatric consultation and reported the case to police at the hospital. When previous hospital records were examined, it
was seen that there were lots of emergency department records which belong to her other children with similar complaints. In physical
examination of the three children, numerous assault traces were found possibly occurred at different times and the radiographs revealed
several fractures of varying ages those healing with normal callus formation, and prominent subperiosteal new bone formation. The
mother was examined by a psychiatrist. In psychiatric evaluation she was fully conscious. Her affect was flat and speech was slowed. Her
thought content was dominated by the ideas of loneliness. Her attention was insufficient, memory was poor. There was no pathology in
perception. IQ score was 83. She did not fulfill DSM-5 criteria for any personality disorder. She declared that her husband was a truck driver
and much of the year she was staying home only with her children. She has been feeling that she has been ignored by her husband. She
has used a truck chock to hurt the children. She was reported to the prosecutor’s office and all children were placed in a social institution.
It is very important to diagnose MSBP because of high mortality rate and severity. Experienced health personnel are necessary for an early
diagnosis. Teamwork is crucial for proper management and effective treatment of the cases. It is important to remove children from the
dangerous ambiance and ensure their safety as soon as possible if needed.
Keywords: bone, child abuse, munchausen
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[Abstract:0356] Dissociative, somatization and factitious disorders
A patient with severe self-injurious behaviors: a case report
Erdal Pan1, Abdullah Bolu2, Dogan Alhan1, Suleyman Akarsu3
Eskisehir Military Hospital, Eskisehir-Turkey
1
Aircrew’s Health Research and Training Center, Eskisehir-Turkey
2
Aksaz Naval Hospital, Mugla-Turkey
3
e-mail address: [email protected]
Behaviors that effort to damage to the physical integrity are often accompanied by some psychiatric disorders such as psychosis, mental
retardation, severe personality pathology. Sometimes these cases are evaluated as psychiatric disorder like Body Integrity Identity
Disorder (BIID). Body İntegrity İdentity Disorder is a rare psychiatric condition with an intense desire to become paralysis or one or more
limb amputation. In this report, a case with finger amputation admitted to a plastic surgery clinic has been presented. 21-year-old male
patient admitted to a plastic surgery clinic due to cutting his toes with a razor blade. He was referred to psychiatry polyclinics after medical
intervention. According to the patient’s history, he had cut right / left hand forefinger from the distal phalanx about 4 years ago and also
tried to cut other fingers despite the intervention of his parents. Recently, he had behaviors that trying to cut his toes. The patient was
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hospitalized. There were no signs of psychosis according to the patient’s clinical interview and psychometric measures (Beck Anxiety
Inventory, Beck Depression Inventory). Borderline personality traits in the patient’s personality organization and difficulties in impulse
regulation were determined after Minnesota Multiphasic Personality Inventory (MMPI). Self - injurious behaviors are commonly seen in
personality disorders, psychotic disorders, and sexual identity disorders among psychiatric disorders. Most commonly, these behaviors
are seen in personality disorders especially borderline personality disorder. While severe self-injurious behaviors are commonly seen in
patients with psychotic disorders, milder behavioral pathologies are expected in patients with borderline personality. Our case differs in
this respect.
Keywords: self-injurious, self-mutilation, amputation
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[Abstract:0553] Dissociative, somatization and factitious disorders
A psychogenic polydipsia case who drink 12 liters of water per day
M. Hanifi Kokacya, Faruk Kurhan, Canan Demircan, U. Sertan Copoglu, Mustafa Ari
Department of Psychiatry, Mustafa Kemal University, Faculty of Medicine, Hatay-Turkey.
e-mail address: [email protected]
Psychogenic polydipsia is a rare condition characterized by excessive water drinking without any physiologic stimulant. It can be seen
with many psychiatric disorders or by itself. This poster presents a case of psychogenic polydipsia.
A 20-year-old single girl, admitted to internal medicine service due to excessive water consumption (up to 12 lt/day) and frequent
urination for 4 months. Complete blood count and biochemical tests, brain MRI findings were normal. After water deprivation test and
desmopressin medication diabetes insipitus was ruled ou and she is referred to psychiatry clinic.On mental state examination she was
conscious, orientated and cooperative and had good self care and age-appropriate look. Her speech was clear. Her speed of thinking
was lowered. Mood was slightly depressed. No delusion or hallucination detected. On psychical examination was in normal limits. Except
hyponatremia (119 mmol/L) laboratory tests were normal. Hypophysis MRI was normal. According to the history taken form patient and
mother, she was jealous about her elder sister as she was more social and skilled. 2 years ago she graduated high school, but failed college
exams for two times. She was blaming herself as she couldn’t pass college exams. She had anger and cry attacks. She attempted suicide
twice by cutting her wrists. She was refereed to psychiatry department and advisedvenlafaxine, escitalopram with a diagnosis of major
depression. But she didn’t used her medicines regularly.
Last 4 months she had started to drink 10-12 liter water per a day. She used to carry water bottles in her handbag every time. When
she drinks water she was feeling relaxed. In clinic fluoxetine 20 mg/day was started. Amount of drinking water was lowered gradually.
Daily psychotherapautic interventions were carried out to cope with self-incriminating thoughts and depressive mood. After 30 days
of admission daily water consumption was decreased to 8 liters and her mood was euthymic. Her sodium level was in normal limits.
She was released from hospital. On her follow-ups in 3rd month daily water intake was 7 liter. Her treatment is going on with fluoxetine
20mg/day and monthly interventions.The etiology of psychogenic polydipsia is uncertain and multifactorial. It’s pathogenesis may be
hypersensitivity to vasopressin, a defect in osmoregulation or an increase in dopamine activity. Psychogenic polydipsia may be associated
with several psychiatric disorders including psychotic featured manic episodes, and commonly schizophrenia with up to 18% of patients
in mental hospitals displaying polydipsic behavior. In our case she did not have any psychiatric condition. In general sodium levels
between 130 and 135 mmol/L are asymptomatic. Our patients sodium level was 119 mmol/L and she was asymptomatic. In treatment
of psychogenic polydipsia, therapeutic options such as fluid restriction and behavioral approaches have been found to be effective in
reducing its severity. This case report highlights that psychogenic polydipsia can be presented with alone excessive water intake and
differential diagnosis is important if hyponatremia is present.
Keywords: psychogenic polydipsia, asymptomatic hyponatremia, treatment options
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[Abstract:0690] Dissociative, somatization and factitious disorders
Dissociative findings occurring after subarachnoid hemorrhage
Sumeyye Kurtulus Calli, Yagmur Sever Agman, Elif Yilmaz, Engin Emrem Bestepe
Erenkoy Training and Research Hospital, Istanbul-Turkey
e-mail address: [email protected]
Organic mental disorders may cause many psychiatric symptoms. In clinical trials, reports of cases with dissociative symptoms during
organic mental disorders are increasing.34 year-old, female, high school graduated, not working, divorced patient lives in Istanbul alone.
She was brought to psychiatric emergency service by Police, therefore she was seen while crying at metrobus station alone for hours and
after questioning she had difficulty in speaking and also she could not remember whom and where she was. During her first psychiatric
examination, she was conscious, partially oriented and cooperated. Her mood was depressive, affect was upset. She was speaking
perseverative in puerile attitude. The patient’s routine biochemical results were normal, total blood count and thyroid hormone levels
were also normal. She was hospitalized with diagnosis of dissociative disorder. Haloperidol 5 mg/day treatment was started. During
examination in service, patient’s amnestic periods were noticed. In the second day of hospitalization, she was conscious, oriented and
cooperated. In her last medical history, she suffered subarachnoid hemorrhage (SAH) 3 years ago, after this some crying attacks and
amnesia periods were seen. Her Short Mental Score was 22, Dissociative Experiences Scale score was 52. Childhood Trauma Questionnaire
was significant. Her MRI findings demonstrated past cerebrovascular event. The relatives of patients were called and is was learned that
she had never had psychiatric symptoms before SAH and never used any drugs or alcohol. Potential of dissociative findings caused by
organic mental disorders is an arguable issue. In ICD-10, organic dissociation category exists although it has not found in DSM category
system yet. We try to underline the importance of dissociative experiences in organic mental disorders.
Keywords: dissociative, organic, hemorrhage
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[Abstract:0708] Dissociative, somatization and factitious disorders
Case study: the effect of Faraday application in conversion disorder
Ozer Ozmut, Alpay Ates, Selin Gure, Hakan Balibey, Recep Tutuncu, Cengiz Basoglu, Servet Ebrinc, Ayhan Algul, Mesut Cetin
Department of Psychiatry, GATA Haydarpasa Training Hospital, Istanbul-Turkey.
e-mail address: [email protected]
Conversion disorder is characterized by several symptoms or deficits, which affect on sensory or motor functions without general medical
condition and neurological condition. A few typical examples involve partial paralysis, blindness, deafness, and pseudoseizures. Generally
people who suffer from conversion disorder live in rural area and have low socio-economic status. It seen two or ten time more in female
than male and, it can develop at any age but most commonly occurs between early adolescence and early adulthood. Present study
suggested that faraday application speeds up in conversion disorder’s treatment process. We worked with a patient who entered in our
service with walking disabilities. His neurological and medical examinations showed that any negative physical conditions. He is a 20-yearold male patient. Generally if we talk about him, he is in late twenties, has low socio-economic status, he had seven siblings. His attention
to his environment decreased, he did not attempt to communication. He suggest that he suffered from leg pain and walking disabilities
since 15 years. Generally, he walked like a duck and he mentioned that “I do not why I walk like this, but especially I walk like a duck in
stressful situations or environment, also everyone is joke about my walking style”. He also had several adaptation problems in his platoon.
According to his family, he lived normal and healthy family environment, while he was twelve year-old dropped out his school and worked
with his father in bazaars. When we evaluated his problem from the psychodynamic approach, we thought that his sexual conflicts in his
unconscious can caused by walking disabilities. His repression defense mechanism failed for the coping with his intrapsychic conflicts.
He diagnosed conversion disorder. We started to his treatment with the medicine of paroxetine 20 mg/day. In addition we used to five
session of Faraday with low voltage on his leg’s medial muscles, which included vastus medialis. After 5 days his walking disabilities and
pains decreased. Our present study showed that Faraday application is effective on conversion walking disorder.
Keywords: conversion disorder, faraday, walking
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[Abstract:0818] Dissociative, somatization and factitious disorders
A patient with dissociative and psychotic symptoms: a case report
Ada Salaj, Rumeysa Tasdelen, Ilhan Yargic
Department of Psychiatry, Istanbul University, Cerrahpasa Faculty of Medicine, Istanbul-Turkey
e-mail address: [email protected]
Dissociation has an important role in formation of psychosis. Even though Schneiderian symptoms are pathognomic in schizophrenia,
there can be found in dissociative disorder too.
A 33-year-old man, married with 3 children, was accepted at the Emergency Clinic after a dissociative fugue. He has visual hallucinations
and Schneiderian symptoms. His nephew died in his arms after a trauma three years before; after that depressive symptoms, cluster
type headache and hallucinations began. He was admitted three times to a psychiatric inpatient service after several suicide attempts
which was amnesic. The patient was not discharged in complete remission from the hospital. He had been exposed to multiple trauma
in his early childhood, was raped in prison, stayed for three days in canalization water and survived for 2 months in a strike. DES score
was 33. The diagnosis was made as dissociative disorder. He has three close relatives with schizophrenia diagnosis. When admitted he
was on olanzapine 10 mg, carbamazepine 600 mg and topiramate 75 mg treatment, fluoxetine was added to his treatment while at the
hospital. While visual hallucinations and amnesia alleviate partially, olfactory and gustatory hallucinations appeared. Olanzapine was
stopped because of side effects and Aripiprazole was started. As the symptoms continued 13 courses of ECT were given but no clinical
response. After this 9 mg of Risperidone was started. Meanwhile fluoxetine was stopped; and Duloxetine(60mg) was started. There was
still no clinical response and clozapine (500 mg) was started but not well tolerated by the patient. Clozapine was given titrated at 300 mg
and risperidone was stopped because of side effects. Then Amisulpride 200 mg 1x1 was added to the treatment. His work performance
was getting worse and he had a superficial affect. The patient was diagnosed with Atypical Psychosis. He was admitted two more time
with suicide and homicide risk because of auditory hallucinations. His work performance was getting worse. The patient’s treatment was
arranged as risperidone 6 mg, Duloxetine 60 mg and clozapine 150 mg. The patient’s symptoms were getting better and the patient
decided not to take any medication. The patient had no symptoms for a period of time.
According to the researches dissociative episodes can be false positive to psychotic symptoms. Dissociative symptoms can be in even
psychosis and appear in form of Schneiderian-like symptom.
Keywords: dissociative, psychotic, trauma
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DUAL DIAGNOSIS
[Abstract:0477] Dual diagnosis
Addiction and ADHD
Fatih Canan
Department of Psychiatry, Akdeniz University, Antalya-Turkey.
e-mail address: [email protected]
Attention deficit/hyperactivity disorder (ADHD) is one of the most common psychiatric disorder of childhood. It is estimated that 3 to 9%
of children have ADHD and follow-up studies have suggested that approximately 10 to 70% have ongoing symptoms in adulthood. As a
result, it may be assumed that adult ADHD occurs in 1 to 5% of the adult population.
The co-occurrence of ADHD and substance use disorders has received considerable attention in recent studies. Children with ADHD are at
risk for comorbid conduct disorder in childhood and antisocial personality and substance use disorders in childhood, as well as antisocial
personality and substance use disorders in adulthood. Moreover, adolescents with substance use problems have been found to have high
rates of ADHD. ADHD and substance use disorders are linked to each other in a variety of ways. Cognitive, genetic, and neurobiological
mechanisms are blamed to explain this relationship. The essential symptoms of ADHD may mimic the effects of psychoactive substance
use. Thus, it is difficult to diagnose one disorder in the presence of the other. The treatment of substance-use disorders is also complicated
by the presence of ADHD. Individuals with ADHD may demonstrate earlier onset of the substance abuse and a pattern of more frequent
or intense use. In addition, the symptoms of ADHD, including inattention and impulsivity, often hinder treatment efforts directed at the
concurrent substance-use disorder.
Keywords: addiction, attention deficit/hyperactivity disorder, comorbidity
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S298
[Abstract:0544] Dual Diagnosis
Delusions during epilepsy treatment after lamotrigine add-on: a case report
Murat Eren Ozen1, Shinnosuke Saito2
1Department of Psychiatry, Adana Private Hospital, Adana-Turkey
2Department of Psychiatry, Jichi Medical University, Shimotsuke-Japan
e-mail address: [email protected]
Epilepsy is one of the most common neurological problems affecting approximately 1% of the world’s population. Epilepsy may appear
in comorbidity with other mental disorders. Numerous factors such as epileptic seizures, cerebral damage, antiepileptic side-effects
and psychosocial factors may interact and be held responsible for the development of cognitive dysfunctions and mental disorders in
epileptic patients. Some psychiatric problems have been reported in patients using lamotrigine (LTG) to treat mental disorders (mainly
bipolar) or epilepsy. The main aim of this case report is to discuss this issue and the related psychiatric problems.
A 23-year-old male patient with a 8 year history of epilepsy, and history of a bipolar disorder SIBling. Seizures were out of control in
last 3 months, although taking carbamazepine 400mg twice daily and oxcarbazepine 300 mg twice daily doses. After administration of
lamotrigine (LTG) with increments of 25 mg per week, at dosage of 100mg twice daily, with the ongoing treatment aforesaid, seizures
ceased. Patient’s mother was anxious about her son’s thoughts, which were about the neighbors that began following him. Mental
assessment revealed his thoughts as paranoid delusions due to LTG treatment which began at the dose of 150mg per day, and increased
gradually. LTG decrement to 150 mg resolved the thoughts of following. Seizures did not occur after a month on 150mg per day of LTG.
Since the psychiatric symptoms disappeared, no psychotropic agent was administered.
Review of the literature shows that psychotic episodes caused and onset of features are generally rapid and closely related to an increase
in the dose of LTG itself, or to a change in a concomitant medication leading to an increase in LTG serum levels; symptoms rapidly improved
after decreasing the dose or withdrawing the drug; one patient who was re-exposed to lamotrigine again presented these symptoms.
In conclusion, lamotrigine is an effective drug, very useful in the treatment of epilepsy and mood disorders, but it appears to be capable
of inducing psychiatric symptoms or acute episodes.
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İt is possible that lamotrigine, by reducing glutamate release, triggered the acute psychosis. This risk is higher mainly in patients prone
to psychiatric disorders.
Keywords: epilepsy, lamotrigine, delusion
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S298-S9
[Abstract:0653] Dual diagnosis
Association of PFAPA syndrome and psychiatric disorders: 3 case reports
Yunus Emre Donmez, Dilsad Yildız Miniksar, Ozlem Ozel Ozcan
Department of Child and Adolescent Psychiatry, Inonu University, Faculty of Medicine, Malatya-Turkey
e-mail address: [email protected]
Periodic fever, pathos stomatitis, pharyngitis, and cervical adenitis syndrome (PFAPA syndrome) is characterized by repetition of fever
attacks. In this presentation, we aimed to discuss the presence of 3 case reports with psychiatric symptoms addition to diagnosis of PFAPA
syndrome and literature knowledge to draw attention that PFAPA syndrome which is lately defined as an autoinflammatory disease and
psychiatric diseases may be associated. A 6 year-old male was admitted to our clinic with complaints of difficulty in leaving his parents.
According to information received from his parents, these were learned that he had difficulties in staying at school after he started 1st
class of primary school, he left his parents after his parents waited at school a few months, but at this time, he did not leave his teacher
at school, and he had fear of harm to his parents or himself. At the result of administered psychiatric examination and psychometric
assessments considering for DSM-IV diagnostic criteria, the patient was diagnosed with separation anxiety and was initiated cognitive
behavioral therapy for the treatment. The patient who was refractory to medical treatment and had recurrent episodes of fever in the
treatment process was diagnosed by PFAPA syndrome.
A 52 month-old male, kindergarten student, was admitted to our clinic with complaints of difficulty in leaving his parents. According
to information received from his family, these were learned that the patient did not want to leave his parents and he has fear of harm
to his parents or himself. Additionally, it was learned that the patient was followed by diagnosed with PFAPA syndrome. At the result
of administered psychiatric examination and psychometric assessments, the patient was diagnosed with separation anxiety and was
initiated cognitive behavioral therapy for the treatment.
A 7 year-old male was admitted to our clinic with complaints of distractibility. According to information received from his family, these
were learned that the patient was reluctant to do his homework, he was doing his homework with his parents’ warning and help, he
had the difficulty in maintaining attention and he experienced sometimes difficulties to sit in the classroom. Moreover, as in the other
two cases, it was learned that the patient was followed by diagnosed with PFAPA syndrome. At the result of administered psychiatric
examination and psychometric assessments, the patient was diagnosed with attention deficit hyperactivity disorder and was initiated
methylphenidate treatment.
Although the exact etiology is unknown but now PFAPA syndrome is defined as an auto-inflammatory diseases. These are expressed
by researchers at an increasing rate that autoimmune mechanisms also play role in the etiology of a number of psychiatric disorders,
autoimmune diseases and psychiatric disorders frequently occur together. Therefore, we believe that the PFAPA syndrome, which is
defined as an auto-inflammatory disease, may be associated with psychiatric disorders. In the literature review for the coexistence of
PFAPA syndrome and psychiatric disorders, any studies or case reports have not seen and this presentation has the distinction of being
the first in this field.
Keywords: autoinflammatory disease, PFAPA syndrome, psychiatric disorders
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FORENSIC PSYCHIATRY
[Abstract:0727] Forensic psychiatry
Techniques of distinguishing between real and malingering patients in health reports, retirements,
and disability processes
Huseyin Gulec
Erenkoy Training and Research Hospital, Istanbul-Turkey
e-mail address: [email protected]
Odysseus suitable ambient and when chirping the battle horn was revealed by the arms of Achilles deceptive behavior that used to
escape from responsibility. As deceptive behavior in psychiatric practice physician not a frequent occurrence, be considered in the
physician patient communication is a condition that is expected to come to mind. Discrimination of people with real patients that mimic
patient is frequently not come up with this aspect even reach important epidemiological value in specific applications. As a result of a
process running after a win, funny as it may, there are aspects to be infuriating. The other party’s attitude towards the physician will be
exhibited by the gain attitude may not always be equipped. Even physicians are faced with the risk that this front in advance of damaging
conviction. It is one of the medical practice where there is a knife-edge condition. Performance without non-medical, sometimes it is very
difficult that may be impossible to resolving, our mission is aimed to discuss the points proposed to be considered. Maybe the war will
not be able to play the horn appropriate environment and places, or even wars may not even have horns. However, Odysseus there was
a buildup of himself as being a deserter.
Keywords: detection of malingering, avoidance of responsibility, secondary gain
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S300
[Abstract:0764] Forensic psychiatry
Schizophrenia and epigenetics in forensic psychiatry
Filiz Ekim Cevik1, Huseyin Cakan1, Fatih Oncu3, Esma Cansu Cevik2, Ibrahim Balcioglu4
Istanbul University, Institute of Forensic Sciences, Istanbul-Turkey
1
Dokuz Eylul University, Faculty of Medicine, Izmir-Turkey
2
Department of Psychiatry, Bakirkoy Prof. Dr. Mazhar Osman Training and Research Hospital, Istanbul-Turkey
3
Department of Psychiatry, Istanbul University, Cerrahpasa Faculty of Medicine, Istanbul-Turkey
4
e-mail address: [email protected]
Schizophrenia is a serious psychotic disorder, which has a generalised affect on individuals, families, communities, and state economies.
In addition to biopsychosocial development, mental states in children and adults, individuals’ passed illnesses and crimes-committed are
core stones in criminal assessment.These patients’ social aspects,relations to crimes and unability to get a place in the community life
are important. The individual might both be a suspect and a victim. Significant dangers awaiting the patients are as follows: possibility
for them to harm themselves and their surroundings and to get treated very badly. In all of psychiatric disorders, the risk of violent
behaviors are not the same,however, in correlation with the increase in violence in the society violent behaviors of the psychiatric
cases are getting more generalised and most probably increasing. Swanson et al., in their study done in 1990, found out that violent
behaviors in people with serious psychiatric disorders (schizophrenia, mood disorders) are 5 times more frequent, whereas in people
who use alcohol and illegal drugs they are 12-16 times more frequent. Studies done in the close past show that there is an increased
risk in criminal acts in people with schizophrenia. This increased risk is at an intermediate level,however, is still statistically significant. In
addition to sociodemographical features, etiological factors leading to schizophrenia are not exactly known, though it has been thought
that genetical predisposition, viral infections, pregnancy and birth complications play roles. Genetical predisposition and environmental
factors play a role together in the development of most of the psychiatric disorders. The terminology ‘epigenetics’, which is used in these
studies, is used to express different procedures that cause long term differences in gene expression without causing any change in DNA
base sequence,genetical code. The role of epigenetics in stress, depression,drug abuse and schizophrenia is still being discussed. In order
to find out possible biological markers within the brains of patients with schizophrenia, more than 100 markers have been investigated
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and reelin and glutamic acid decarboxylase(GAD) are frequently being studied. In addition, in a postmortem study, as a result of the
screening of the entire genome change in many genes’ methylation leves related neurodevelopmental, glutamatergical and GABAergical
systems has been stated. For research purposes, L-methionine, a methyl donor,has been given to patients with schizophrenia and this
has made the symptoms worse, showing that methylation plays an important role in this disorder’s neurobiology. Epigenetical studies
have also focused on dopaminergical system, however,the number of studies in this area is low. Within the frontal lobes of patients
with schizophrenia, there has been found out a decrease in COMT (Catechol-O-methyl transferase) gene promoter’s methylation and an
increase in COMT expression,yet,this finding has not been repeated by other studies. Fixation of the epigenetical changes in schizophrenia
has been a target in most of the pharmacological experiments. Due to genetical differences between individuals, drugs’ pharmacokinetics
and pharmacodynamics change. When pharmacokinetics change, drug’s metabolism within the body changes. Therefore, genetics in
schizophrenia is very important to determine the association between genetical polimorfism and drugs.
Keywords: forensic psychiatry, schizophrenia, epigenetics
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GERIATRIC PSYCHIATRY
[Abstract:0566] Geriatric psychiatry
Binswanger’s disease presentation as obsessive compulsive disorder with psychotic features
Hakan Kullakci1, Mustafa Karaoglan2, Recep Tutuncu1, Hakan Balibey1, Ayhan Algul1, M. Alpay Ates1, Cengiz Basoglu1
Department of Psychiatry, GATA Haydarpasa Training Hospital, Istanbul-Turkey
1
Department of Neurology, GATA Haydarpasa Training Hospital, Istanbul-Turkey
2
e-mail address: [email protected]
Binswanger disease, also known as subcortical leukoencephalopathy, is a form of small vessel vascular dementia caused by damage to
the white brain matter. White matter atrophy can be caused by many circumstances including chronic hypertension as well as old age.
This disease is characterized by loss of memory and intellectual function and by changes in mood. It usually presents between 54 and 66
years of age, and the first symptoms are usually mental deterioration or stroke. Herein we present a case of Binswanger’s Disease followed
as obsessive compulsive disorder with psychotic features.
A 54-year-old male patient was admitted by his family to our clinics with the complaints of irritability, forgetfulness, talkativeness,
insomnia, obsessions, increased sexual desire. He had also diabetes mellitus type 2 and essential hypertension. Brain MRI showed linear
signal enhancements in favor of epandimitis granulosa in both lateral ventricles and neighborhood periventricular deep white matter.
In addition, hyperintense T2A-Flair in both anterior-middle section of centrum ovale, both corona radiata and the periventricular and
subcortical white matter was probably secondary to small vessel disease. Cranial MRI findings were consistent with Binswanger’s disease.
Mini-Mental Test scores were in normal ranges (27/30). ACE-R (Addenbrooke’s Cognitive Examination - Final Revised Version A
(2005)):Revealed difficulties in verbal fluency (10/14) and memory (18/26). There were moderate disturbances in retrospective and
long term memory. Sub-test findings suggested frontotemporal pathology. In conclusion patients with psychiatric disorders who have
multifocal symptoms and vascular risk factors should be considered in the differential diagnosis of Binswanger’s disease.
Keywords: binswanger, dementia, psychiatric
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[Abstract:0567] Geriatric psychiatry
Fahr’s syndrome presenting with frontotemporal like dementia
Hakan Kullakci1, Mustafa Karaoglan2, Recep Tutuncu1, Hakan Balibey1, Ayhan Algul1, M. Alpay Ates1, Cengiz Basoglu1
Department of Psychiatry, GATA Haydarpasa Training Hospital, Istanbul-Turkey
1
Department of Neurology, GATA Haydarpasa Training Hospital, Istanbul-Turkey
2
e-mail address: [email protected]
Fahr’s disease (FD) is a rare disorder where bilateral, almost symmetric, calcium and other mineral deposits occur in basal ganglia,
cerebellar dentate nucleus and white matter. The clinical pattern is variable and may be associated with neuropsychiatric symptoms,
seizures, cerebellar or extrapyramidal dysfunction and dementia. Sporadic and familial cases have been reported with or without
calcium/phosphorus metabolism. A rare form of frontotemporal dementia with neurofibrillary tangles and Fahr-type calcifications
(DNTC) has been observed mainly in Japan.. We report the singular case of a 75-year-old man with dementia and mood-disorders but
neither extrapyramidal symptoms nor a metabolic disorder. Brain CT showed Fahr-type calcifications in the basal ganglia, cerebellum
and centrum semiovale as well as temporal atrophy; MRI showed diffuse atrophy predominantly in parietotemporal regions. The clinical
and radiological features of our patient point to this uncommon form of dementia. We have recently seen a 75-year-old man who was
referred with progressive mental deterioration for the previous year. The first symptoms were those of hyperphagia, euphoria,talking
so much, spending a lot of money, short-term sleep. One year later, he had stomach surgery from stomach adenocancer. Finally he was
unable to perform daily living activities with decreased verbal fluency, and inability to make decision. There was no family of dementia.
On neurological examination we did not observe signs of parkinsonism or abnormal movements. Mini-Mental Test scores were in normal
ranges (26/30). ACE-R (Addenbrooke’s Cognitive Examination - Final Revised Version A (2005)):Revealed difficulties in verbal fluency
(4/14) and memory (16/26). There were moderate disturbances in retrospective and short term memory. Sub-test findings suggested
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frontotemporal pathology and mild cognitive impairment(MCI). Standard blood tests were normal included calcium and phosphorus
and so was the serologic tests. In hormone panel parathormone was high with 83.9 (15-68.3) Computed Tomography showed extensive
bilateral calcification in the dentate nuclei of the cerebellum, basal ganglion and centrum semiovale. In conclusion a rare form of sporadic
presenile dementia with neurofibrillary tangles, temporal or frontotemporal atrophy and Fahr-type calcifications and no senile plaques
has been reported mostly in Japanese patients. Calcification in the dentate nucleus and basal ganglia is one of the most characteristic
features and this disease is named with the acronym DNTC. Neurofibrillary tangles are made up of tau and phosphorylated-tau protein.
Our patient fits this of dementia because it is sporadic, and with neither extrapyramidal symptoms nor metabolic abnormalities. The most
appropriate diagnosis would be Fahr’s syndrome due to probable DNTC. The term “Fahr’s syndrome” thereby seems more appropriate
than “Fahr’s disease”.
Keywords: Fahr’s disease, dementia, calcification
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[Abstract:0671] Geriatric psychiatry
A case report: bipolar disorder with late onset or frontotemporal dementia?
Rabia Kevser Boyraz, Emel Kocer, Ismet Kirpinar
Department of Psychiatry, Bezmialem Vakıf University, Faculty of Medicine, Istanbul-Turkey
e-mail address: [email protected]
A 75 year-old male patient, retired, his complaints were insomnia and feeling restless. His wife complained his spending money unwisely,
borrowing money from people and not paying back, irritability, shouting, talking to himself, collecting old clothes from streets, arranging
cement to build another room under his house, having chats with sexual content. These problems were persisting for a few months and
then disappearing. His premorbid personality was calm and harmony. He had no history of family story, as they know, seizures, head
trauma, alcohol intake or substance usage. He developed irritability in the last 5 years; and consulted a doctor 4 years ago with the
symptoms of not knowing what to say, irritability and unwillingness. He has been prescribed escitalopram- 20 mg for depressive episode.
He overcame the difficulty of expressing himself except irritability and unwillingness. He developed new habits, written above, in the last
2 years. He has been prescribed with Valproic acid- 1000 mg with the diagnosis of manic episode, and the dosage of escitalopram was
lowered to 10 mg. He was brought to our clinic by his wife since the problems persisted. During consultation his mood was euthymic. He
had no grandiosity, his speech speed was normal. He looked uninterested during consultation but was responding angrily when his wife
was speaking about his symptoms. The diagnosis has been reviewed again due to the progressive and inappropriate behavior changes.
Considering the facts that no manic symptoms during consultation and no repeated mood episodes history we suspect on the organicity,
especially FTD (Frontotemporal Dementia). Blood tests are normal, MRI shows common atrophy, especially in the frontotemporal
areas. MMSE score is 20. According to the battery, no perception problem, coherent learning performance in the organization, but
problems with memory and executive functions. Initially, mood swings with excessive and unnecessary spending, insomnia, irritability,
conversations with sexual content, repeated character of symptoms, thought to be manic episode of bipolar disorder. However, with the
results of cognitive tests and neuroimaging methods, symptoms like irritability and agitation, apathy, personality and behavioral changes
as socially inappropriate behaviors brought us to change the diagnose as FTD.
FTD, which is characterized by progressive behavioral changes, executive function and language problems, can be misdiagnosed as
psychotic disorder, depression, late onset bipolar disorder because of the personality and behavioral changes in early stages. Irritability
and agitation are frequently observed in all types of dementia. However, cross-sectional studies show that euphoria and disinhibition are
seen more frequent in FTD. In elderly patients with mania irritability, apathy, confusion can be more frequent than elevation and euphoria.
Considering that differential diagnosis can be overlooked under short outpatient visit times because of the common symptomatology,
we aim to emphasize the importance of evaluating elderly patients with the point of view of common neuropsychiatric symptomatology
with this case report.
Keywords: frontotemporal dementia, bipolar disorder with late onset, behavior changes
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IMPULSE-CONTROL DISORDERS
[Abstract:0215] Impulse-control disorders
Deliberate self-harm by insertion of foreign bodies: a rare case
Suleyman Demir, Aslıhan Okan Ibiloglu, Mehmet Gunes, Abdullah Atli, Mehmet Cemal Kaya, Mahmut Bulut, Aytekin Sir
Department of Psychiatry, Dicle University, Faculty of Medicine, Diyarbakir-Turkey
e-mail address: [email protected]
“Deliberate self-harm and self-inflicted foreign body” is defined as the intentional, direct injuring of body tissue without suicidal intent.
Early exposure to a stressful or trauma-inducing environment presents a significant risk factor to later developing deliberate self harm
or self injurious. A 28-year-old female had a past history of 12 years of self injurious behavior (SIB), which into all over her body (such
as neck, wrist, forearm, leg). The patient was born in the lower income family as well as stressful environment of a mother who suffered
from recurrent depressive illness and a schizophrenic father. Firstly, at the age of 16 years she injured herself in the neck, with the sewing
needle. She became increasingly more uncommunicative, followed to died by suicide of her brother. Since that time, she would often
refuse to change her clothes, bathe, or maintain even minimal hygiene. She has very poor insight into the nature of her self injurious
behavior. Her mood was depressive.
On physical examination, the head of the needle was palpable under the skin. A foreign body, which appeared to be similar to a needle,
was found in the lower limb which embedded in the soft tissues, on lateral plain X-ray. The surgical scar was detected due to an thyroid
operation. She was consulted with the department of neurology and neurosurgery, due to the complaints of severe headache for about 2
years. Electroencephalogram (EEG) revealed slowing but no seizure activity. MRI (magnetic resonance imaging) of the brain was revealed
the presence of a needle, for about 2 cm in length, as well as metal artifacts at the edge of cerebellum with the regional encephalomalacia
of cerebrum. Her neurosurgeon suggested removing the needle from her brain would be more dangerous than keeping it intact. She
was treated with carbamazepine 800 mg/day, risperidone 4 mg/day, and clonazepam 4 mg/day, with partial effect. Subsequently, a
serotonergic antidepressants (paroxetine 20 mg/day) was administered in place of clonazepam, valproic acid 1500 mg/day was placed,
and risperidone 4 mg/day was discontinued to gradually, at the end of 12 weeks. At 11 months, the patient continued the same medical
treatment and she was satisfied with the results.
Deliberate self harm or self injurious have many features similar to impulse control disorders or addiction. Within clinical populations,
those who self-injure tend to possess high levels of depression and anxiety and comparatively few coping mechanisms. Foreign bodies
are frequently missed during the initial evaluation, and not all patients present immediately following an injury. There is a growing body
of evidence that serotonergic antidepressants are useful in the treatment of SIB as well as most were receiving concurrent psychotropic
and/or anticonvulsant medications. In our opinion, delays in seeking medical attention and attempts at self-removal may lead to further
morbidity and mortality in all such cases. To the best of our knowledge this is the first case, reporting self mutilation by the sewing needle,
repeatedly after the brain injury.
Keywords: self-harm, self-injurious, treatment
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[Abstract:0278] Impulse-control disorders
Pathological gambling behavior secondary to treatment of Parkinson disease with pramipexole
Nefise Ozturk, Kadir Ozdel, Fatih Yigman, Canan Efe
Department of Psychiatry, Ankara Diskapi Yildirim Beyazit Education and Research Hospital, Ankara-Turkey
e-mail address: [email protected]
Pathological gambling is being unable to resist impulses to gamble. It usually begins in early adolescence in men, and between ages 20
and 40 in women. It is a long-term disorder that tends to get worse without treatment. Over the past decade, dopamine agonists (DAs)
have frequently been reported to induce problematic compulsive behaviors like pathological gambling. Onset of age, clinical course,
treatment and prognosis is different when pathological gambling is secondary to the treatment with DAs. The patient was presented in
this case report because he had pathological gambling behavior secondary to treatment of Parkinson’s disease with pramipexole.
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To date, most case reports and series have involved Parkinson’s disease (PD) patients who, spend large amounts of money in gambling
and exhibit inappropriate sexual activities within months of starting therapy with drugs such as pramipexole or ropinirole. Rates of clearly
pathological behaviors as high as 13% have been reported with therapeutic DA doses, defined as 2 mg pramipexole or 6 mg ropinirole
daily.
Mr.T., a 45-year-old man, with no previous history of pathological gambling. He was first seen for psychiatric consultation 2 years after
onset of his gambling behavior. Mr. T had been diagnosed with Parkinson’s disease 3 years previously. Treatment for Parkinson’s disease
included dopamine agonists (pramipexole), anticholinergics (bornaprine), and irreversible inhibitors of monoamine oxidase (rasagiline).
He became more dysfunctional and impulsive over a 2-year period. He began to uncontrollably shopping, playing lottery and horses.
He decided to seek treatment when his gambling escalated. He was hospitalized and evaluated by the department of psychiatry and
neurology. He met DSM-IV criteria for pathological gambling. He had signs of depression and he met DSM-IV criteria for major depression.
Pramipexole was discontinued, piribedil added. Escitalopram added for his depressive symptoms. His gambling stopped within days of
discontinuing the pramipexole.
Mr. T’s pathological gambling behavior appeared to be secondary to dopaminergic treatment for Parkinson’s disease. The clear relationship
between the starting of the pramipexole and symptom onset, the advanced age of the patient at the time of the onset, absence of a family
history of psychiatric illness, and rapid resolution after discontinuation of pramipexole helped to distinguish secondary pathological
gambling from primary one for this patient. This case supports to the theory of increased stimulation of dopaminergic reward systems in
pathological gambling and impulsive behaviors. The dopaminergic system, and in particular the dopamine D2 receptor activity, has long
been implicated in reward mechanisms in the brain. DAs have stimulatory action on dopamine D2, D3, and D4 receptors. Pramipexole
and ropinirole, specifically, are relatively selective for the D3 receptor, for which they have a high affinity. D3 receptors are concentrated in
the mesolimbic pathways that govern reward behavior, including pleasure and addiction. In addition to dopamine and norepinephrine
neurotransmitter dysfunction in pathological gambling, clinical studies have identified a relationship between serotonergic dysfunction
and impulsivity. Additional neurobiological research that investigates the association between pathological gambling and correlates of
dopamine, is necessary.
Keywords: parkinson’s disease, pathological gambling, pramipexole
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[Abstract:0394] Impulse-control disorders
Kleptomania emerged after a stressor in a depressed patient in remission and adjunctive bupropion
therapy
Mehmet Fatih Yilmaz1, Can Sait Sevendik1, Mehmet Akif Camkurt2
Ardahan State Hospital, Ardahan-Turkey
1
Afsin State Hospital, Afsin, Kahramanmaras-Turkey
2
e-mail address: [email protected]
Kleptomania is an impulse control disorder with inability or great difficulty in resisting impulses of stealing objects which are needless
for personal use, regardless of their monetary. A co-morbidity between mood disorders, eating disorders, anxiety disorders, personality
disorders, and kleptomania is mentioned recently. Selective serotonin reuptake inhibitors, mood stabilizers and opioid antagonists are
used for treatment of kleptomania. In this case we present a patient under treatment with venlafaxine 150mg/d for depressive and anxiety
symptoms, emerged kleptomania one year ago after a social stressor, treated with 150 mg/d bupropion adjunct therapy for kleptomania.
A 42-year-old female patient, referred to psychiatry 7 years ago with anhedonia, feeling depressed, sleep and appetite disturbance,
anxiety. Her symptoms have begun after her daughter at 6 was forced to watch sexual content movie by their neighbor’s daughter at
age of 7. After that her daughter begun to fear from males, crying frequently, trying to separate her parents in bed at nights. Venlafaxine
37.5 mg/d was initiated and after the dose was raised to 150mg/d slowly. She was well with this treatment until she saw and argued with
her ex-neighbor in a market. She begun to steal objects such as hair pin, napkin, glass, brace, mostly from her neighbors houses. She was
feeling very guilty and ashamed after that but could not stop her urge to steal. We added 150mg/d bupropion to her current treatment
with venlafaxine 150 mg/day. After 15 days she was feeling very well and her stealing attitudes were almost ended. She was totally normal
after a month and continues her treatment as venlafaxine 150 mg/day and bupropion 150 mg/day
Treatment of kleptomania is unclear in literature. Serotonin reuptake inhibitors, mood stabilizers and opioid antagonists and as well as
psychodynamic and psychoanalytic therapies. In our case kleptomania is emerged while using venlafaxine. Bupropion is used for impulse
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control disorders like pathological gambling and trichotillomania. To the best of our knowledge this is the first reported kleptomania case
treated with adjunct bupropion therapy. Larger and controlled studies are needed to understand kleptomania and its pharmacotherapy.
Keywords: bupropion, depression, kleptomania
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S305-S6
[Abstract:0759] Impulse-control disorders
Glutamatergic agents in the treatment of children and adolescents with trichotillomania: topiramate
augmentation
Ipek Percinel
Department of Child and Adolescent Psychiatry, Osmaniye State Hospital, Osmaniye-Turkey
e-mail address: [email protected]
Trichotillomania is classified under “Obsessive Compulsive and Related Disorders” in the DSM-5. There is no generally accepted algorithm
for its treatment. Cognitive behavioral therapy alone or combined with psychopharmacological agents are frequently used for the
treatment of trichotillomania. Selective serotonin reuptake inhibitors, tricyclic antidepressants, typical/atypical antipsychotics, opioid
antagonists, lithium and bupropion are the molecules that were reported to have been used for the treatment of trichotillomania. Recent
studies have identified a possible role for glutamatergic dysfunction in the pathophysiology of obsessive compulsive disorder (OCD)
and OCD-related disorders. Topiramate is an antiepileptic drug, which is involved in the modulation of glutamatergic activity in the
brain. The drug has been shown to block voltage-gated sodium and calcium channels, increase GABA activity depending on dosage by
binding to a site distinct from benzodiazepine binding site on the GABA receptor complex, selectively antagonize kainite/AMPA subtype
glutamate receptors, and poorly inhibits carbonic anhydrase enzyme. Examining the literature, we have found only one open-label study
on effectiveness of topiramate in the treatment of trichotillomania. The study, which was conducted on adult patients, reported a notable
improvement in hair pulling behaviors of patients with topiramate treatment. We have found no relevant study conducted on children
and adolescents. This report aimed to discuss the place and effectiveness of topiramate augmentation in the pharmacological treatment
of trichotillomania on the basis of the current literature knowledge.
Keywords: child, topiramate, trichotillomania
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[Abstract:0853] Impulse-control disorders
Carbamazepine treatment in kleptomania; a case report
Bulent Devrim Akcay1, Beyazit Garip2
Department of Psychiatry, Konya Military Hospital, Konya-Turkey
1
Department of Psychiatry, Sirnak Military Hospital, Sirnak-Turkey
2
e-mail address: [email protected]
Kleptomania is associated with impulse control disorders characterized with stealing invaluable subjects that are not necessary for
the person. It is described in DSM-5 as ‘’impulse control and behavior disorders’’ a psychiatric disorders. The prevalence and etiology
of kleptomania is not well described because of social stigmatization. Kleptomania is really so rare. As a result of research related with
kleptomania indicated that it has related with anxiety disorders, obsessive compulsive disorder, mood disorders, substance dependency,
personality disorders, eating disorders and sexuality disorder. Kleptomania usually begins in early adolescents period and continues for a
long time. There is no sufficient data related with spontaneous remission and long term prognosis. Mood stabilizers and antidepressant
drugs could be useful to the treatment of kleptomania that was indicated growing body of case reports. Different kinds of studies were
mentioned that most of the antidepressants and antipsychotics can be applied for this impulse control disorders. 42 year-old male patient
is married. He has graduated from the university, two kids, living with her husband and kids. He was arrested for stealing a amulet five
years ago. Her psychiatric course and forensic problems initiated after this negative life events. He described his complain as irritability,
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anhedonia, unwillingness, stealing invaluable subject without paying any money and experiencing a huge remorse after stealing action.
Stealing behavior first initiated 25 years ago when he was in the university. When the stealing urge occurs he has experienced a common
tension before initiating, but after stealing something, he experienced to have a huge and common relaxation. He accumulated all the
stolen objects behind the laundry basket. Patient emotion was depressed. He has not only obsessive but also intrusive thought related
with stealing action. In addition to that, he concentrated on some kinds of legal problems. Patient was diagnosed with depressive disorder
and kelptomia according to DSM-5 diagnostic criteria. Patient has been treated with depressive disorders and impulse control disorders.
Lithium and valproic acid treatment was terminated because of adverse reaction. Patient current treatment was sertraline 100 mg/day.
In addition to his current treatment we initiated 400 mg/day carbamazepine. The scale of kleptomania score at the beginning of the
treatment was 30, Beck Depression Score was 38, Hamilton Depression Score was 32. At the end of the third month evaluation score was
significantly lower compared with the initiating period. It was indicated K-SAS;12, BDS;22, HDS;14 respectively. Patient’s thought related
with stealing significantly ameliorated, urges and behaviors relating with stealing improved at the end of the treatment period.
Treatment of kleptomania is fairly problematic and it is really hard to achieve intended succeed. The most important issue that is
complicated kleptomania is comorbid psychiatric disorders like depression, anxiety, gender identity problems and other emotional
problems. To make a right diagnosis of the kleptomania is quite important and will be the first step to make good treatment. We concluded
that carbamazepine could be useful for the treatment of kleptomania and it is possiable to get a result at the end of the treatment.
Keywords: impulse control disorder, carbamazepine, kleptomania
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MILITARY PSYCHIATRY
[Abstract:0355] Military psychiatry
Persistent traumatic brain injury caused by primary blast injury
Taner Oznur1, Suleyman Akarsu2, Abdullah Bolu3, Barbaros Ozdemir1
Department of Psychiatry, Gulhane Military Medical Academy, Faculty of Medicine, Ankara-Turkey
1
Aksaz Naval Hospital, Mugla-Turkey
2
Aircrew’ s Health Research and Training Center, Eskisehir-Turkey
3
e-mail address: [email protected]
Indirect damages on the human body by the effect of the pressure waves are called primary blast injury. The frequency of the formation of
primary blast injury has been increased f with the using of new generation war explosives. A patient with a traumatic brain injury formed
a bullet with a high kinetic energy is presented in this case report that rarely seen in the literature.
E.K. was a 36-year-old, male, university graduate.Amnesia, difficulty in concentrating, limited neck movement, electrification, sensation
and numbness spread over the whole body with forward flexion of the neck, tinnitus in the right ear, headache which lasted until about a
day and 4-5 times per month on the right side, drowsiness and dizziness during periods of headache, episodic seizures defined as losing
control over the movements. Seizures components: Losing control over the movements (progressing from the neck to the bottom),
hemicranial severe headache, nausea, huskiness in the right eye, stuttering, not describe any loss of consciousness and sensation during
seizure. Seizure duration was 30 to 45 minutes and seizure frequency was biweekly.
Patient had been shot by a bullet with a high kinetic energy from the assault rifle in 2011. Inlet orifice of the bullet was at the left back
of the neck and outlet orifice was at the right side inferior region of the neck. Severe headaches (pulsatile-right hemicranial locatedunresponsive to non steroid analgesics) had begun after the trauma. Hearing loss and tinnitus in the right ear, restriction in neck motion,
weakness in the right arm and in the fingers especially in the first 3 fingers. In the first 3 months after the trauma, seizures defined as
losing control over the movements had initiated. Numbness spread over the whole body with forward flexion of the neck during these
seizures had happened. After the third month, severity and frequency of headaches were decreased (4-5 times per month, lasting 1-2
days). Left arm was seen as powerless as suggestive of somatization in the neurological examination. EMG was normal. 1.2 sec delay
in the central transmission time was detected in SEP. Response inhibition, impairments in controlling the motor movements and
deprivation of cognitive flexibility were detected in the Stroop test. Test results indicated the pathology in the function of the frontal
areas. Brain magnetic resonance imaging was normal. Hypermetabolism in the right frontal lobe anterior segment and mild cerebellar
hypometabolism were detected in Brain PET. Deterioration in cognitive functions and other complaints were considered compatible with
the PET findings, so that patient was diagnosed as traumatic brain injury. Venlafaxine 75 mg / day and Piracetam 2400 mg / day were
started. The risk of developing neuronal and diffuse white matter damages including myelin and axonal structures and complaints related
to developing these damages should always be taken into consideration in such cases.
Keywords: blast injury, brain injury, traumatic
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S308
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MISCELLANEOUS
[Abstract:0265] Miscellaneous
A case with subclinical hypothyroidism developed due to black cumin use as a supplemental and
alternative treatment
Hasan Mayda1, Halil Ibrahim Guzel2, Erman Bagcioglu3
Department of Psychiatry, Mardin Kızıltepe State Hospital, Mardin-Turkey
1
Department of Psychiatry, Konya Aksehir State Hospital, Konya-Turkey
2
Department of Psychiatry, Afyon Kocatepe University, Faculty of Medicine, Afyonkarahisar-Turkey
3
e-mail address: [email protected]
Currently, psychiatric diseases can be treated by drugs, psychotherapies, and somatic treatments. Despite modern treatment methods,
relapse, partial treatment response, and non-responsiveness may be encountered in psychiatric diseases. Disease relapse, difficult
treatment, difficulties in reaching healthcare facilities may encourage patients and their families to prefer alternative treatment methods.
Supplemental and alternative treatments (SAT) are frequently preferred in physical and psychiatric diseases, but patients and physicians
can hardly predict medical complications caused by them. Although there are many studies about SAT use in psychiatric diseases, they
are limited to case reports. We present here a 58-year old female patient who is followed up for schizoaffective disorder for 8 years, and
has used “black cumin” supplement as SAT for more sufficient treatment. She has developed “subclinical hypothyroidism” which is nonresponsive to medical treatment and is recovered only after discontinuation of black cumin intake.
This case indicates that black cumin, which is commonly consumed as SAT by patients, may cause thyroid dysfunction.
Keywords: alternative treatment, black cumin, hypothyroidism
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S309
[Abstract:0399] Miscellaneous
Priformis syndrome that misdiagnosed as antipsychotic related dystonia
Osman Virit1, Lutfiye Pirbudak2, Bahadir Demir1, Ferdi Doganay2, Haluk A. Savas1
Department of Psychiatry, Gaziantep University, Gaziantep-Turkey
1
Department of Anesthesiology and Reanimation, Gaziantep University, Gaziantep-Turkey
2
e-mail address: [email protected]
Movement disorders are common side effects of antipsychotics due to blockage of dopamine D2 receptors, and they are well known by
clinicians. One of them is acute dystonia which is generally improve by anticholinergic treatment, but there may be some difficulty in
treatment of chronic or late dystonia. We report a patient who is misdiagnosed as antipsychotic related dystonia.
The current study presents a 20-year-old male patient experiencing the manic phase of bipolar disorder, who developed piriformis
syndrome (PS) during antipsychotic therapy. The anteflexion position associated with PS was confused with dystonia and treated;
however, the patient did not respond to treatment. The patient was hospitalized and administered biperiden, benzodiazepine, baclofen,
tetrabenazine, and electroconvulsive therapy (ECT). Neurology and physical therapy consultations also supported the diagnosis of
dystonia, instead of PS, and the patient remained irresponsive to their treatment, including botox. The algology department discovered
PS and the patient recovered upon the injection of bupivacaine and triamcinolone into the piriformis muscle.
Since physicians concentrate on only their own area of expertise, they may fail to consider other etiologies, especially rarely situations.
Advanced diagnostic examinations should be carefully performed especially in therapy -resistant cases. Additionally, psychiatrists should
stay current on newly developed disciplines such as algology.
Keywords: piriformis syndrome, antipsychotics, dystonia
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[Abstract:0777] Miscellaneous
Periodic catatonia: a case report
Murat Yalcin1, Huseyin Fatih Seker2, Engin Emrem Bestepe2
Department of Psychiatry, Kocaeli Derince Training and Research Hospital, Kocaeli-Turkey
1
Department of Psychiatry, Erenkoy Training and Research Hospital, Istanbul-Turkey
2
e-mail address: [email protected]
Catatonia has been described as one of the most enigmatic phenomena in psychiatry and neurology, the syndrome is showing
symptoms such as catalepsy, waxy flexibility, stupor, posturing, negativism, mutism and echolalia. Periodic catatonia (PC) is a rare and
usually misdiagnosed form of catatonia, involves rapid-onset, brief, recurrent episodes of hypokinetic or hyperkinetic catatonia. These
episodes can last 4–10 days and reoccur over a period of weeks to years. Patients are generally asymptomatic between episodes. The
pathophysiology of PC is less clear than that of catatonia in general.
Mrs. E, is a 46-year-old divorced woman, college graduate, not working and lead a solitary life in Istanbul. She was brought to our hospital`s
emergency service by his brother because of her catatonic state. His brother reported that he she was frightened and paranoid since 3-4
days, had auditory hallucinations and paranoid thoughts, and became mute and staring within the past two days, hence he found her
in a catatonic state in her bed before he brought her to the emergency service. Her personal history revealed that her first complaints
began twenty five years ago with the present symptoms, she had at least seven episodes of catatonia over the past 25 years, and episodes
were during in a range of one to seven days. It is also interestingly reported that she had spontaneous remissions within 1-2 days in some
episodes. Her last hospital admission was one year ago, after the patient voluntarily discontinued her medication of risperidone 1 mg/
day, claiming that she can anticipate catatonic episodes so she will take her medicaments if necessary.
In her mental state examination, she was appearing younger than stated age, staring vacantly into space, making no eye contact with
others, and maintaining the same. She exhibited psychomotor retardation and rigidity. She also exhibited catatonic signs, including
mutism, negativism, staring, posturing, waxy flexibility, urinary incontinence. In her blood investigation her creatine phosphokinase (CPK)
level were 2561.
She was diagnosed with periodic catatonia and started on lorazepam 2.5 mg day in divided doses. Significant reduction in her catatonic
symptoms was noted within the first day of treatment with a decreasing CPK level of 1513. Her mutism and withdrawal were considerably
reduced. She could be engaged in conversation and the symptoms remitted completely within 2 days. The patient was discharged in third
day of her hospitalization.
The hallmark of PC is a history of recurrent brief episodes separated by periods of complete or near-complete remission. It is a rare,
atypical and urgent condition, generally requiring hospitalization for evaluation and treatment. Differential diagnoses include functional
psychiatric illness, intoxications, metabolic encephalopathy, lupus, HIV, central nervous system infections. Benzodiazepines and
electroconvulsive therapy are first line treatments.
Keywords: periodic, catatonia, benzodiazepines
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S310
[Abstract:0830] Miscellaneous
Diogenes’ syndrome in a schizophrenia patient
Murat Yalcın1, Selma Hilal Avcı2, Engin Emrem Bestepe3
Department of Psychiatry, Kocaeli Derince Training and Research Hospital, Kocaeli-Turkey
1
Department of Psychiatry, Istanbul Medeniyet University, Istanbul-Turkey
2
Department of Psychiatry, Istanbul Erenkoy Training and Research Hospital, Istanbul-Turkey
3
e-mail address: [email protected]
Diogenes’ Syndrome (DS) is characterized by marked self-neglect, domestic squalor, suspiciousness, emotional lability, social withdrawal,
apathy, lack of concern about one’s living conditions, hoarding of rubbish (syllogomania). The syndrome has been defined as a ”failure of
social and personal care” reflecting a public health point of view, rather than a psychiatric one. It was named after Diogenes of Sinop, an
ancient Greek philosopher who lived in a barrel in the 4th century BC.
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The eponym was first suggested in 1975 by Clark and collaborators, who described thirty geriatric patients with personalities characterized
by suspiciousness, aloofness, hostility, and unfriendliness admitted to hospital in a state of severe self-neglect, and who were living in
gross domestic squalor. It was, however, MacMillan and colleagues (1966) who conducted the first thorough investigation. They called the
syndrome “senile breakdown”. The estimated annual incidence of DS is 0.5 per 1000 of the population aged 60 or over living at home, but
DS may go unrecognized because it may mimic other behavioral or cognitive disorders. DS has been linked with several other psychiatric
conditions including psychosis, obsessive compulsive disorder (OCD), dementia, affective disorders, personality disorders, alcohol and
substance abuse, autism and frontal lobe impairment.
Mrs. T, a 57 year-old divorced housewife, with a previous history of schizophrenia, brought by her relatives to our emergency service
because living in an abandoned building and in conditions of extreme squalor. She has been lived with her mother until death, one year
ago, than she escaped from his son’s house and was missing for the past six months. Her relatives fortunately found her, in a garbage
house, by a social media website calling for help for her. In her personal history, her relatives reported a 35 year history of schizophrenia
with more than ten admissions to hospital and no symptomatic remission in the past 15 years. They reported that her father has lived too
as homeless at the end of his life and was found dead in an abandoned building. In her mental examination, she was disheveled, wearing
dirty clothes, unkempt, was foul smelling and having a very poor personal hygiene. She was very agitated, and was verbally abusive to
staff, she was appearing older than stated age. She was having a dysphoric mood, loosened associations, and pressured speech. Her
thought processes were incoherent and not goal directed. She had no insight. She was restarted on her previous psychiatric medication,
namely haloperidol and biperidene. Clozapine treatment was not started because of her poor social support. An awareness of Diogenes’
Syndrome, risk factors that contribute to causation and familiarity with systemic difficulties in management are important in appropriate
recognition and management.
Keywords: Diogenes’ syndrome, self-neglect, schizophrenia
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S310-S1
[Abstract:0850] Miscellaneous
Olanzapine and duloxetine combination in fibromyalgia treatment; a case report
Bulent Devrim Akcay1, Beyazit Garip2
Department of Psychiatry, Konya Military Hospital, Konya-Turkey
1
Department of Psychiatry, Sirnak Military Hospital, Sirnak-Turkey
2
e-mail address: [email protected]
The etiology of fibromyalgia is still unknown. Fibromyalgia disease is characterized with common body pain, sensitivity of the certain part
of the body, fatigue, decreased pain threshold, weakness, sleep disorders and increased psychiatric disorders comorbidity. Fibromyalgia
is a rheumatologic disease which is not related with joint.
A women age is 32 year-old and married. She has two kids and works in a private company located in city center. She applied the medical
center with pain and spasm which spreads through the back, neck and shoulder body region. After the neurological examination and
tests, we didn’t find any neurological disease. She referred to the physical therapy specialist and diagnosed fibromyalgia after applied all
the detailed tests and evaluations. Non-steroidal anti inflammatory treatment and muscle relaxants treatment has been to the patient but
the pain didn’t ameliorate. So we decided to add the amitriptyline treatment at the dose of 25 mg/day and increased gradually 50 mg /
day. Patient’s complaints didn’t improve at the and of this treatment so we tried to apply different kind of antidepressants like paroxetine,
escitalopram and venlafaxine. But all the medical intervention that were applied to the patient didn’t significant results. She had been
complaining with sleep disorder, difficulty in appetite, weight loss, social and occupational disabilities in recent times. She was referred to
psychiatry service because of psychical complaining and psychiatrist initiated the duloxetine 30 mg/day at the beginning of the treatment
and dose duloxetine dose was gradually increased 60 mg/day. In addition to this treatment olanzapine 2.5 mg/day oral dose have been
initiated to the patient. Alter the one month later, visual pain scale decreased from 8-9 than 2-3 level. The number of sensitivity point
decreased from 14/18 to 4/18. Back Depression scale score decreased from 14 to 5 point. We indicated that this clinical improvement was
going on during the 2 and 3 month visits.
Different kinds of antidepressants can be used to the treatment of fibromyalgia. In addition to antidepressants treatment, low dose
atypical antipsychotic add on therapy could be useful and give some positive results.
Keywords: fibromyalgia, olanzapine, treatment
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S311
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[Abstract:0851] Miscellaneous
A patient following with major depression disorder has radial nerve enfection; herpes zoster disease
Bulent Devrim Akcay1, Muammer Korkmaz2, Mehmet Aytug Dikililer3, Beyazit Garip4
Department of Psychiatry, Konya Military Hospital, Konya-Turkey
1
Department of Neurology, Gulhane Military Medical Academy, Ankara-Turkey
2
Mevki Military Hospital, Anıttepe Family Practioner Center, Ankara-Turkey
3
Department of Psychiatry, Sirnak Military Hospital, Sirnak-Turkey
4
e-mail address: [email protected]
A 26 age of male patient who was diagnosed major depressive disorder has been followed up and venlafaxine 150 mg/day dose was
initiated. He was aware of erythema on he left arm when he woke up. After two days, aqueous bulging and pain developed on the
erythema region of the skin. In addition to this, he has pain and numbness on the line of radial nerve trace. Some of the lesion that
was indicated on the radial nerve trace was incrustation and vesicular. It was found out the end of patient neurological examination,
hypoestesia on the radial nerve trace at he left and forearm, left triceps reflex reduction and mild paresis left forearm extension compare
with right one. Patient was diagnosed with herpes zoster disease that infected to the radial nerve. Acyclovir and gabapentin treatment
was initiated for the treatment of viral infection and pain. Patient skin lesion and neurological complains improved at the end the 15 days.
Herpes zoster disease can be seen some certain medical disease that is able to deteriorate immune system and intensive stressful life
events. Radial nerve infection with zoster is quite rare. Especially, diagnosed with major depressive disorders patient should be followed
carefully and examined detail when the painful skin lesion developed. Patient should be consulted with a dermatologist when these kind
of symptoms was discovered.
Keywords: major depression disorder, radial nerve, herpes zoster disease
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S312
[Abstract:0856] Miscellaneous
Management of agitated patient
Ali Doruk, Murat Gulsun
Department of Psychiatry, Gulhane Military Medical Academy, Ankara-Turkey
e-mail address: [email protected]
Agitation is defined as non-purposeful and repetitive increased motor restlessness that is accompanied by anxiety, tension. Excitation
is a severe form of the agitation. It is pointless and motor behavior escalated that is not influenced by external stimuli. Approaching
of agitated or excited patient must be based on the underlying cause. The patient history and physical examination should be done
properly for investigating the underlying reasons of agitation or excitation. Firstly, the patient may need to be sedated. Diagnosis and
treatment process should be done together quickly in the management of agitating-excited patient. Likewise, pharmacological and nonpharmacological methods should be combined.
In cases of agitation, it becomes a fuzzy balance or imbalance between the patient and the environment. It is usually composed of four
groups as controllers, spectators, agitators and unaware persons around the agitated patient. The controllers who govern the patients
should be disabled before the patient is sedated. People that cause, increase or maintain the agitation should be removed from around
the patient. These measures will prevent damage to the patient and the people around. Doctor’s calm behavior from body language to
verbal communication may limit the dramatic and noisy behaviors of the patient to more reasonable levels. Physical restraint measures
and pharmacological approaches are inevitable if effective results would not be taken with communication skills and the regulation of
environmental-patient interaction.
Antipsychotics and benzodiazepines may manage the level of agitation that a patient exhibits. However, correct treatment should address
the specific underlying medical disturbance of agitation in such cases. The goal of using medication is essentially to calm the patient, so
that he or she can be more accurately assessed by clinicians. Medication should not induce sleep. In the acute setting, this more easily
permits a diagnosis of the underlying cause of the agitation and allows patients to have some participation in their own care. More
practically, however, patients who are not a sleep are easier to discharge from the emergency department.
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Patients should be involved in the process of selecting medication to whatever extent possible (eg, oral vs intramuscular). If the patient
is able to cooperate with taking oral medications, these are preferred over intramuscular preparations. Haloperidol, risperidone,
olanzapine or lorazepam may be preferred as oral medications. Haloperidol, olanzapine, ziprasidon or diazepam is priority drugs to use
for intramuscular preparations.
Keywords: management, agitation, excitation
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S312-S3
[Abstract:0857] Miscellaneous
Electroconvulsive therapy during pregnancy
Armagan Ozdemir
Department of Psychiatry, Bakirkoy Prof. Dr. Mazhar Osman Training and Research Hospital, Istanbul-Turkey
e-mail address: [email protected]
The treatment of psychiatric disorders during pregnancy period poses a clinical challenge because the clinician is treating at least two
patients simultaneously. Maternal psychiatric illness and medication may have potential adverse effects on the fetus’ and mother’s health,
so treatment options should be preferred according to risk-benefit assessment. Electroconvulsive therapy (ECT) is a valuable option in
the pregnant patient for severe cases where there is poor nutritional intake, catatonia, treatment resistancy, a high risk of suicide or
homicide and other life threatening conditions (for example malignant neuroleptic syndrome). Although there have been no controlled,
prospective trials evaluating ECT use in pregnancy, reviews and case reports have reported ECT administered during pregnancy to be
a relatively safe. Despite ECT guidelines have no clear statements about ECT use in pregnancy as a contraindication, ECT clearly rarely
used during pregnancy in most clinical settings. ECT during pregnancy is considered only under very stringent diagnostic and clinical
indications because still pregnancy is a period where associated risks may be substantially higher.
In a review of data evaluation of 339 cases treated with ECT during pregnancy between 1941 and 2007, it was found that many of these
patients underwent ECT treatment for depression and that partial remission was obtained in 78% of them. Whereas there are cases that
report ECT application is safe during the first, second and third trimesters, there are also cases that report ECT application may have
caused premature birth at the second and third trimesters. In a metaanalysis of 300 cases for ECT use during pregnancy most common
ECT-related complications during pregnancy include disturbances in fetal cardiac rhythm which is usually transient and selflimiting, mild
vaginal bleeding, abdominal pain, induction of uterine contractions, and premature labor. In the literature, the use of tocolytic treatment
after ECT or prophylactic tocolytic medication before ECT in order to avoid preterm labor was suggested. Other potential risks related
to ECT during normal pregnancy include spontaneous abortion, uteroplacental insufficiency, or placental abruption. Mortality and
morbidity for these complications are extremely low for both the mother and the fetus. Direct effect of anesthetic agents on the fetus is
still relatively unknown.
Although the safety of ECT and pregnancy has been discussed in many reviews, clinicians should be aware of potential risks. Close
monitoring of mother and fetus during and after ECT treatment is crucial. In the guidelines, some recommedations for different trimesters
are mentioned (use of cardiotocography, ultrasound between treatments, tilt position for mother, tocolytic treatment, inhalation
anesthesia) to prevent complications. ECT during pregnancy should be administered by a multi-disciplinary specialist team consisting of
psychiatrist, gynecologist/obstetrician, and anesthesiologist.
Keywords: ECT, electroconvulsive, pregnancy period
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[Abstract:0861] Miscellaneous
How to write a paper and to publish it in international journals?
Haci Murat Emul1, Tevfik Kalelioglu2, Erhan Yuksek2
Department of Psychiatry, Istanbul University, Cerrahpasa Faculty of Medicine, Istanbul-Turkey
1
Department of Psychiatry, Bakirkoy Prof. Dr. Mazhar Osman Training and Research Hospital, Istanbul-Turkey
2
e-mail address: [email protected]
The words ‘publish or perish’ make sense to psychiatrists whether he/she is a clinician or striving to establish an academic career.
Considerably, without the critical and scientific thinking including in continuing education, interpreting the evidence based findings,
investigation, writing and publication, we may lose our professional credibility in clinical practice. The expectation on clinicians is growing
to publish more. While struggling with research and its publication: perseverance is essential, keeping the research question sufficiently
focusing is also important, keeping in mind that the real life is ongoing that may inevitably interrupt the efforts / hopes on research. There
may be several stages while dealing with a research and its publication. In this scientific writing course we aimed to discuss and interact
with the audience about these several stages such as:
• Evolution and purpose of publications
• Basic structure and types of scientific papers, writing the title, title page, abstract and keywords
• The whole text writing including: Introduction, Results, Discussion, References
• Scientific language and writing style
• Effective use of tables and figures
• Data analysis and statistics
• Submission of a manuscript
• Understanding peer review and the editorial process
• Dealing with rejections and revisions
• Authorship responsibilities and publication ethics
• Review of draft manuscripts
In addition, we will be prepared to write manuscript of ours in English. We would like to write introduction, a little bit mentioning on
methods and results, then would write discussion section in front of the audience to allow them to interact with us. Prior to each step, Dr
Tevfik Kalelioglu and Erhan Yuksek will present brief information about the concerned title. In example, Tevfik Kalelioglu will discuss about
introduction section such as: the introduction should give the reader the essential information to understand the aim of the study and to
state the research question. A good introduction will ‘‘sell’’ the study to readers and could answer the question of “why you did the study”.
The purpose of writing the methods section is to provide another scientist to be able to reproduce the study and compare the results
with the information you enable in your paper. So with this workshop we are planning to share how to write a striking introduction and
emphasize to design a well-structured method section which may cause the article to be rejected even by the editorial review. Or my
colleague Erhan Yuksek will briefly discuss the importance of reference writing, using a program such as end-note or reference manager.
Also he will show how to use end-note while writing reference in the text. Also, he may inform us about the importance of the title and
abstract writing as: the title and abstract are the most important sections of a manuscript. They are important for editors who will read the
title and abstract and decide if it should be considered for peer review process; for reviewers, who will get a first impression of the paper;
and for readers, as the title, abstract, and keywords are often the only parts of the paper that are freely accessible to everyone online,
including readers in developing countries.
Keywords: publication, international journal, internship
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S314
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[Abstract:0868] Miscellaneous
School refusal: from diagnosis to management
Sabri Herguner
Department of Child and Adolescent Psychiatry, Necmettin Erbakan University, Meram School of Medicine, Konya-Turkey
e-mail address: [email protected]
School refusal is characterized with features of worry about the safety of the family, feat of the teacher, running back home from the
school and nervousness. Previously this condition was referred as school phobia but school refusal is a more comprehensive, it does not
imply that the attendance problem is inevitably associated with specific stimuli located within the school setting. There is no etiology
of school refusal; rather it varies from child to child. A broad range of precipitating factors associated with the home, the school and the
individual may contribute to the development of school refusal. Most commonly, school refusal is reported to affect about 1 percent of
the school aged population. It is equally common in boys and girls. Treatment involves the use of behavioral and cognitive procedures
directly with the young person. The aim is to help the child to cope with the stressors associated with returning to school or maintaining
regular school attendance. It includes relaxation training, cognitive therapy, enhancement of social competence and exposure.
Keywords: diagnosis, school refusal, treatment
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MOOD DISORDERS
[Abstract:0144] Mood disorders
Medroxyprogesterone induced mania in-patient with bipolar affective disorder: a case report
Memduha Aydin, Bilge Cetin Ilhan, Abdulbaki Akyildiz, Ibrahim Eren
Department of Psychiatry, Konya Training and Research Hospital, Konya-Turkey
e-mail address: [email protected]
Medroxyprogesterone acetate (MPA) is a steroidal progestin, a synthetic variant of the steroid hormone progesteron. It is used as a
contraceptive within hormone replacement therapy for the treatment of endometriosis, dysmenorrhea and amenorrhea. Depression is
one of the most common psychiatric side effects of progesterone. MPA is thought to cause mood changes and the results of recent studies
suggest that it may have a role in the regulation of manic symptoms. To our knowledge, there is only one case report of MPA-induced
mood shift. In this report, we aimed to discuss possible induction of manic symptoms by oral MPA through a case report with bipolar
affective disorder.
Miss A, 19 years-old female, had history of bipolar affective disorder for 3 years. She was diagnosed to have secondary amenorrhea,
being followed in a gynecology clinic for two years. Gynecologist prescribed her MPA (10 mg/day) pills for menstrual regulation 2 months
ago. She began to suffer from insomnia 2 days after starting MPA treatment and started feeling herself energized with symptoms added
the following days, of irritable mood, feeling of anger, increased talkativeness, increase in goal-directed activity. After the 10th day, she
stopped treatment at menstruation onset and she was admitted to the hospital with manic episode (Young Mania Rating Scale: 32).
It was the second psychiatric hospitalization of her, as she was initially hospitalized with manic episode 3 years ago, where she had
been treated successfully with risperidone 2 mg/day and valproic acid 1000 mg/day. In her more recent hospitalization, her risperidone
medication was reduced gradually because of elevation in prolactin hormone levels that caused amenorrhea and galactorrhea, followed
by ceasing of valproic acid medication herself, due to gain of weight. Other than that, she only used quetiapine 12.5mg/day due to
sleeping problems for 2 years. She had neither manic nor depressive episodes during for the past 3 years. Six months ago, fluoxetine 20
mg/day was started for her mild depressive symptoms, which she did not use more than 2 months. No hypomanic or manic symptoms
were observed during fluoxetine treatment. She was in remission for three years during the prescription of MPA. As manic symptoms
emerged after the onset of MPA treatments, risperidone and valproic acid was started, which was then switched to aripiprazole and
lithium treatment because of side effects.
Recent studies suggest that hormone treatments such as selective estrogen receptor modulators or progestins may be useful in the
treatment of mania. Estrogen and progesterone combination appeared to be effective as adjuvant treatment for mood stabilization.
MPA may have benefits in the treatment of manic symptoms, as described in a few recent studies. As there is no previous information in
the literature on MPA inducing manic episodes in bipolar affective disorder patients, our report may lead further research on that issue.
Keywords: bipolar disorder, mania, medroxyprogesterone acetate
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[Abstract:0180] Mood disorders
Isotretinoin-induced manic episode: a case report
Mesut Isik1, Pinar Guzel Ozdemir1, Osman Ozdemir1, Serap Gunes Bilgili2
Department of Psychiatry, Yuzuncu Yil University, Faculty of Medicine, Van-Turkey
1
Department of Dermatology, Yuzuncu Yil University, Faculty of Medicine, Van-Turkey
2
e-mail address: [email protected]
Isotretinoin (13-cis-retinoic acid) is one of vitamin A derivative retinoids and has been used in mild and severe acne cases. There have been
several reports of adverse psychiatric reactions to isotretinoin, including depressive symptoms, suicide, worsening of mood symptoms,
psychotic symptoms. In this article, we introduced a case report which had no previous psychiatric story and occurring manic attack after
oral isotretinoin treatment.
The 19-year-old male patient has been brought to hospital by his relatives for the symptoms of insomnia, increase in psychomotor activity
and speaking amount, grandiose and mystic delusions, new interest areas related with the hallucinations, increase in libido, irritability,
hyperactivity which has started 15 days ago. His complaints started after two weeks of isotretinoin 30 mg/day treatment. The patient
did not have any psychiatric disease, abuse of substances or any other medical story in his past. In his family history, he had an uncle
and an aunt with bipolar disorder and psychotic disorder. In the first examination of the patient who was hospitalized for treatment and
follow-up, it was observed that he had xerosis on his face due to isotretinoin treatment, keilit in his lips, his orientation was normal, the
speed and amount of speech increased, his attention was distractible, his perception was normal, associations were scattered, he had
clang association, and mystic and grandiose hallucinations. The frustration tolerance was low, his affect was euphoric, sometimes irritable
and dysphoric; psychomotor activity was increased, sleep and appetite decreased, libido increased, and there was no insight. He had
35 points from the Young Mania Grading Scale. The hemogram, biochemistry, thyroid, liver and kidney function test, B12, folate levels
were normal. The patient was consulted with dermatology department for the acne vulgaris. Azithromycin was started 500 mg per a day,
clindamycin gel, was suggested. The treatment started as olanzapine 10 mg/day and lithium carbonate 900 mg/day. On the 24th day of his
hospitalization, he received zero point from Young Mania scale, and turned into premorbid status, and he was discharged.
In this article, a case was presented who did not have previous psychiatric story, had manic episode with the treatment of isotretinoin
and has been treated completely with the mood stabilizer medication treatment. Healthy person who had family history in terms of
psychiatric disease and the patient who had a psychiatric disorder especially bipolar disorder, poses a high risk for the emergence of new
symptoms or the exacerbation of symptoms. As a consequence, it is considered that the use of isotretinoin may be high risk especially in
individuals who had previous psychiatric disease and family history therefore the clinician should examine this situation.
Keywords: acne vulgaris, isotretinoin, manic episode
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[Abstract:0183] Mood disorders
Scalp burning sensation: can it be a “relapse signature” in bipolar mania
Mesut Yildiz, Sedat Batmaz, Emrah Songur
Department of Psychiatry, Gaziosmanpasa University, Faculty of Medicine, Tokat-Turkey
e-mail address: [email protected]
Bipolar disorder is a common mental illness characterized by recurrent episodes of mania/hypomania and depression. In the context
of bipolar disorder, there are two types of prodromes, one of bipolar disorder and the other of recurrence of mood episodes in those
with established bipolar disorder. Identifying prodromal features that predate the onset of bipolar disorder may enable the prevention
of bipolar disorder and aid early intervention. Mood lability/swings and depressed mood were the most common putative prodromal
features followed by racing thoughts, anger/irritability, physical agitation and anxiety. In detecting prodromes of relapse, one study
showed that relatives of patients with mania were better then patients. We here present a case of bipolar affective disorder who’s manic
/hypomanic episode starts with burning sensation in scalp.
A 62-year-old woman is being followed nearly for 40 years for bipolar affective disorder. Her complaint began in the early twenties
and she used various medications for the recurring depressive and hypomanic/manic episodes. From age 20 to 50 her depressive
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episodes were prominent and she used lithium carbonate, lamotrigine, valproic acid + sodium valproate and antidepressants in different
combinations. But fort he last 10 years her manic/hypomanic episodes are more prominent. She was being followed by valproic acid +
sodium valproate 1000 mg/ day and quetiapine 300 mg/day mostly. Various medications were added in recurring episodes. She and her
son was knowledgeable about the disease and prodromal signs of recurrence. For the last 10 years she was experiencing two or three
manic/hypomanic episodes per year. Before almost all manic/hypomanic episodes the patient experienced “burning sensation in scalp”.
After this annoying complaint she was becoming more talkative and grandiose and sleeping less then before. The patient and her son
knew that a new episode is about to come when she feels the “burning sensation in scalp”.
Prodromes are defined as the early signs and symptoms that herald a full-blown illness or a recurrence. Bipolar prodromes are any
cognitive, behavioral and affective signs or symptoms that signal an oncoming episode. Unlike these signs and symptoms, we here report
that a somatic symptom can be a prodromal symptom of relapse in manic/hypomanic phases of bipolar affective disorder. When patients
or relatives of them see the “relapse signatures” of any kind, psychiatrists must pay attention to them.
Keywords: bipolar disorder, mania, prodromal signs
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[Abstract:0239] Mood disorders
Persistent cerebellar syndrome due to lithium intoxication: a case report
Ertac Sertac Orsel, Atila Erol, Hilal Kapudan, Semra Karayilan, Mustafa Ozten
Department of Psychiatry, Sakarya University, Faculty of Medicine, Sakarya-Turkey
e-mail address: [email protected]
Lithium has been commonly used for the treatment of several mood disorders in the last 60 years. Toxic levels can be seen frequently
in clinical practice due to narrow therapeutic serum levels. The influence of lithium intoxication on body is evaluated as two different
groups; reverSIBle or irreverSIBle. The concept of irreversible is used for squeal observed or fatal cases at least one year after. Syndrome of
lithium effectuated neurotoxicity (SILENT) is a definition that resulting lithium intoxication and symptoms related to the nervous system
are continued for at least 2 months after lithium has been stopped. The patient in our case is a 60 year old woman whose diagnose was
bipolar disorder, depressive episode and continued dysarthria, ataxia after suicide attempt with lithium 10 years ago.
A 60 year-old, primary school graduate, married, housewife, had three children, female patient. Symptom described included persistent
low mood and feeling like she wants to stand alone and die. She had lost motivation in activities of interest and she was also noticed to
become increasingly socially withdrawn. Somatic symptoms include sleep-onset insomnia and loss of appetite. In her history she was
follow up 20 years with a diagnose of bipolar disorder. She had four severe manic episode and one severe depressive episode in the
first decade of the disease. The last severe episode was depressive and there has been one suicide attempt 10 years ago related to the
exacerbation of her depression. After high dose lithium uptake she was monitored in intensive care long time with loss of consciousness.
Before intoxication she did not have any neurological disease or symptoms. Her neurological symptoms were ataxia and dysarthria after
suicide attempt and still going for 10 years. She used valproate 1000 mg and had no severe episode for past 10 years. On psychiatric
examination, her speech was dysarthric. She had depressive affect with low mood. On neurological examination she had ataxia, dismetria
and dysdiadochokinesia. Magnetic resonance imaging was performed with cerebellar atrophy. Bipolar disorder depressive episode was
diagnosed and addition to the treatment valproate 1000mg, quetiapine 300 mg added. Remission in depression was observed in control
examination after one month and her neurological symptoms which has existing for 10 years was on going at the same rate.
Upon reviewing the literature it is reported complete remission of the neurological symptoms in most of the patients after discontinuation
of lithium treatment. But in some cases even though lithium stopped cerebellar syndrome such as ataxia, dysarthria, dysmetria and
tremor may continue. SILENT syndrome is more common in women and over the age of 30. In our case the patient was female and age
was 50 when lithium toxicity occur. Neurological symptoms and risk factors should be considered in patients with using lithium.
Keywords: cerebellar and silent syndrome, lithium, neurotoxicity,
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[Abstract:0250] Mood disorders
Cyclic cushing induced atypical mood disorder
Nefise Kayka1, Taha Can Tuman1, Gulistan Merve Karaca2, Osman Yildirim1
Department of Psychiatry, Abant Izzet Baysal Training and Research Hospital, Bolu-Turkey
1
Department of Psychiatry, Erenkoy Research and Training Hospital, Istanbul-Turkey
2
e-mail address: [email protected]
Cortisol is a glucocorticoid hormone, involved in the immune response with lipid and carbohydrate metabolism, acting on the work of
many organs and made by the adrenal glands. Cyclic Cushing’s syndrome (CCS), is a rare disorder that consist of endogenous cortisol
secretion with a fluctuating course in inter cyclic phases. This irregular secretion can vary from days and years. In this presentation, we
report a patient of atypical mood disorder induced by cyclic Cushing.
A 44-year-old female patient was brought to emergency unit by her relatives with symptoms of disorganized speech and insomnia for
two days. It was learned that the patient was under the treatment with venlafaxine 150 mg per day and risperidone 4 mg per day with
a diagnosis of bipolar affective disorder for seven years. It was learned that previous day she woke up early in the morning, she was
confused and she started to say “ I gave birth a baby”. She have started to cry frequently. She was admitted to psychiatry unit for thoughts
of death, agitation, disorganized behavior, visual hallucinations and perseverative speech. On mental status examination consciousness
was clear, she was not cooperating, she was confused and getting psychomotor agitation, she did not give appropriate answers to
questions. Her attention was scattered, she had visual hallucinations and paranoid delusions. Quetiapine 100 mg per day treatment was
started, confusion, visual hallucination and disorganized behavior disappeared within a few days and it was observed that the patient had
difficulty remembering the previous days. She had hypertension and diabetes and cushingoid appearance on physical examination. The
patient was referred to internal medicine, cortisol levels were measured and dexamethasone suppression test (DST) was performed. DST
results were repeated 2 times, first seen in normal limits, DST could not be suppressed in the second. Due to the rapid improvement of
the patient’s psychiatric complaints and DST results, the patient was considered to be psychiatric situation due to cyclic Cushing disease.
CSS is characterized with paradoxical response to DST and variable cortisol levels. Because of variable cortisol secretion consists of
different psychiatric views. As in our case, insomnia, feeling flood, emotional lability, distractibility, confusion, hypomania, delusions and
hallucinations may be due to increased cortisol levels. Increased cortisol may lead mostly to the depression in the chronic phase and
mania in the acute phase. In the early stages irritability, melancholy can be seen, psychosis is more common in severe cases. In a study
reviewing 65 CCS cases, mood disorder was detected in one of four patients. Memory and attention problems seen in Cushing’s patients
may continue until next year. The incidence is increasing in the forties as in our cases and more than three times seen in women. In
addition, detailed physical examination and medical history with truncal obesity, buffalo hump, muscle weakness, striae, acne, hirsutism,
amenorrhea are such as Cushing’s symptoms should be investigated. In our case, rapid improvement of psychiatric symptoms, two
different responses to DST, normal cortisol levels is thought CCS.
Keywords: atypical mood disorder, cushing, cyclic
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[Abstract:0295] Mood disorders
An organic bipolar affective disorder devoloping after cranial injury with subdural hematoma:a case
report
Emine Cengiz Cavusoglu, Elvan Ciftci, Filiz Izci, Rabia Bilici
Department of Psychiatry, Erenkoy Training and Resarch Hospital, Istanbul-Turkey
e-mail address: [email protected]
Here, we aimed to discuss a case which is an organic bipolar affective disorder which was developed after subdural hematoma due to an
occupational accident.
A 53-year-old male patient had an cranial injury after an occupational accident about 13 years ago. He had surgical treatment with the
diagnosis of subdural hematoma at that time. Shortly after the operation, he had complaints of increasement in the amount of speech,
libido and self- esteem, decreasement in the duration of sleep, wearing colorful clothes and making inconvenient jokes. Then, he was
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started treatment for manic episode caused by organisity. He had not any psychiatric or organic problem before the accident. He had one
to two mostly manic episode in each year and more than one psychiatric hospitalization. He was admitted to our clinic with complaints
of increasement in the amount of speech, libido, energy, spending lots of money, sleeplessness and believing in having superior power
developing in the last 15 days. His physical and neurological examination were in normal. In the mental state examination, selfcare
was moderate, psychomotor activity was increased, mood was elevated, affect was euphyoric, spontanity and rate of the speech was
increased, association of the ideas was accelarated. Any perceptional disturbance was not described, but he had the grandiose delusion
related with having special power and the persecutary delusion related with will be damaged. The speed of thoughts and spontan
attention were increased. The orientantion and cooperation was accurate. The memory functions and the capacity of abstraction were
normal. The insight was not enough. The score of Young Mania Rating Scale (YMRS) was 24. Treatment was started as lithium 600mg/ d,
valproat 1000mg/d, olanzapin 20mg/d which he used before for bipolar affective disorder with manic episode, lorazepam 3,75 mg/d for
agitation. His routine biochemical analysis, complete blood count, thyroid function test, urine analysis and electrocardiogram were in
normal range. His cranial computerized tomography was reported as craniostomy defects in the right parieto-temporal region compatible
with undergone surgical treatment and ischemic lesions in the left temporal cortical-subcortical white matter. His electroencephalogram
was normal. Any pathologic change was not seen between his new and old cranial CTs. His antipschyotic treatment regiment was
changed with haloperidol 20mg/d, biperiden 5mg/d i.m form due to increasement in the restlessness and pschyotic symptoms. After
one week, his YMRS score was declined. His injectable treatment was stopped and oral form of same antipschyotic treatment was
started, lorezepam was stopped. In the 4th week of his hospitalization after his complaints were regressed, he was discharged with the
treatment of haloperidol 20mg/d, biperiden 2mg/d lithium 900mg/d, valproat 1000mg/d and quetiapine 100mg/d. Cranial injuries may
cause cerebral organic pathologies by affecting meninges, blood vessels, brain tissue and cranial nerves. The most affected areas causing
pscyhiatric disorders after cranial injuries are prefrontal cortex, temporal cortex and hypothalamus. Beyond development of manic
episodes after cranial injuries, in our case recurrent depressive and manic episodes were seen, symptoms containing trauma and ischemia
in the temporal parietal area were seen.
Keywords: cranial injury, subdural hematoma, bipolar affective disorder
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[Abstract:0325] Mood disorders
Acceptance and commitment therapy for depression
Mehmet Emrah Karadere
Hitit University, Corum Training and Research Hospital, Corum-Turkey
e-mail address: [email protected]
Depression is a common mental disorder, characterized by sadness, loss of interest or pleasure, feelings of guilt or low self-worth,
disturbed sleep or appetite, feelings of tiredness, and poor concentration. Depression is a significant contributor to the global burden
of disease and affects people in all communities across the world. Today, depression is estimated to affect 350 million people. The World
Mental Health Survey conducted in 17 countries found that on average about 1 in 20 people reported having an episode of depression
in the previous year. Depressive disorders often start at a young age; they reduce people’s functioning and often are recurring. For these
reasons, depression is the leading cause of disability worldwide in terms of total years lost due to disability. Cognitive-behavior therapy
(CBT) as a broad approach to psychotherapy has become the most widely utilized and researched of all psychotherapeutic methods.
Systematic reviews have concluded that CBT is effective for a wide range of disorders and problems (e.g., depression, anxiety syndromes,
eating disorders, sexual dysfunctions), in a variety of patient populations. Within a broader historical context acceptance and commitment
therapy (ACT) can be regarded as a member of the “third wave,” or generation, of cognitive behavioral therapies.
ACT has emerged as among the most widely practiced and researched of the new CBT treatments. Based in a contextual theory of
language and cognition known as relational frame theory, ACT makes use of a number of therapeutic strategies, many borrowed
from other approaches and subsequently further developed within the ACT model. The ultimate goal of ACT in working with clients
with depression is not to eliminate their depression. Rather, it is the promotion of psychological flexibility. The six core processes that
contribute to psychological flexibility (the hexaflex) according to ACT are: Self as context, Defusion, Acceptance, Contact with the
present moment, Values, Committed action. Conversely, each of the six core positive processes also entails a corresponding, opposing,
pathogenic process—for example, fusion opposes defusion, experiential avoidance opposes acceptance, and so on—that contributes to
psychopathology, human suffering, and other manifestations of psychological inflexibility. ACT for depression is a therapeutic approach,
rather than a set of techniques, that is part of the third wave within behavior therapy. ACT seeks to minimize the ways in which language
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contributes to psychological rigidity and human suffering while also strengthening the ways in which it can support valued living and
psychological flexibility. As a second-order change approach, ACT for depression does not seek to change depressive ways of thinking or
regulate dysphoric mood, but instead tries to target the contexts and processes that prevent continued valued living in the presence of
such private events. So in this presentation, I intend to summarize the ACT in depression research and to talk about their frequent cases
of psychological rigidity in depressive patients.
Keywords: acceptance and commitment therapy, CBT, depression
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[Abstract:0372] Mood disorders
Successfully treatment of steroid induced mania with quetiapine
Hakan Ogutlu1, Halil Ozcan2, Esra Ozhan Ibis1, Atakan Yucel2, Tuba Ulkevan2
Department of Child and Adolescent Psychiatry, Ataturk University, Erzurum-Turkey
1
Department of Psychiatry, Ataturk University, Erzurum-Turkey
2
e-mail address: [email protected]
Glucocorticoid use may induce psychiatric disorders such as mania, depression, psychosis, delirium, insomnia, agitation and etc.
Frequently psychiatric symptoms appear three to eleven days after the beginning of steroid treatment at any dosages (generally high
doses). Here we report a patient with hydrocortisone induced mania and her successfully treatment with quetiapine.
A 50-year-old male patient having diagnosis of secondary adrenal insufficiency due to operation of pituitary adenoma one year ago and
currently on hydrocortisone 10 mg/day treatment admitted to cardiology clinic with symptoms of severe chest pain. He was transferred
to cardiology intensive care unit with diagnosis of acute pericarditis probably due to secondary adrenal insufficiency than 160 milligram/
day methylprednisolone was started and hydrocortisone was ceased. On 4th day of treatment refusal of taking his drugs, increased speech,
euphoria, increased activity and insomnia was seen. In his psychiatric examination; he was fully conscious and oriented. Euphoric mood,
grandiosity, logorrhea, flight of ideas, reduced attention, irritability, insomnia was detected. Neurological findings were normal. He scored
32 on Young Mania Rating Scale (YMRS). Based on these findings, he was diagnosed as steroid induced mania. We started quetiapine 200
mg/day, methylprednisolone continued at 40 mg/day because of medical needs. After three days, his speech was normal; euphoric mood,
grandiosity, irritability and insomnia markedly improved. Then methylprednisolone was ceased and 10 mg/day hydrocortisone started
again. On 7th day of quetiapine treatment YMRS score was 4 and her psychiatric complaints completely improved. On the 14th day she was
discharged with fully remission.
Steroid induced symptoms increase risk of morbidity and mortality. Important point is treatment of steroid induced mania. Also if it
is possible cessation of steroid or reducing the dose should be done if not mood stabilizers, antipsychotic drugs are the choices of
treatment in steroid induced mania. In this case we used quetiapine as an antipsychotic agent with mood stabilizing effects and had a
quick treatment response with no side effects. We suggest that clinicians should be careful about steroid induced mania and quetiapine
use must be taken into consideration for the treatment of this situation.
Keywords: steroid, mania, quetiapine
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[Abstract:0468] Mood disorders
Aripiprazole induced acute myopia in an adolescent
Ozalp Ekinci, Nuran Ekinci, Fevziye Toros
Department of Child and Adolescent Psychiatry, Mersin University, Faculty of Medicine, Mersin-Turkey
e-mail address: [email protected]
Aripiprazole, an atypical antipsychotic, is frequently used in child and adolescent psychiatry. Ocular side effects of aripiprazole are
reported to be very rare. Hereby, we present an adolescent case who developed acute myopia with aripiprazole use.
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A 16-year-female was referred to our clinic with the complaints of sadness, nervousness, crying, irritability, anger outbursts and worries
about failure at school. With the diagnosis of major depressive disorder, she was started on fluoxetine 20 mg/day. At her 1st months’
visit, there was a marked improvement in her depressive symptoms with no adverse effects observed. However, her anger outbursts and
irritability symptoms were reported to continue. As an augmentation of fluoxetine, aripiprazole was added to the treatment regimen with
the dose 5 mg/day. 10 days after the addition of aripiprazole, the patient reported sudden onset blurring of vision in both eyes. She was
reported to have a new onset of difficulties on seeing blackboard at school. The patient did not have a current or history of any ophthalmic
disease. With the suspect of a medication induced adverse reaction, she was consulted to the ophthalmology clinic. Her ophthalmologic
evaluation revealed bilateral myopia of-1.0 diopters. Pupils and intraocular pressures were found in normal range. With the diagnosis of
aripiprazole induced myopia, she was advised to discontinue the medication. 1 week later, the patients’ ocular complaints completely
resolved.
Researches on aripiprazole induced myopia are very limited. In the available literature, there are three reports in adult cases. In two of
these cases, myopia developed shortly after the aripiprazole treatment, which is similar to our case. In one of these reports, Selvi et al.
described both myopia and diplopia in their case. Our case did not have complaints of diplopia. To the best of our knowledge, aripiprazole
induced myopia has not been reported previously in an adolescent. In the present case, the rapid resolution of symptoms with the
discontinuation of aripiprazole strongly suggests a correlation between the drug and the adverse effect. The specific mechanism of acute
myopia with psychotropic medications is largely unknown. Different mechanisms have been proposed including accommodation spasm,
ciliary body effusion, the effect of ocular serotonergic, interneuronal fibers, disruption in ciliary functions and peripheral uveal effusion. It
is difficult to relate these mechanisms with the known mechanism of action of aripiprazole on dopaminergic and serotonergic receptors.
Sudden onset myopia can be distressing for patients and families. Ophthalmologists and child and adolescent psychiatrists must be aware
of this reverSIBle adverse drug reaction.
Keywords: aripiprazole, myopia, adolescent
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[Abstract:0481] Mood disorders
Hyperglycemia induced mania: a case report
Betul Kurtses Gursoy, Arda Yesil, Yasemin Gorucu
Department of Psychiatry, Afyon Kocatepe University, Afyon-Turkey
e-mail address: [email protected]
Diabetes mellitus is a chronic disease of endocrine system that causes serious symptoms including depression, anxiety disorders, eating
disorders, delirium, alcohol and tobacco addiction, and psychotic disorders. It is also suggested that diabetes presence and poor glycemic
control triggers bipolar disorder and especially manic episode occurrence.
A 54-year-old female referred to our unit with increased goal-directed activities, decreased need for sleep, increased talkativeness,
excessive spending and increased libido. The patient was a known case of bipolar affective disorder with a total duration of illness of 15
years with only one manic episode in the past. The patient affirmed that she stopped taking prescribed medicine because ‘she felt well’
and relieved of the symptoms. She had been in remission for the past 15 years.
Based on the story taken from the spouse it was observed that the patient’s current complains started 5 months ago and increased in
the last 2 weeks. He observed that the patient slept 2-3 hrs. In the last few days but without any increase in the mobility, time to time
unreasonable laughter, increase in libido and money expenditure.
Physical and neurological examinations were normal. At the psychiatric examination, she was cooperative and orientated to time, place,
and person. Her mood was elevated. She was easily getting nervous, distractible, and agitated. The speaking speed and speak amount of
the patient, who cannot answer the focus and memory relevant questions, increased and was out of the purpose. It was understood in the
evaluation of perception that there were not any delusions and hallucinations. Young Mani Scale (YMS) score was 24 in first assessment.
After psychiatric examination after the patient was taken into the service, blood gas and HbA1C tests were done and internal medicine
consultation was asked upon fasting glucose level: 632 and glycosuria was detected in urine analyze. Except blood glucose level,
laboratory studies (CBC, thyroid function test) were with in normal limits. HbA1C value of the patient, to whom diabetes mellitus
treatment was done, was found 16.1. It was revealed that patient was diagnosed with diabetes mellitus but stopped taking prescribed
medicine. Due to psychiatric complaints, aripiprazole 30 mg/day ve chlorpromazine 100 mg/day treatment was initiated. In addition,
Cranial MRI was also performed in terms of the of organic etiology. MRI showed bilaterally nonspecific T2 and flair hyperintensities in
frontal lobe which were considered as microangiopatic ischemic gliotic focuses. Patients sleeplessness complaint is resolved in the first
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day after treatment. Follow up during fifth day showed patients blood sugar level stabilized and also increased talkativeness was resolved
and psychomotor activity-mobility was partially improved. The patient started interacting with other patients voluntarily. After 10 days
she discharged from hospital and YMS score decreased to 8.
It has been recognized that bipolar disorder is associated with diabetes mellitus, type 2 in particular. However, further studies needed to
clarify this relationship. Bipolar disorder and diabetes mellitus may affect the course of patients’ symptoms, and thus clinicians should be
aware of this negative relationship.
Keywords: bipolar disorder, manic episode, diabetes mellitus
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[Abstract:0530] Mood disorders
Hyponatremia and tonic-clonic seizures after psychogenic polydipsia in a patient of mania with
psychotic features
Gulsah Guclu Celme, Taha Can Tuman, Osman Yildirim, Mehmet Hamid Boztas, Nefise Kayka
Abant Izzet Baysal Training and Research Hospital, Bolu-Turkey
e-mail address: [email protected]
Psychogenic polydipsia (PPD), is characterized by excessive intake of water without thirst. PPD is important because of it can lead to water
intoxication. The cause of neurological symptoms caused by water intoxication due to the decrease in serum Na level. Patients usually
apply with symptoms of headache, nausea, vomiting and confusion but seizures, respiratory arrest, pulmonary edema may also be the
cause of application. Water intoxication is seen most often in schizophrenia patients (80%) in 6-20% of patients in psychiatric clinics. It
has been reported water intoxication in mental retardation, bipolar disorder, alcohol dependence, eating disorders and organic mental
disorders. In this presentation we report a case of mania with psychotic features, who developed psychogenic polydipsia and accordingly
hyponatremia.
A 44-year-old female diagnosed with bipolar disorder for eleven years. She has been using lithium 900 mg/day, amisulpride 400 mg/day,
biperiden 2 mg/day. She had complaints with self-talking, claiming that she was an artist, drinking a lot of water (about 10 liters), frequent
urination, insomnia, rejecting food intake and drug use for fifteen days. The patient was admitted to the emergency unit with syncope.
Hyponatremia and hypokalemia are detected in the patient and lithium levels were measured by considering the lithium intoxication
and serum lithium level had come within normal limits. Abnormal findings were not detected in brain tomography. When we asked why
do you drink a lot of water, he denied drinking lots of water. Generalized tonic-clonic seizure occurred on 3rd day of hospitalization. We
found hyponatremia in blood tests (126 mmol/L). Electroencephalography and magnetic resonance imaging of the brain were normal.
The patient’s morning cortisol level was normal, urine osmolarity was low and the patient was referred to the department of internal
medicine, fluid restriction was suggested for psychogenic polydipsia. Lithium treatment stopped and treatment of quetiapine 100 mg
per day and valproic acid 1000 mg per day were added. It was determined that the patient’s secretly drink water. After fluid restriction,
sodium levels were within normal limits and seizures were not observed. After psychotic and manic symptoms regressed, patient was
discharged in full remission.
Water intoxication can occur via too fast or excessive amounts of water intake. Headache, blurred vision, muscle cramps, confusion,
lethargy, delirium, seizures, coma can be observed. In our case, the patient had widespread muscle pain, headache, blurred vision and
seizure. Thirst and drinking water is controlled by the lateral hypothalamus. Dopamine serves as an important neurotransmitter in this
region. Polydipsia connected with increase dopaminergic activity is shown in animal experiments. In our patient, symptoms of mania,
polyuria and polydipsia recovered after starting fluid restriction, valproic acid, quetiapine and amisulpride treatment. Antidopaminergic
effects of this drugs might be effective both mania and polydipsia. Psychogenic polydipsia arises often in psychiatric patients. This
can sometimes lead to morbidity and mortality of hyponatremic complications. For this reason acute or chronic polydipsia should be
questioned if any psychiatric patient develop seizures or confusion.
Keywords: mania, hyponatremia, psychogenic polydipsia
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[Abstract:0534] Mood disorders
Amazing effect on stuttering mania
Arif Demirdas, Mehmet Akgonul, Abdullah Akpinar, Kadir Demirci
Department of Psychiatry, Suleyman Demirel University, Faculty of Medicine, Isparta-Turkey.
e-mail address: [email protected]
Stuttering is a speech disorder characterized by repetitions and prolongations of sounds or syllables, resulting in the impairment of
speech fluency. There are studies asserting the role of psychosocial stress in the development of stuttering, and it is known that many
psychiatric disorders may coexist with stuttering. Herein we report, for the first time, that stuttering resolves after entering a manic
episode in a patient with acquired stuttering.
Case: A 27-year-old female who is single and a university graduate. She works in an office. She was brought to the outpatient psychiatric
clinic by her mother, with complaints of impulsivity, a decreased need for sleep, an increase in the quantity and speed of speech,
pressurized and fluent speaking, and mystic-grandiose delusions lasting for 15 days. The mother explained that her daughter used to
stutter but that she talked normally now.
In the young woman’s psychiatric examination, her appearance and age was compatible with her socioeconomic status, and her self-care
had increased. Her mood was irritable, and her affect was anxious. Her speed and quantity of speech had increased. She had grandiose
and mystic delusions. Her spontaneous caution had increased, while her judgment and insight were poor. Her need for sleep had reduced,
and her energy and psychomotor activity had increased. She was hospitalized in the psychiatry clinic with the diagnosis of bipolar
affective disorder, manic episode.
According to the information obtained from her mother, she had had difficulty in speaking since she was nine years old. It was learned
that she had a stuttering problem where, for example, she would pronounce words in two or three segments. She had applied to
psychiatry clinics for stuttering three times before, but her family said that there had been no decrease or healing of the stuttering. It was
learned that her brother and cousin had also acquired stuttering, while a cousin had schizophrenia. Her routine examinations revealed
iron deficiency anemia, and replacement therapy was administered. Olanzapine and lithium combination therapy was also initiated. In
the third week of the treatment, her speech quantity and psychomotor activity decreased. Her delusions disappeared, and her insight was
better. In the period during her hospitalization and up to being discharged, she did not stutter.
Stuttering has two subtypes: developmental and acquired. The etiology of neither of the subtypes has been clarified yet. Herein we
present a case whose brother and cousin also had acquired stuttering and whose stuttering completely resolved after a bipolar manic
episode. There are several studies regarding the etiology of stuttering. It is predicted that stuttering may arise from a deficit of neural
processing in the speech center, including the basal ganglia. There are also neurochemical studies particularly about the role of dopamine
and serotonin, and there are clinical observations suggesting that pharmaceutical drugs may have a role in the etiology of stuttering.
Keywords: stuttering, mania, bipolar disorder
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[Abstract:0541] Mood disorders
Bipolar disorder accompanying Wilson’s disease: a case report
Ali Barlas Mircik, Nazmiye Kaya
Department of Psychiatry, Necmettin Erbakan University, Meram Faculty of Medicine, Konya-Turkey.
e-mail address: [email protected]
Wilson’s disease is an autosomal recessive congenital disease which results as a hepatic and neuropsychiatric disease at different degrees.
In between 30-50% of patients, neuropsychiatric symptoms are seen such as mood disorders, personality disorders and cognitive
disorders. We report here a case of bipolar disorder accompanying Wilson’s disease.
A 23-year-old female patient who has a family history of mood disorder in her father, has been treated for seven years with a diagnosis
of bipolar affective disorder. Patient’s first complaints started when she was 13 year-old and she was prescribed sertraline 50 mg/ day
with a diagnosis of major depression. When she was 16 year-old, she referred to psychiatry out-patient clinic with spending excessive
amounts of money, insomnia, persecutory delusions and she hospitalized with the diagnosis of bipolar affective disorder manic phase. A
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year ago she was admitted to our psychiatric in-patient clinic with tension, restlessness, suicidal thoughts, involuntary neck movements
and diagnosed with bipolar affective disorder - depressive phase. Lithium carbonate 1200 mg/day and quetiapine 300 mg/day treatment
was initiated. Wilson’s Disease was suspected as the likely cause for involuntary head and neck movements. Blood test results were as
followed, ceruloplasmin blood concentration 45 mg/dl (reference range 20-60), copper blood concentration 160,58 µgr/ day (reference
range 80-150), ALT 14 U/L (reference range 20-40), AST 16 U/L (reference range 20-40), 24-hour urinary copper excretion 242 µgr/day
(reference range 15-70). Brain MRI was reported as normal. No Kayser-Fleischer rings were observed by ophthalmologist. With the results
of laboratory tests and liver biopsy, the patient was diagnosed with Wilson’s disease and the chelation therapy was started. Involuntary
muscle movements improved significantly with the chelation therapy. Patient was discharged after improvement of her depressive
symptoms. She is on remission now.
The patient was diagnosed with Wilson’s Disease, seven years after she was diagnosed with bipolar affective disorder. Wilson’s disease
is an autosomal recessive illness characterized by accumulation of copper in tissues. Neurological symptoms usually start between the
ages of 15 and 21 years. In our case involuntary neck movements also began during these years. Psychiatric symptoms are seen in higher
prevalence in patients with Wilson’s Disease than in the general population. These symptoms can be found in 30–50% of Wilson Disease
patients. Most common manifestations are anxiety, mood disorders and psychotic symptoms. In our case mood symptoms started at the
age of 13, then 3 years later bipolar affective disorder was diagnosed. Psychiatric manifestations can be found at any time in the course
of the illness, causing misdiagnosis of Wilson’s disease. Considering possibility of Wilson’s disease for psychiatric patients with involuntary
movements, can be important in terms of prognosis.
Keywords: Wilson’s disease, psychiatric symptoms, bipolar disorder
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[Abstract:0542] Mood disorders
Mania triggered by the use of steroid in a patient with multiple sclerosis
Halil Ibrahim Tas1, Mehmet Fatih Ustundag2, Kemal Akpinar2, Halil Ozcan2
Seka State Hospital, Kocaeli-Turkey
1
Department of Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
2
e-mail address: [email protected]
Corticosteroids are used in the treatment of many illnesses, mainly autoimmune and hematologic diseases. A wide variety of psychiatric
symptoms such as anxiety, panic attacks, delirium, agitation, aggressiveness, cognitive impairment, psychotic symptoms, suicidal
thoughts, depression and mania have been reported associated with the use of corticosteroids.
A 40-year-old male, married, with 2 children, working in the municipality with no prior self or family history of any psychiatric disease was
admitted to neurology department with complaints of double vision, imbalance and numbness sensation in leg. Multiple sclerosis acute
attack was diagnosed he was hospitalized and started intravenous 1 gr/day methylprednisolone. At the third day of hospitalization, our
department was consulted because of symptoms such as logorrhea, decreased need and duration to sleep, extreme mobility, restlessness,
increased sexual desire, distracted attention, grandiosity, etc. According to the DSM-5, mania associated with the drug use was diagnosed.
Young Mania Rating Scale score was 29. Steroid treatment was stopped with approval of the neurology department. The patient was
transferred to psychiatry service. Three-hundred milligrams quetiapine and 300 mg lithium both three times a day were started. His manic
symptoms gradually decreased. At the end of 10 days, Young Mania Rating Scale Score was 4. Quetiapine treatment was reduced to 300
mg/day. Lithium was discontinued. Quetiapine was discontinued at the end of the first month. In clinical follow-ups his mental state
examination revealed no pathology. He and his relatives were informed about the prognosis of multiple sclerosis. The patient was also
informed about the possibility of future attacks and the risk of using steroids leading to manic shift.
Risk factors for the development of psychiatric symptoms after corticosteroid use are defined as the use of high doses of corticosteroids,
the use of drugs that alter the activity of cytochrome enzymes, hypoalbuminemia, the rheumatic diseases, the presence of psychiatric
family history, female gender, some premorbid personality traits. In the treatment of mania or hypomania occurring after corticosteroid
use, first reduction or discontinuation of corticosteroids, then mood stabilizers and/or neuroleptic agents are recommended.
Keywords: mania, steroids, treatment
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[Abstract:0543] Mood disorders
Transcranial magnetic stimulation applications in the treatment of depression in pregnancy
Hakan Balibey
Department of Psychiatry, GATA Haydarpasa Training Hospital, Istanbul-Turkey
e-mail address: [email protected]
Transcranial magnetic stimulation (TMS) is a noninvasive and safe technique for motor cortex stimulation. TMS is used to treat
neurological and psychiatric disorders, including mood and movement disorders. TMS is an emerging novel treatment modality for
psychiatric disorders, particularly major depression. A device for delivery of TMS was approved by the US Food and Drug Administration
for treatment of major depressive disorder in adults. TMS can also treat perinatal and postpartum depression.
Postpartum depression (PPD) is a prevalent illness, affecting 10-15% of new mothers. PPD is the most common complication of childbirth
and is a significant public health concern. Many mothers are reluctant to take medication because of concerns about side effects or
exposure of their newborn infant through breastfeeding. PPD disrupts maternal homeostasis and has an insidious impact on the lives of
families by affecting maternal-infant bonding, breastfeeding, child-rearing practices, and overall child well-being. Furthermore, PPD has
been shown to place children at significant risk of impaired cognitive and emotional development. Unfortunately, PPD is associated with
both maternal suicide and infanticide.
In this presentation TMS experiences in postpartum and perinatal depression will be shared.
Keywords: transcranial magnetic stimulation (TMS), postpartum and perinatal depression, experiences
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[Abstract:0556] Mood disorders
Oxidative stress and bipolar disorders
Ahmet Unal
Department Of Psychiatry, Gaziantep University, Faculty Of Medicine, Gaziantep-Turkey
e-mail address: [email protected]
Generating reactive oxygen species (ROS), metabolism of oxygen, which is essential to life, is a potential source of danger to the cells.
Interacting with many biological molecules such as crucial proteins and membrane lipids, ROS may lead to fragmentation of proteins,
loss of membrane integrity and ultimately cell death. Recently, there is increasing evidence for the role of oxidative stress in the
pathophysiology of bipolar disorder (BD). Especially, it has been considered that oxidative stress caused damage to critical brain circuits
that regulate mood, emotions and motor behaviors, therefore symptoms of BD are thought to emerge as a result of disturbances in the
mechanisms regulating the mood. In studies, some changes in antioxidant enzyme levels, lipid peroxidation and nitric oxide levels of
patients with BD were determined. Because of different clinical manifestations of the disease, data related with oxidative stress varies
periodically and oxidative parameters normalize with treatment.
Keywords: oxidative stress, antioxidant enzyme levels, bipolar disorder
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[Abstract:0586] Mood disorders
Relation between Wilson’s disease and bipolar disorder: a case report
Esra Aydin Sunbul, Emel Basoglu, Esra Koca, Yusuf Ozay Ozdemir
Department of Psychiatry, Erenkoy Training and Research Hospital, Istanbul-Turkey
e-mail address: [email protected]
Wilson’s Disease (WD) is a relatively rare inherited disorder of copper metabolism. It has broad clinical spectrum. Psychiatric manifestations
of WD can be categorized into five groups: Personality changes, affective disorders, psychosis, cognitive impairment and others. There
are few reports of mania or hypomania in WD. A 36-year-old man was admitted to psychiatric unit for bipolar disorder, manic episode
according to DSM-IV criteria. At the moment of hospitalization he presented rapidly alternating mood (sadness and euphoria), increase
in psychomotor activity and energy, increase in spending, increase in the amount of speech. At the time of hospitalization, therapy was
based on 900 mg lithium carbonate and quetiapine 300 mg per day. After 10 days, he was discharged from the hospital voluntarily. He
admitted to internal medicine outpatient clinic because of abdominal pain. In laboratory examination, he had low serum ceruloplasmin
level (0.08 g/L), high GGT level (193 U/L). 24 hours urinary copper excretion was 150 microgram per day Upper abdominal MRI revealed
lesions with intense contrast. Kayser-Fleisher rings was detected with slit-lamp examination. After WD was diagnosed by laboratory
findings and radiological examinations, a low copper diet was given and penicillamine was started. Patient was followed in psychiatry
outpatient clinic with euthymic mood. Dominant neuropsychiatric abnormalities are noted during the course of WD and pose
diagnostic and therapeutic challenges. Diagnostic possibility of WD should be considered in all patients presenting with family and
past history jaundice, neuropsychiatric disorder and premature deaths in other SIBs, recent onset behavioral and personality changes
and extrapyramidal features, sensitivity to neuroleptics, poor therapeutic response to symptomatic therapy, undiagnosed bleeding
symptoms, and recurrent or pathological fractures.
Keywords: bipolar disorder, neuropsychiatry, Wilson’s disease
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[Abstract:0626] Mood disorders
Two oncologic surgeries and two manic episodes: a case report
Arif Demirdas, Ekrem Didin, Kadir Demirci, Abdullah Akpinar
Department of Psychiatry, Suleyman Demirel University, Faculty of Medicine, Isparta-Turkey.
e-mail address: [email protected]
As applicable for many psychiatric disorders, the etiology of bipolar disorder remains unclear. Most studies focus on biological etiology.
Bipolar disorder is among the primary cognitive disorders. It is known that, diseases secondary to impairment of the general medical
condition constitute a cluster of psychiatric disorders. Secondary mania accounts for 1.75% of the psychiatric patients applying to
hospital, and 4.67% of all manic patients. Herein we present a case with manic attacks following two abdominal operations.
Case: A 59-year-old married woman. She is a housewife and high school graduate. She was brought to our psychiatry clinic with
complaints of impulsivity, decreased need for sleep, increase in quantity and speed of speech, pressurized speaking, and increase in
energy, following a surgical procedure of open cholecystectomy+partial liver resection performed 10 days ago. She was hospitalized with
the prediagnosis of bipolar disorder, manic episode.
According to the information obtained from her family, the patient underwent left total nephrectomy due to renal cell carcinoma in 2012.
The family stated that the patient had been hospitalized in a psychiatry clinic for 27 days due to bipolar disorder manic episode after the
operation. Her treatment was regulated with olanzapine, complete remission was achieved. However, the patient gave up her control
visits asserting that she had recovered. She had not been on treatment for the last 2.5 years.
In her psychiatric examination Her mood was euphoric, occasionally irritable, and her affect was anxious. Her spontaneous attention had
increased and the insight was poor. The need for sleep had decreased and the level of energy and psychomotor activity had increased.
No delusions or hallucinations were detected. She had diagnoses of diabetes mellitus and iron deficiency anemia. She had undergone an
operation due to goiter 6 years ago. The patient was diagnosed with bipolar disorder, manic episode without psychotic symptoms, due
to her clinical features existing for last 10 days. Her treatment was regulated and titrated as valproic acid, risperidone, and clonazepam.
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She was discharged with the ongoing treatment.
We aimed to discuss a patient with two manic episodes following surgical procedures due to malignity. According to the information from
her family, she did not have manic symptoms for last 2.5 years. The patient went through another manic attack with the same symptoms
after the second surgery.
Krauthammer et al (1978) remarked the possible reasons for secondary mania. These were stated as; drugs, infections, cerebral neoplasms,
and metabolic disorders. As well as being in a smaller ratio, surgical procedures were noted to cause secondary mania. Elderly patients are
another high risk group for secondary mania due to comorbid conditions and neurological alterations. While the symptomatic treatment
strategy for acute mania is similar in both conditions, the treatment regarding the underlying condition is more important for cases with
secondary mania. In this context; the manic symptoms that may follow surgery, medications, physical diseases and surgical stress should
be handled with care.
Keywords: bipolar disorder, mania, surgery, cancer Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S327-S8
[Abstract:0656] Mood disorders
Toxoplasma seropositivity and mood disorder: a case report
Gulsah Meral Ozgur1, Onat Yilmaz2, Cengiz Basoglu1, Servet Ebrinc1, Mehmet Alpay Ates1, Ayhan Algul1, Hakan Balibey1, Recep Tutuncu1
Department of Psychiatry and Microbiology, GATA Haydarpasa Training Hospital, Istanbul-Turkey
1
Department of Psychiatry, Kasimpasa Military Hospital, Istanbul-Turkey
2
e-mail address: [email protected]
Although psychiatric symptoms can be associated with some systemic or central nervous system infections, there have been only a few
case reports associating toxoplasmosis and psychiatric disorders. The reactivity for toxoplasmin intra- dermal test was found to be highest
in the manic depressive patients especially in the depressive mood. Possibility of a relationship between toxoplasma infection and the
occurrence of schizophrenia and obsessive-compulsive disorder has been suggested. And also, it has been found that the individuals with
first- episode schizophrenia had significantly increased levels of IgG, IgM, and IgA class antibodies to toxoplasma proteins, as compared
with the control subjects. A patient whose psychiatric symptoms might be associated with toxoplasmosis infection is discussed in this
case report.
A 38 year-old male patient under antidepressant treatment for a few months presented with impaired sleep, loss of appetite, multiple
somatic complaints to our outpatient clinic. After hospitalization for further investigation, his cognitive functions quickly declined and
disorganized behaviors were observed. Brain CT scan, brain magnetic resonance imagination and laboratory tests revealed no organic
etiology except for Toxoplasma IgM-IgG seropositivity and Toxoplasma avidity test 63%. Together with the treatment of venlafaxine
150 mg per day and olanzapine 5 mg per day, pyrimethamine and sulfadiazine was added to his treatment. Marked improvement in
symptoms and complaints were observed in days and patient was symptom free on his follow-up at three months.
There has been strong indication that toxoplasmosis can be associated with various psychiatric disorders. Although the co-occurrence
of psychiatric symptoms and infection can be incidental in this case, clinicians should be aware of these etiologic factors for appropriate
intervention and early treatment of patients.
Keywords: mood disorder, toxoplasma seropositivity, toxoplasmosis
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[Abstract:0657] Mood disorders
An old age bipolar disorder case responsive to risperidone treatment
Gamze Erzin, Sema Goka, Davut Ocak, Didem Ozkan, Neslihan Altunsoy, Makbule Cigdem Aydemir
Department of Psychiatry, Ankara Numune Training and Research Hospital, Ankara-Turkey
e-mail address: [email protected]
Bipolar disorder is a disease that first symptoms occur at the age of 18-22, however, in clinical practice it is often associated with late
adolescence and early adulthood periods. In 90% of the patients with bipolar disorder, the starting age of the disease is under 50. In only
5% of the patients, the symptoms start after their 60s. In the literature, there is a consensus on organic reasons that they are the cause
of late-onset bipolar disorder. The major organic causes are neurological factors, especially the white matter hyper-intensity and cortical
atrophy. It is a rare case that mania appears in the old ages for the first time. Therefore, we decided to discuss the issue over a patient with
bipolar disorder whom we found interesting in terms of her age.
Sixty-four hers old female patient without psychotic symptoms, who has started to have symptoms like excessive and frivolous speech,
irritability, hyperactivity, anger and aggression, complaints of insomnia 30 days before the application were followed up with the
diagnosis of manic episodes. Young Mania Scale (YMRS) was 43. The patient scored 25 points in mini mental test. Considering organic
etiology, Magnetic resonance imaging (MRI) and electroencephalography (EEG) was planned for differential diagnosis. In the MRI, cortical
sulcus hemispheric wide and deep, there is ischemic, nonspecific gliotic signal changes available in the bilateral periventricular white
matter. EEG was normal. Neurological examination of the patient was normal. According to disease history, the patient did not have
forgetfulness and continued her daily live without help before the complaints. According to history and the examinations, dementia
syndrome was excluded. There were no significant problems in routine blood chemistry. Vital signs were stable. Patient was evaluated as
manic episodes. When the patient’s history deepened, it was understood that it was her first mania. It was understood that the patient
was diagnosed with manic episodes two weeks ago in another clinic. She started to use 20 mg Olanzapine and did not any change.
The patient was started 1 mg risperidone and increased to 2 mg at follow-up. The patient’s ongoing symptoms in the first 2 weeks like
excessive speech, mobility and insomnia are started to reduce from week 3. In the 4th week of followed, her YMO score was 12. Organic
causes must be carefully reviewed in elderly patients with mania and hypomania cases. We would like to present a case of mania which
we ruled out organic cases, do not benefit from olanzapine and responsive to risperidone treatment.
Keywords: bipolar disorder, old age, manic episode
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[Abstract:0680] Mood disorders
Steroid responsive depression
Gozde Gultekin1, Murat Emul1, Ayse Deniz Elmali2, Sabahattin Saip2, Doga Ugurlar3
Department of Psychiatry, Istanbul University, Cerrahpasa Faculty of Medicine, Istanbul-Turkey
1
Department of Neurology, Istanbul University, Cerrahpasa Faculty of Medicine, Istanbul-Turkey
2
Department of Neurosurgery, Istanbul University, Cerrahpasa Faculty of Medicine, Istanbul-Turkey
3
e-mail address: [email protected]
Corticosteroids have been commonly prescribed in the treatment of medical conditions. These medications may have psychiatric
side effects such as depressive, manic or psychotic symptoms. Side effects are generally seen dose and time dependent, reversible
and frequently over the prednisone-equivalent doses >20 mg/day. There are some unusual case reports that corticosteroids improve
depressive symptoms. Here we present a case about steroid responsive depression.
Mrs. H, a 38-year-old woman, was admitted to the Neurology Department of Cerrahpasa Medical Faculty with a week history of aphasia.
She has diagnosed depression for three years, and used escitalopram 20 mg per day for three years, valproate 1500 mg and risperidone 1
mg per day for one year. She hasn’t any other medical condition. In her family history her father had depression, suicide attempt and died
because of lung cancer. Her physical examination was completely normal. In her neuropsychiatric assessment she had depressive mood,
anhedonia and motor aphasia. BDI score was 24. We didn’t change her psychiatric treatment. Investigations including blood account, urea
and electrolytes, liver function tests, blood glucose, thyroid function tests, B12 and folate, X-ray chest were normal. A lesion has shown in
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MRI that 46*40 mm, central heterogeneous contrasted, edematous in left frontoparietal area. It looked like a high grade glial tumor so was
carried out a biopsy. Biopsy specimen was seen necrotic vasculitis. Then intravenous prednisone 1000 mg per day was administered for a
week. After treatment her aphasia improved. Three weeks after the first psychiatric assessment, her depressive symptoms didn’t continue,
no manic or psychotic symptoms and BDI was 9.
Mrs. H’s depression responsive steroid. The improvement might not be associated with regression of vasculitis or improvement of
aphasia because vasculitis has been for weeks and aphasia has been days but depression has been for three years. It’s known that steroid
administration may induce depression. There are some case reports that prednisone augmentation-responsive depression associates with
hypocortisolemia. Advanced research needed for hypocortisolemia and depression interrelating and we might measure cortisol level that
has long-term depressive symptoms.
Keywords: depression, hypocortisolemia, prednisone
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[Abstract:0694] Mood disorders
Recurrent depression in rheumatoid arthritis: a case report
Yagmur Agman, Sumeyye Kurtulus Calli, Ishak Saygili, Medine Yazici Gulec
Erenkoy Training and Research Hospital, Istanbul-Turkey
e-mail address: [email protected]
Rheumatoid arthritis (RA) is the most common chronic, inflammatory arthritis. The reason is still unknown. Depression levels in RA
patients are significantly higher compared to healthy people. We report a case getting multiple drug treatment diagnosed with RA
and also recurrent major depression with psychotic feature. A 31-year-old female, single patient. She was born in Germany and move
to Turkey at university years, left university at 2nd class. She has no siblings and lives in Istanbul with her family. Her symptoms of
introversion, unhappiness, inactivity, pessimism and suicidal thoughts last for 1 year. With these symptoms, she has been hospitalized
for 6 times in 2014. In one hospitalization, she was treated with 9 sessions electroconvulsive therapy. She was being followed with
the diagnose of recurrent major depression without psychotic feature up to her last hospitalization. After her all discharges, she
used sertraline, venlafaxine, quetiapine and valproic acid with different combinations and doses. Although she was using prescribed
medicines regularly, her depressive symptoms were arising after 1 month remission periods. In her last hospitalization, psychotic
symptoms such as suspiciousness were seen. According to information getting from her family, she was hospitalized due to reference and
persecutive delusions and suicidal attempt 10 years ago and diagnosed with non-organic psychosis. After this hospitalization, she was
in clinical remission throughout 10 years. Psychiatrically, her mood was irritable, affect was anxious. Her speech amount was decreased,
psychomotor activity was also decreased. She had persecutive delusion. Her insight and judgment were inadequate. In her medical
history, she was diagnosed with RA at 12 year-old, and was taking methotrexate for 27 years, prednisolone for 17 years, and an tumor
necrosis factor antagonist (TNF alpha) named abatecep with monthly infusions for 1 year. She was diagnosed with major depression
with psychotic feature and discharged with risperidone 6 mg/d, biperidene 4 mg/d and valproic acid 1250 mg/day orally. Two sets of
contributory factors to depression among patients with RA are generally examined – the social context of the individual and the biologic
disease state of that person’s RA. In our case, some of these factors are usage of steroid and methotrexate and decreased sociability
owing to immobilization. But we think about that worsen in her psychiatric clinic may be connected with usage of TNF alpha at same
periods. In the literature, there are some reports proving not only relation between TNF and cytokines and depression but also relation
between usage of etanercept -TNF alpha antagonist- and cases of schizophrenia-like disorder. Therefore RA patients should be followed
by multidisciplinary approach including psychiatry.
Keywords: depression, rheumatoid arthritis, tumor necrosis factor
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[Abstract:0731] Mood disorders
Adolescent depression that occurs during mother’s psychotic symptoms: a case report
Hayati Sinir, Feyza Hatice Sevgen, Umut Karaaslan, Hatice Altun
Department of Child and Adolescent Psychiatry, Sutcu Imam University, Faculty of Medicine, Kahramanmaras-Turkey
e-mail address: [email protected]
Major depressive disorder is among common psychiatric disturbances in children and adolescents and is considered to be a leading
cause of morbidity and mortality in this population. Depression in children adolescents resembles adult depression in its core features,
albeit with some important developmental variations. Although the etiology of depression is not completely understood, the evidence is
strongest for a transaction between biologic, personality, and environmental factors. Environmental adversities such as abuse and neglect,
stressful life events, and family dysfunction (e.g., high levels of conflict, parenteral psychiatric illness ) also appear to play significant roles
in increasing the risk of depression. In this case report, young male diagnosed major depressive disorder that occur during mother’s
psychotic symptoms, will be presented. The patient, 16 year old male. He was admitted to the outpatient clinic with complaint of feel
sad, lose interest in typically enjoyable activity, problems concentrating, lack energy and motivation, poor school performance, hopeless
about the future, anhedonia. As reported by the patient, these complaints had continued for six month and he had never had any
psychological complaints before. The patient was diagnosed with depression because of these findings. In interviews with the mother:
she said that her son was threatened by the mob. Mother, about two weeks ago, was found in a criminal complaint. In interviews with
the Father; said the mother was not right when he spoke. Due to psychiatric examination, mother diagnosed with paranoid disorder. The
patient’s symptoms, was associated with mother’s psychiatric disorders. Mother was directed to adult psychiatry. The mother’s treatment
was started. Treatment of patient was also started in our clinic. for depressive symptoms, antidepressant drug began (fluoxetine 20 mg/
day). weekly follow-up was performed. The patient’s symptoms, significant improvement was observed by the treatment of the mother.
Family mental illness is a risk factor in the development of depression In this presentation: without any psychiatric symptoms is the last
6 months skepticism of his mother, concerns and constraints due to complaints presented a depressive disorder cases occurring. In this
case, it was emphasized that the information received from parents, must be validated with each other, and How do symptoms occur in
children with psychiatric disorders in parents as shown. Discuss the etiology of depression is intended.
Keywords: depression, adolescent, risk factor
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[Abstract:0746] Mood disorders
Use of ginseng twice, two manic episodes: a case report
Gamze Akcay, Merih Altintas, Sertac Alay, Huseyin Gulec
Erenkoy Training and Research Hospital, Istanbul-Turkey
e-mail address: [email protected]
In parallel with growth of pharmaceutical industry, marketing of herbal products increases gradually as well and use of herbal products,
being thought to be fully harmless due to claim that they are “natural”, gets increasingly widespread. However, under the light of reported
cases, it is thought that such products are not too innocent and that they may be the reasons or trigger of psychiatric diseases. In this
report, we purposed to mention about a person who had two manic attacks because of ginseng use.
The patient who was 29 year-old male, single, elementary school graduated, changing frequently jobs and unemployed at the moment
and living with his family had complaints such as the decrease in need for sleep-starting 2 days after ginseng using, increase in speaking,
aggression, euphoria, wasting too much money, increase in self-confidence. He had been hospitalized with the diagnosis of bipolar
disorder-manic episodes. He was discharged from hospital with quetiapine 400 mg/g 1.5 months ago and he used his medicines regularly.
However, after the use of ginseng a second time, his complaints such as increase in speaking and activity, decrease in need for sleep,
irritability, increase in religious interests, increase in self-confidence and decrease in eating and drinking started again. Upon the fact that
his complaints increased considerably and that he started making risky behaviors, he was brought by his family to our hospital and he was
hospitalized in our service with diagnosis of manic episode. In the first psychiatric examination, it was seen that his self-care decreased
and psychomotor activity increased and his attitude towards interviewer was somehow threatening. His mood, with his words, “I am great,
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I feel like flying” and affect was irritable. His speaking spontaneity and tone was increased. He had no described hallucinations. He had
flight of ideas. He had mystic and grandiose delusions. His impulse control was low. His judgment was not good and he had no insights.
Manic/psychotic cases depending on or triggered by use of ginseng were reported and it was claimed that such kind of herbal medicines
might trigger psychiatric disorders.
Therefore it seems rather hard to reach a final conclusion by means of data obtained about association of herbal products with psychiatric
disorders. Due to widespread use, we need more psychopharmacological data. At this stage, supportive interviews with patient and
having no blaming attitude facilitate to establish a therapeutic cooperation to speaking about potential risks of herbal product use. In
this report, it was observed that again another episode was triggered by second use in a case where manic episode emerged following
one-time use of ginseng. Attention was attracted to the importance of the fact that the people with episodes triggered after the use of
natural product should be informed about these products and their impacts.
Keywords: ginseng, mania, bipolar disorder
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[Abstract:0784] Mood disorders
A case of lithium intoxication without clinical manifestations
Gulay Gunay1, Emre Cirakoglu2, Armagan Ozdemir2, Nesrin Buket Tomruk2
Department of Child and Adolescent Psychiatry, Bakirkoy Prof. Dr. Mazhar Osman Training and Research Hospital, Istanbul-Turkey
1
Department of Psychiatry, Bakirkoy Prof. Dr. Mazhar Osman Training and Research Hospital, Istanbul-Turkey
2
e-mail address: [email protected]
Lithium is widely used in prevention and treatment of bipolar disorder as a mood stabilizer for more than 50 years. Lithium has simple
pharmacokinetics that require regular dosing and monitoring. Its mechanisms of action are complex and its effects are multi-faceted,
extending beyond mood stability to neuroprotective and anti-suicidal properties. Its use in bipolar disorder is under-appreciated,
particularly as it has the best evidence for prophylaxis, qualifying it perhaps as the only true mood stabilizer currently available.
A 50 year-old female patient has referred to psychiatric emergency service with a manic episode and was admitted to hospital. Her
complaints were irritability, insomnia, restlessness, and delusion of having her aborted baby alive for 3 weeks. She has been treated as
bipolar disorder for 15 years. She has been taking lithium 900 mg/day and quetiapine 100 mg/day as maintenance treatment and was
asymptomatic for the last 2 years. Following the death of her brother, mania symptoms had initiated. During this period she applied to
emergency clinic 3 times and her manic symptoms is worsened despite the increase of the dose of quetiapine to 600 mg/day. She had
fine tremor in physical examination; she was fully conscious, oriented and able to communicate, she had no other neurological symptoms.
However, she talked excessively, had an elevated and irritable mood and had no insight. Electroencephalogram, electrocardiogram, and
routine blood tests assessing thyroid, liver and kidney function, blood glucose, hemogram, ferritin, vitamin B12, folic acid were all normal.
Lithium blood level was 2.86 mmol/L but still there was no clinical finding of intoxication. We have stopped lithium medication and
administered %0.9 NaCl isotonic fluid 1000 cc bid. 2 hours after the first treatment lithium level dropped to 1.64 mmol/L and 2 days late
to 0.34 mmol/L. After 3 days we restarted lithium and monitored her closely. Her manic symptoms resolved and she was discharged in
clinical remission. She was followed up for 3 months in outpatient clinic and she was in remission.
In this case we have seen toxic lithium levels without clinical findings. Though %75 of patients may have toxic blood lithium levels
during the treatment course, lithium intoxication is infrequent. Intracellular lithium levels remain normal in acute intoxication, so it is well
tolerated compared to chronic intoxication. Blood lithium level is irrelevant to clinical intoxication. Clinicians should be aware that lithium
toxicity is irrelevant to blood concentration.
In this case report, it is aimed to remind clinicians that lithium toxicity may be present without overt clinical manifestations and therefore
close monitoring of blood levels is crucial. In acute mania blood lithium concentration is considered safe at 0.8-1.2 mmol/L. Lithium
intoxication is one of the several life threatening complications of psychotropic medications. There are three types of intoxication: acute,
acute on chronic and chronic. Symptoms are seen in cardiovascular, gastrointestinal, neurological and renal systems. Although lithium
has a narrow therapeutic index, toxic effects are seen even within therapeutic limits. On the contrary, some patients may persist clinically
asymptomatic at higher levels of lithium.
Keywords: lithium intoxication, asymptomatic, manic episode
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[Abstract:0793] Mood disorders
Neuroleptic malignant syndrome: a case of a milder form
Gulay Gunay1, Armagan Ozdemir2, Emre Cirakoglu2, Nesrin Buket Tomruk2
Department of Child and Adolescent Psychiatry, Bakirkoy Prof. Dr. Mazhar Osman Training and Research Hospital, Istanbul-Turkey
1
Department of Psychiatry, Bakirkoy Prof. Dr. Mazhar Osman Training and Research Hospital, Istanbul-Turkey
2
e-mail address: [email protected]
Neuroleptic malignant syndrome (NMS) is described as a rare, life-threatening, idiosyncratic adverse reaction induced by antipsychotics
or dopamine antagonists. It is characterized by fever, muscle rigidity, autonomic instability and mental status changes. Though NMS is
often seen during first generation antipsychotic use, there are also case reports of NMS caused by second generation antipsychotics. We
report a case with a milder form of neuroleptic malignant syndrome which was diagnosed at its early stage and was treated successfully.
The case is a 56 year-old female patient who was referred to the emergency department of psychiatry with agitation, self-mutilation,
irritability and refusal to take medication. She has been suffering from recurrent depression and was treated with various psychotropic
drugs for more than 25 years and her symptoms had exacerbated in the last 2 years. She has been taking olanzapine 5 mg/d and
venlafaxine 75 mg/d for the last week. At emergency department, the patient was treated with 10 mg haloperidol and 5 mg biperidene
applied intramuscularly and she was admitted to inpatient clinic. Lorazepam 2 mg/d was given to her for irritability and insomnia. The
patient experienced urinary retention, altered level of consciousness and muscular rigidity in her limbs, while her vital signs remained
normal. Laboratory abnormalities included elevated serum creatine phosphokinase (CPK) level (2.693 U/L), aspartate aminotransferase,
and lactate dehydrogenase. Complete blood count, body temperature and other vital signs were normal. Chest X-ray, cranial MRI and
EEG findings were normal. In electrocardiogram there was sinus tachycardia and right bundle branch block. The patient was consulted to
neurology, internal medicine and cardiology for the increased level of CPK and acute chest pain. Troponin levels were normal and acute
coronary syndrome was excluded. The patient was diagnosed with NMS and haloperidol was discontinued immediately. Supportive
treatment such as IV fluid replacement and bromocriptine 7,5 mg/d and diazepam 10mg/d were started. In the following days, her
muscular rigidity ameliorated, her mental status and laboratory findings improved. After 10 days she was clinically asymptomatic and
laboratory test results returned to normal limits. Quetiapine was initiated and its dose was gradually increased to 300 mg /d.
NMS is recognized for more than 50 years. Its mortality rate is high. There are important aspects in its treatment. First, antipsychotics
should be stopped immediately and supportive treatment should be given. Later, benzodiazepines with lorazepam being the first-line
agent, should be given. Bromocriptine or dantrolene can be used as dopamine agonists. Benztropine and diphenhydramine can regulate
acetylcholine and dopamine levels. Electroconvulsive therapy can be an alternative and lifesaving treatment in refractory cases.
Clinicians should keep in mind that there may be milder forms of NMS where some of the cardinal features like hyperpyrexia and
leukocytosis may be absent.
Keywords: neuroleptic malignant syndrome, milder form, recurrent depression
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[Abstract:0800] Mood disorders
Elevation of liver enzyme levels, observed in a patient using agomelatine
Mustafa Solmaz, Hilal Arslan Akgul, Irem Erat, Ramazan Konkan, Hasan Belli
Bagcilar Training and Research Hospital, Istanbul-Turkey
e-mail address: [email protected]
In this case report, it is planned to inform about elevation of liver transaminases in treatment with Agomelatine, Melatonin MT1/MT2
agonist and serotonin 5HT2C antagonist, which is newly presented in our country and warned about following liver transaminases
enzyme levels in 6th, 12th and 24th weeks.
A 66 year-old housewife, came to our clinic on 12.01.2014 with complaints of malaise, anxiety, crying, sadness, drowsiness, inability to get
rid of the thoughts that comes to her mind. These complaints began when her brother-in-law went missing 14 years ago, and severity of the
complaints increased with her inconvenient feelings about guilty over not being able to help enough with her son’s wedding, which took
place 9 months ago. The patient didn’t describe a mania/hipomania periods and was entered into our clinic with the diagnose depressive
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mood disorder. Blood tests results were all within normal limits except for high cholesterol and glucose levels. CT was also normal.
The 14-year history of the disease contained 4 admission with a diagnosis of depression. venlafaxine 225 mg/day, clonazepam 2 mg/day
and 100 mg/day of lamotrigine irregular use was present after discharge. Treatment of patient was done with venlafaxine 225 mg/day
and agomelatine 25 mg/day. Clonazepam dose was split into two as morning and evening. Held on the 10th day of hospitalization, There
were no abnormalities with the tests except elevation in glucose and cholesterol levels. During the patient’s stay in hospital, her mood
was depressive, with occasional thoughts, that won’t reach to a state of delusion, of demons entering her stomach. On the 25th day of her
treatment, delusions formed that she will turn into animal, so Olanzapine 5 mg/day was added to the treatment. These ruminative and
highly resistant thoughts were expressed out loud spontaneously by the patient during majority of the day. On the 29th day of admission,
thoughts about having chagrin, restlessness and regret continued. In observations, In the 4th week of hospitalization, AST:52 U/L and
ALT:45 U/L levels were measured. Liver enzymes rise was assumed to be due to the use of Agomelatine and so it was cut. Treatment was
continued with venlafaxine 75 mg/day and risperidone 3 mg/day. After 2 days of treatment change, the patient had ruminative thoughts
after he saw a dog from the window, telling things such as ‘’I’m a dog, and I am too dirty”.
Due to unresponsiveness of the patient’s to the drug therapy, Electroconvulsive Therapy (ECT) with Anesthesia and Muscle Relaxant
was planned. After 1 week, the repeated tests resulted in decreased levels of liver enzymes (AST:33.5U/L ALT:37.7U/L ) and the patient
underwent 10 sessions of ECT. Due to euthymic state of the patient’s mood, not having nor active psychotic symptoms neither active
suicidal ideation, the patient was discharged and taken to the outpatient clinic follow-up.
It was observed that the control of liver transaminases levels more frequently instead of 1-month intervals which is suggested in the
guides, may be useful.
Keywords: agomelatine, liver transaminases elevation, depressive mood disorder
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[Abstract:0810] Mood disorders
Attention deficit hyperactivity disorder and disruptive mood dysregulation disorder treatment: a
case report
Ferda Volkan, Zeynep Vatansever, Isik Karakaya
Department of Child and Adolescent Psychiatry, Kocaeli University, Kocaeli-Turkey
e-mail address: [email protected]
Disruptive Mood Dysregulation Disorder (DMDD) is characterized by severe recurrent temper outbursts that are inconsistent with
developmental level and manifest verbally or behaviorally. Between outbursts, children with DMDD display a persistently irritable or angry
mood, most of the day and nearly every day. Over arousal symptoms of patients observed with severe chronic and non- episodic irritability
frequently. Some of the symptoms associated with DMDD are also present in other child psychiatric disorders, such as depression, bipolar
disorder and oppositional defiant disorder. Some children with DMDD also have a second disorder, such as problems with attention or
anxiety. Treatment of DMDD is difficult because of not any algorithm. Methylphenidate is the most common pharmacological agent in
the treatment of Attention Deficit Hyperactivity Disorder (ADHD). Atypical antipsychotics (e.g. risperidone, aripiprazole, olanzapine…) can
be added to treatment in some cases because of unsatisfactory clinical response and comorbidities such as conduct disorder, pervasive
developmental disorders, disruptive mood dysregulation disorder or mental retardation. Aripiprazole is one of the FDA-approved atypical
antipsychotics which antagonist of the serotonin (5-HT2A) receptors, partial agonist of dopamine (D2) and serotonin (5-HT1A) receptors.
Most common side effects are insomnia, tremor, nausea and vomiting. Valproic acid use as an anticonvulsant and mood-stabilizing drug,
primarily in the treatment of epilepsy and bipolar disorder. The mechanisms of its therapeutic actions are not well understood. It may act
by increasing gamma-aminobutyric acid levels in the brain or by altering the properties of voltage dependent sodium channels. The most
common side effects are nausea, vomiting, diarrhea, thrombocytopenia and tremor.
In this article, we report a 6 years 5 months old male patient who has ADHD, DMDD treated with valproic acid, aripiprazole and OROS
methylphenidate. This issue wants to get attention that these three psychopharmacologic agents are usable concomitantly ADHD and
disruptive mood dysregulation disorder.
Keywords: attention deficit hyperactivity disorder, disruptive mood dysregulation disorder, valproic acid
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[Abstract:0836] Mood disorders
Catatonia in a very rapid cycling bipolar patient: Is catatonia a disease in itself?
Hakan Ogutlu1, Halil Ozcan2, Mehmet Fatih Ustundag2
Department of Child and Adolescent Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
1
Department of Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
2
e-mail address: [email protected]
Catatonia is described as a motor immobility and behavioral abnormality syndrome with multiple medical and psychiatric etiologies.
Some researchers report that catatonia is a separate syndrome regardless of a type of any psychiatric disorder or medical condition.
According to the etiology of catatonia, treatment strategy can change. In this case, we report a pregnant patient who had manic
symptoms for 3 days after that had depressive symptoms for 3 to 4 days and than revealed catatonia without representing any core mood
symptoms meanwhile.
A 24 year-old 28-week pregnant patient was admitted to our clinic, with complaints of refusal of eating, unable to speak, unwillingness to
move and insomnia. According to the history; she had been diagnosed as bipolar affective disorder six years ago. Until now she had had
seven manic episodes. One week ago, last manic episode started with euphoria, spending a lot of money, lack of appetite and insomnia.
Part of mania took three days. After this part, she had depressive symptoms such as anhedonia, weakness, unwillingness, decreased
speech, pessimistic thoughts, decreased motor activities, lack of appetite and insomnia. The last day, she had mutism, negativism, she
was unresponsive to orders, unable to speak. In her psychiatric examination she was fully conscious, oriented. Blunted affect, mutism,
negativism, psychomotor retardation, catatonic posture, waxy flexibility, refusal of oral intake and insomnia was detected. We diagnosed
patient as Bipolar affective disorder Not Otherwise Specified Type and Catatonia. She scored 23 on Bush-Francis Catatonia Rating Scale,
6 on Young Mania Rating Scale (YMRS) and 5 on Hamilton Depression Rating Scale (HAM-D) during the days of catatonic episode. We
started olanzapine injection 5 mg once daily, then dose was increased 5 mg twice daily 1 week later. We fed her with total parenteral
nutrition. Eleven days later she started to speak, eating, walking and taking her medicine. She also declared no core mood symptom in
catatonic period. Three weeks later her YMRS score was 0 and HAM-D score was 1.
Antipsychotics and electroconvulsive therapy are the choices of treatment of catatonia. We want to emphasize that catatonia may be
an independent syndrome or episode during diseases process. In this case we used olanzapine as an antipsychotic agent with mood
stabilizing effects and the patient had a quick treatment response with no side effects.
Keywords: catatonia, olanzapine, bipolar disorder
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[Abstract:0860] Mood disorders
Disruptive mood dysregulation disorder as a bridge between oppositionality and mood disorders
Evren Tufan
Abant Izzet Baysal University, Izzet Baysal Mental Health and Diseases Training Hospital, Bolu-Turkey
e-mail address: [email protected]
The clinical importance of severe, impairing and chronic irritability among youth has been recognized since 1990s although its diagnostic
relevance has been controversial. Some authors posited that pediatric Bipolar Disorder (BP) could be divided into “narrow” and “broad”
phenotypes with the former displaying classical symptoms of mania/ hypomania (i.e. grandiosity/ euphoria) in an episodic course while
the latter was characterized by unyielding irritability as a hallmark symptom.
Disruptive Mood Dysregulation Disorder (DMDD) a novel diagnosis listed in DSM-5 is partly introduced to resolve this quandary and
is characterized by severe, pervasive, impairing, developmentally inappropriate and recurrent temper outbursts that are grossly out of
proportion to the situation at hand. The outbursts should occur at least three times per week for one year or more with a symptom-free
interval of less than 3 consecutive months. Between outbursts, children with DMDD display a persistently irritable or angry mood, most
of the day and nearly every day. The onset of symptoms must be before age 10, and a DMDD diagnosis should not be made for the first
time before age 6 or after age 18. Bipolar Disorder, Oppositional Defiant Disorder and Intermittent Explosive Disorder should be excluded
for diagnosis. It is thought that DMDD is related to Depressive Disorders.
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DMDD is criticized due to its potential to pathologize physiological behavior (i.e. temper tantrums) with a consequent elevation in use of
psychotropic medications, paucity of empirical evidence supporting the validity of diagnosis, low test- retest reliability and supporting
studies focusing at selected centers and a not entirely overlapping diagnosis (i.e. SMDD). On the other hand, there are also studies
supporting its validity as a distinct diagnosis.
As a new entity, the treatment guidelines for DMDD as well as its sociodemographic and clinical features among diverse populations are
still not elucidated. This presentation will focus on the convergent and divergent validity of DMDD diagnosis via analysis of data from a
tertiary treatment center.
Keywords: DMDD, disruptive mood dysregulation disorder, DSM-5
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[Abstract:0862] Mood disorders
Bipolar disorder and neuroinflammation
Murat Erdem
Department of Psychiatry, Gulhane Military Medical Academy, Ankara-Turkey
e-mail address: [email protected]
There are several alterations associated with inflamatuar system such as increased glucocorticoid resistance, blood-brain barrier
disturbance, alterations of neurotransmitter metabolism, impairment of functional connectivity, increased oxidative stres, microglial and
astrocytic activity in bipolar disorder. Also increased neuronal damage and decreased neurotrophic support are occured in bipolar disorder.
Proinflammatory cytokines increase in bipolar manic or depressive episode but not euthymic period. Mood stabilizer and antipsychotic
treatment reduced proinflammatory cytokine levels during 10 weeks at some studies. In a meta-analysis, sIL-2R, TNF-α, sTNFR1, sIL-6R, and
IL-4 levels in manic, depressed and euthymic bipolar patients higher than healthy control group. In another meta-analysis the author found
that IL-4, IL-6, IL-10, sIL-2R, sIL-6R, IL-1RA, TNF-α and sTNFR1 levels in manic patients were higher than healthy control group. Systemic
Toxicity Index value, which is calculated by determining of Neurotrophins (BDNF, Neurotrophin-3), oxidative stress markers (thiobarbituric
acid, total oxidant capacity) and inflammatory cytokines (IL-6, IL-10 and TNF-α), was the highest in sepsis cases while in bipolar depressive
and manic patients were higher healthy control group. The studies indicate that inflammatory changes in bipolar patients are indicator of
beginning mood episode, the changing associated with ilness activity or the consequences of a mood episode.
Keywords: bipolar disorders, mood disorders, mood stabilizer
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[Abstract:0863] Mood disorders
Recent advances in bipolar disorder: neurobiology and treatment
Nicol Ferrier
Institute of Neuroscience, Newcastle University, Tyne and Wear-United Kingdom
e-mail address: [email protected]
Bipolar Disorder (BD) is a common, highly disabling condition associated with increased morbidity and mortality. While pharmacological
treatments for BD can to some extent reduce the frequency and severity of episodes in some individuals, much of the burden of BD
remains irremediable and it is the fifth leading cause of disability in working-age adults worldwide. Much of this disability is due to the
problems patients have in returning to work which is, in turn, consequent upon the pervasive deficits in neurocognitive functioning that
have been described. However a number of important advances have been made in the understanding of the neurobiology of BD in the
last decade. Through the work of large consortia, a number of genes have been identified and their role, particularly in cell signalling
and processing, has now been investigated. Neuroimaging studies have revealed important changes in white matter tracts in BD. These
changes are present from the first episode and may also be present in unaffected first degree relatives. Changes in grey matter have
also been identified in some cases in pre-frontal cortex and regions linked to emotional circuits of the brain. This leads to the prospect
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of establishing the mechanisms through which genes lead to identifiable pathology and this is likely to be a fruitful approach as there is
strong evidence that BD, both white matter pathway integrity and white matter deficits and neuro-cognition are all significantly heritable.
Early life experiences have long been a focus in mood disorders research and understanding the effect of early life stress and genetic load
on brain maturation and white matter pathology will provide critical insights into the risk of developing and maintaining mood disorders.
There has been a parallel increase in research into the treatment of BD which will be reviewed. Evidence has accumulated during this
time which should allow better and safer outcomes for patients. Recent large studies have reaffirmed the effectiveness of lithium in this
condition and the neurobiology of the lithium response and prediction of the lithium response will be discussed. It will be argued that it
continues to have a prime place in the management of BD and that it should be used more frequently and earlier. Advances in the use of
anticonvulsants will also be outlined and the unique role of lamotrigine discussed. Developments in our understanding of the mechanism
of action of antipsychotic drugs has led to the development of newer antipsychotics which may be freer of the metabolic consequences
of earlier drugs and this evidence will also be reviewed. Finally, there has been a welcome increase in the research in non-drug treatments
in BD and the evidence supporting psycho-education, collaborative care and the recognition of early warning signs of relapse will be
presented. Promising new data on cognitive and functional remediation of BD will also be presented.
Keywords: BD, bipolar disorders, mood disorders
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[Abstract:0840] Mood disorders
A case of the codeine phosphate abuser since the seven years
Aslihan Okan Ibiloglu, Mehmet Gunes, Abdullah Atli, Mahmut Bulut, Mehmet Cemal Kaya, Suleyman Demir, Aytekin Sir
Department of Psychiatry, Dicle University, Faculty of Medicine, Diyarbakir-Turkey
e-mail address: [email protected]
Psychoactive drugs are readily available both legally and illegally. Cough mixtures contain drugs that can lead to dependence, tolerance
and withdrawal. Codeine phosphate is used primarily as a cough remedy. It’s usually ingested.
Tolerance develops to different degrees across classes of substances, such as opioid and amphetamine users may develop substantial
tolerance. Withdrawal symptoms are most apparent for opioids, alcohol, and other central nervous system (CNS) depressants (i.e., sedativehypnotics and anxiolytics). Careful history-taking and checking of medical records can help in identifying patients who may be misusing it.
We report here, a codeine phosphate abuser WHO was used in addition to other cold mixtures, approximately seven years. This case study
provides knowledge for all doctors in the detection, assessment and management of patients with cough mixture opioid dependence.
The case was a 24 year-old Turkish single man who was unemployment. He was brought to us by his sister due to the abused codeine
phosphate 10 mg 6 times daily in addition to several other drugs for cold symptoms. He had tried other mixtures containing codeine,
dextromethorphan, diphenhydramine and promethazine. The patient had started taking cough mixtures seven years ago for cough. He
then started taking increasing amounts of cough mixture. He then went from one doctor to another to purchase these cough mixtures.
He admitted to being a heavy smoker (3 to 4 packets of cigarettes a day), but denied alcohol, any other substance abuse or past psychiatric
history. The patient also admitted to taking cough mixtures containing codeine phosphate in more than the prescribed dosage, but
maintained that this was only for the purpose of relieving her cough.
On admission, the results of laboratory tests, physical examination and the findings of cranial magnetic resonance were normal. Although
he denied any psychotic or mood symptoms, he appeared depressed with severely anxious but unaware of his addiction problem. Our
patient claimed to have intentions to reduce his intake of cough mixture. His father with lower socioeconomic status had been polysubstance abusers in the past. Action of codeine defined with the binds to opioid receptors in CNS. It may be causes to generalized
CNS depression, decreases cough reflex, and reduces GI motility. It should be noted that, toxicity from codeine poisoning includes the
triad of; pin-point pupils, depression of respiration, and loss of consciousness. Convulsions may occur. Also, chronic abuse of codeine
phosphate could lead to permanent psychological problems such as depressive disorders, toxic psychosis. Early initiation of use of a
given drug predicts later abuse of that and other drugs, especially prior to age 15. In literature, a higher proportion of male adolescents
use substances than female adolescents, especially at higher levels of use. As in our case, most of cough medicines, codeine phosphate’s
effectiveness as an antitussive agent is, especially in adults. Therefore, efforts should be taken to raise awareness regarding the abuse
potential and adverse effects of this seemingly safe cough suppressant among the general population.
Keywords: codeine phosphate, cold mixtures, substance abuse
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NEUROIMAGING IN PSYCHIATRY
[Abstract:0849] Neuroimaging in psychiatry
A case followed up a psychiatric disorder was diagnosed with sensorineural aphasia
Muammer Korkmaz1, Bulent Devrim Akcay2, Hakan Akgun1, Oguzhan Oz1, Seref Demirkaya1, Beyazit Garip3
Department of Neurology, Gulhane Military Medical Academy, Ankara-Turkey
1
Department of Psychiatry, Konya Military Hospital, Konya-Turkey
2
Department of Psychiatry, Sirnak Military Hospital, Sirnak-Turkey
3
e-mail address: [email protected]
77 year-old female patient was admitted to the emergency service because of praying all the time and repeating the same words. Patient
has been followed up with hypertension for fifteen years and coronary stent was applied one year ago. Patient neurological examination
was in a normal range except sensorineural aphasia and praying all the time. As a result of magnetic resonance imaging, the brain region
that is called as a Wernicke region demonstrated diffusion deficiency so patient was hospitalized in the neurological clinic. Stroke is quite
common in patient who is diagnosed with hypertension and coronary artery disease. But applying with only sensorineural aphasia as
clinical sign or symptom is so rare. Patient with sensorineural aphasia could be evaluated as a psychiatric disorder by the close family.
Those are usefully referred to the psychiatry service. Suddenly developed articulation disorder should be well evaluated and aphasia
should be thought as a differential diagnosis like our case report. It is essential to perform a brain imaging.
Keywords: psychiatric disorder, sensorineural aphasia, stroke
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NEUROPSYCHIATRY AND BEHAVIORAL NEUROLOGY
[Abstract:0179] Neuropsychiatry and behavioral neurology
A case of neurobrucellosis which mimics bipolar disorder a long time
Gasim Gasimzada1, Halil Ibrahim Akcay2, Serap Oflaz1, Hulya Guveli1, Mine Ozkan1
Department of Psychiatry, Istanbul University, Faculty of Medicine, Istanbul-Turkey
1
Department of Neurology, Istanbul University, Faculty of Medicine, Istanbul-Turkey
2
e-mail address: [email protected]
Brucellosis is the most common zoonotic infection in the world, caused by microorganisms belonging to genus Brucella. It is a multisystem
disease that may present with a broad spectrum of clinical manifestations and complications. Nervous system involvement known as
neurobrucellosis (NB), is seen in 3-5% of patients with brucellosis and at any stage of systemic brucellosis and several clinical forms, such
as meningitis, meningoencephalitis, brain abscess, myelitis, radiculoneuritis, cranial nerve involvement and psychiatric manifestations.
The psychiatric manifestations in neurobrucellosis reported before were depression, psychosis, amnesia, agitation, nightmares and
personality disorder as the case reports or case series. The diagnosis of NB is based on the existence of a neuropsychiatric picture not
explained by any other neurologic and psychiatric disease, evidenced by systemic brucellar infection, and the presence of inflammatory
alteration in CSF (cerebrospinal fluid). We report a case of NB, which began with mania, continued with another psychiatric manifestations.
64-years-old male examined by consultation liaison psychiatry in department of Infectious Disease due to consultation. On mental status
examination he was oriented, his affect was normal, his mood was euthymic. There wasn’t pathological content in thought.
In the psychiatric history, he applied to a hospital emergently with manic symptoms(decreased need for sleep, more talkative, increase
in goal-directed activity, inflated self-esteem, distractibility) four years ago and lithium was medicated with Bipolar disorder. During this
episode he had a tonic clonic seizure but it was neglected and patient. After Lithium treatment manic symptoms disappeared for 15
days and depressive symptoms emerged with severe nausea and vomiting. This clinical appearance considered as Lithium intoxication
and valproic acid was medicated. Depressive episodes with gastrointestinal signs repeated with an interval of 3-4 months until last 3
months. He had neurologic symptoms(paraesthesia, gait disturbance, ataxia, hearing loss) and visual hallucinations last year. Moreover,
in the family history, Patient’s mother and 2 SIBlings were diagnosed by brucellosis and treated 4 years ago due to Brucella epidemic in
patient’s village.
In the laboratory, Brucella Wright test was 1/40 positive in CSF (cerebrospinal fluid) examination and in CSF brucella cultured, there
were contrast unenhanced lesions at both periventricular white matter by Magnetic resonance imaging. Through neuropsychiatric
clinical manifestations and positive laboratory sign we considered NB as diagnosis and started antibiotherapy. After the antibiotherapy
neurological symptoms, visual hallucinations and social withdrawal regressed, cognitive functions improved (MMSE score increased from
17 to 23). The psychiatric manifestations of our case with NB are depression, mania, and psychosis. There were no known cases with manic
symptoms of neurobrucellosis. In endemic areas, neurobrucellosis should be considered in the differential diagnosis of patients presented
with neurologic and psychiatric symptoms.
Keywords: bipolar disorder, mania, neurobrucellosis
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[Abstract:0212] Neuropsychiatry and behavioral neurology
Improvement of life quality in huntington disease: In the light of psychiatric symptoms
Elif Ozcan1, Hakan Ogutlu2, Gokhan Ozpolat1, Elif Oral1
Department of Psychiatry, University of Ataturk, Faculty of Medicine, Erzurum-Turkey
1
Department of Child and Adolescent Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
2
e-mail address: [email protected]
Huntington’s disease (HD) is an autosomal, dominantly inherited, neurodegenerative disorder which manifests during middle adult life
(40’s). The diagnostic hallmark of HD includes cognitive deficits, mood alterations and motor disturbances such as chorea and other
motor disorders. 30-40 percent of patients with HD develop major depressive disorder and 10-20 percent also develops only depressive
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symptoms. In a recent study it was shown that the 27% of the patients with Huntington Disease have obsessive or compulsive symptoms,
and in these patients depression, suicidal thoughts, delusions and aggression has been reported more frequently. Furthermore, there
is a positive relation between the carriage of Huntington gene and aggression, irritability. In this case we aimed to show a patient has
psychiatric symptoms that causing difficulties in her daily activities and her caregiver. And it was also shown that gradually relieving of
the symptoms makes her life more bearable.
A 58-year-old female patient was admitted to our psychiatry outpatient clinic, accompanied by his husband with complaints of insomnia
and nervousness. Also, it was learned that contamination obsessions and washing compulsions were started about for 15 years. Patient
with positive Huntington Disease family story was admitted to neurology outpatient clinic because of unintentional movements and
diagnosed HD 10 years ago, but treatment was not planning. She has been sleep problems, frequent attacks of agitation and excitation
for last 3 years. She had to move her house 3 times by the reason of disturbance of her neighbors. At first admit to psychiatric outpatient
clinic, it was suggested quetiapine 25 mg/day and mirtazapine 15-30 mg/day, unfortunately her symptoms was not improved. In current
psychiatric examination; she was fully conscious, oriented, negativism, mood was irritable, insomnia, psychomotor agitation, irritability,
contamination obsessions, washing compulsions were detected and also she has demonstrative choreiform movements and dysarthric
speech. Risperidone 1 mg/day was started. After 1 week, Lorazepam was added and gradually increased to 3 mg/day due to her persistent
insomnia, agitation and excitation. The dose of risperidone was increased to 4 mg at 1-week intervals. Lorazepam was ceased gradually
within 2 weeks, after insomnia, agitation and excitation symptoms had improved markedly. However, her obsessions and compulsions
were occupied whole day and she had lack of insight about her symptoms. The patient was diagnosed OCD and Yale-Brown Obsessive
Compulsive Scale (YBOCS) score was assessed as 40. Paroxetine 10 mg/day was started then increased to 40 mg/day at intervals of 10
days. YBOCS scores were 21 and 14 at examination after 1, 5 and 5 months, respectively. In the Clinical Global Impression scale, the severity
of disease was assessed as 5. After 5 months, patient was evaluated and global improvement was assessed 2, activity index was assessed
5. HD has a big effect on patients’ physical and psychosocial welfare, second being more seriously devastated. Although resumption of
treatment is provided by Neurology clinic in HD, multidisciplinary treatment approach also enables improving behavioral and emotional
problems, even if movement problems are not ameliorated. The quality of life of patient and caregivers could be increased dramatically.
Keywords: huntington disease, obsessive compulsive disorder, quality of life
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[Abstract:0223] Neuropsychiatry and behavioral neurology
Psychogenic gait disorder after the undesirable life event: a case report
Aslihan Okan Ibiloglu1, Suleyman Demir1, Abdullah Atli1, Mehmet Cemal Kaya1, Mahmut Bulut1, Esref Akil2, Aytekin Sir1
Department of Psychiatry, Dicle University, Faculty of Medicine, Diyarbakir-Turkey
1
Department of Neurology, Dicle University, Faculty of Medicine, Diyarbakir-Turkey
2
e-mail address: [email protected]
Psychogenic gait disorders (PGDs), which can present in many different reasons, as a feature in psychogenic movement disorders (PMDs)
are common, accounting for 1.5% to 26% of patients with neurologic complaints. PGDs does not usually resemble any pathological
movement disorder of known organic origin. Useful clues suggesting psychogenic balance and gait disorders are acute onset, selective
disability, relation to minor trauma and improbable longitudinal courses, false weakness, bizarre tremor, pseudoataxia and voice
abnormalities also keep in mind that movement patterns inconsistent with known movement disorder. Here, we report a 54 year-old man
who had suffered from excessive slowness with bizarre gait pattern, for 7 years.
We report on a 54 year-old Turkish man was admitted to our psychiatry department with postural instability, and bizarre gait who was
subsequently diagnosed with psychogenic gait disorder due to conversion disorder (according to DSM-5). His symptoms had begun 7
years before, following a fight after the undesirable life event. He first complained of increasing walking on ice pattern with the postural
instability. He became increasingly slowed in his movement and began to have problems initiating movements gait. When he walked,
his body swayed from side to side but with a narrow base, sudden knee buckling without falling and bizarre gait present, which was
worse in the crowded places. He had tried multiple medications without relief of his involuntary movements and other symptoms, for
unknown periods. Although, the symptoms never occurred during sleep. Neurologic function in the lower extremity was intact on careful
examination. Brain magnetic resonance imaging (MRI) and electromyography (EMG) studies were normal. At the end of the investigations,
all possible organic factors were excluded.
The psychiatric examination revealed, he was a cooperative man but had immature and dependent features. The patient had symptoms
of anxiety, la belle indifference (lack of emotional concern about the disorder) and overflow of emotion during the exam (such as,
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painful expression, etc.). We initiated treatment with paroxetine 10 mg/day and the dosage increased by 20 mg/day, within ten days.
Subsequently, he was given clonazepam, which resulted in partial elimination of the postural instability and involuntary movements. In
addition, we used the cognitive behavioral therapy for his complaints. At 14 months, his symptoms completely improved also, currently
he has regained most of his functionality.
According to the psychiatric categories of PMDs as the abnormal gait may be summarized as belonging to conversion disorder, sometimes
as part of a somatoform disorders, and factitious disorders, until proven otherwise. Of course, it is not easy to diagnose PMDs. Anxiety,
conversion disorder, malingering, factitious disorder, somatoform disorders, medi¬cally unexplained symptoms and depression are
associated with psychogenic movements. Hence multiple psychiatric co-morbidities are common. As in our case, treatment of coexisting
depression or anxiety can improve physical symptoms. We emphasize the importance of bizarre-looking gait evaluation, an incongruent
gait might be the key, during psychiatric examination in every patient suspected to have a PMD.　Keywords: psychogenic gait, conversion, fear of falling
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[Abstract:0236] Neuropsychiatry and behavioral neurology
Psychotic symptoms in a patient with encephalitis with seizures
Derya Arslan, Taha Can Tuman, Ugur Cakir, Osman Yildirim
Department of Psychiatry, Abant Izzet Baysal University, Faculty of Medicine, Bolu-Turkey
e-mail address: [email protected]
Encephalitis is an inflammation of the brain tissue. The most common cause of encephalitis is viral infections. Headache, fever,
nausea, vomiting and confusion are the most common presenting symptoms of the disease. Neurological deficits, seizures, paralysis
and behavioral disturbances may also occur in the progress of encephalitis. Psychotic symptoms may also be come up in the clinic
presentation of encephalitis. The psychotic symptoms may include fluctuating combinations of thought disorder, auditory and visual
hallucinations (either may predominate), delusions (grandiose, religious, persecutory), paranoia, affective change (mania or depression),
and aggression. Auditory or visual hallucinations can predominate. In this paper it has been aimed to report a case with encephalitis with
seizures presented with psychotic symptoms.
A 35-year-old male was presented to hospital with dizziness, insomnia and smell of burn. The frequency of his odor hallucinations were
increased in two weeks, and then he had concomitant generalized tonic clonic epileptic seizures while he has no history of epilepsy. He
had violence at postictal periods. He was examined by a neurologist and a psychiatrist. Auditory and visual hallucinations started after he
was hospitalized in the intensive care unit. Lumbar puncture finding was 25/mm³ leukocyte in CSF. Doxycycline, acyclovir were started
with Valproic acid 1000 mg/day for epileptic seizures. Acute renal failure emerged after 3 days from the start of acyclovir treatment so it
was stopped. MRI and EEG findings consisted with encephalitis. In psychiatric examination; orientation was limited, he was cooperative
when not distracted by hallucinations. He had also developed conceptual disorganization, unusual thought content and blunted affect.
He had aggressive behaviors and auditory and visual hallucinations. His sleep-wake rhythm was reversed. He had also psychomotor
agitation. This composite of symptoms was consistent with the psychotic disorder. His PANSS score was 137 at first psychiatric
examination. Risperidone 3 mg/day added his treatment than the dose of risperidone was increased to 6 mg/day in two weeks. By the
end of two weeks his psychiatric examination findings and violence were normalized. He had been hospitalized for 40 days. PANSS score
decreased 78 after the treatment by antipsychotic drugs in a month.
Encephalitis is associated with high rates of mortality and morbidity despite of treatment. The management of the clinical features is very
important in these patients because of the high rates of death in early stages. It’s well known that autoimmune encephalitis is associated
with the psychiatric symptoms. In our case patient had positive psychotic symptoms including delusions and hallucinations with the
seizures. However the autoimmune markers couldn’t be researched because of the limitation of our laboratory facilities. Antipsychotic
drugs must be added timely for the psychotic symptoms not to be late to control the behavioral disturbances and violence.
Keywords: encephalitis, epileptic seizures, psychosis
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[Abstract:0285] Neuropsychiatry and behavioral neurology
Progressive supranuclear palsy subsequent to major depressive disorder: a case report
Hakan Ogutlu1, Halil Ozcan2, Mehmet Fatih Ustundag2, Atakan Yucel2
Department of Child and Adolescent Psychiatry, Ataturk University, Erzurum-Turkey
1
Department of Psychiatry, Ataturk University, Erzurum-Turkey
2
e-mail address: [email protected]
It has been discussed that Major Depressive Disorder (MDD) and Parkinson Disease (PD) may have same genetic factors. Thirty percent
of PD patients may have depressive symptoms before the appearance of motor symptoms. Depressive symptoms occur in 12–22% of
PD patients. The average time interval of the first depressive episode in patients with PD is 10 years varying from 1 month to 36 years.
A 47-year-old female patient was admitted to our outpatient clinic, accompanied by his husband with complaints of refusal of eating,
difficulty of speech and swallowing, weakness, anhedonia, unwillingness, slowness of movements and insomnia. On her illness history,
it was learned that with diagnosis of MDD she had been treated in an inpatient clinic of another hospital for 15 days with 150 mg/d
venlafaxine and 5mg/d aripiprazole treatment. Anhedonia, unwillingness and insomnia partially improved but other symptoms continued.
Three days after her discharge, she admitted to our outpatient clinic. She had been taken to inpatient clinic for further evaluation. In
her psychiatric examination; she was fully conscious, oriented, affect and mood was slightly depressed, pessimistic thoughts, suicidal
thoughts, psychomotor retardation, anhedonia, insomnia, lack of appetite was detected. In physical examination rigidity on her both
upper extremities, neck, cogwheel rigidity, and mask like face were detected. Other neurological findings were normal. Brain magnetic
resonance imaging and routine serum laboratory tests were within the normal ranges. Hamilton Depression Rating Scale (HAM-D) score
was 20. Mini-Mental State Exam score was 30. Based on these findings, she was diagnosed as MDD with catatonia or drug induced
parkinsonism. We started venlafaxine 225mg/d, clonazepam 2 mg/d, biperidene 3 mg/d; aripiprazole was ceased because of the suspect
of causing or aggravating the extrapyramidal symptoms. On 28th day of admission, depressive symptoms decreased (HAM-D score=11),
but extrapyramidal symptoms continued without any reduction. Besides that tremor and neck dystonia were added and parkinsonism
symptoms worsened. Neurology was consulted because of suspect of a neurodegenerative disorder and she was diagnosed as Progressive
Supranuclear Palsy (PSP) as a Parkinson plus syndrome Ropinirole 8 mg/d treatment was added. After one week treatment with Ropinirole
8 mg/d tremor, speech difficulty, neck dystonia, eating problems, feeling of choking complaints markedly improved.
We want to emphasize that symptoms of parkinsonism can be confused with especially retarded MDD, because of similar symptoms such
as difficulty of speech and swallowing, weakness, unwillingness, slowness of movements, etc. Another confounding factor is the usage of
antipsychotics posSIBly leading to extrapyramidal side effects. We must consider that parkinsonism and MDD could exist together or MDD
precede to parkinsonism. The quality of life of the patient can increase with proper treatment of psychiatric and neurologic symptoms.
Keywords: catatonia, major depressive disorder, progressive supranuclear palsy
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[Abstract:0316] Neuropsychiatry and behavioral neurology
Fahr disease with purely treatment-resistant depression: a case report
Didem Tezcan1, Ayse Nur Inci Kenar1, Kadir Agladioglu2
Department of Psychiatry, Pamukkale University, Faculty of Medicine, Denizli-Turkey
1
Department of Radiology, Pamukkale University, Faculty of Medicine, Denizli-Turkey
2
e-mail address: [email protected]
Idiopathic basal ganglia calcification or Fahr’s disease (FD) is a rare neurodegenerative disease characterized by bilateral and symmetrical
intracranial deposition of calcium mainly in cerebral basal ganglia. Calcifications may also occur in other brain regions such as dentate
nucleus, thalamus, and cerebral cortex. Patients with FD mostly present with movement disorders such as parkinsonism, chorea, tremor,
dystonia, dysarthria or speech impairment often combined with psychiatric symptoms such as psychosis, mood disorders and cognitive
impairment. Purely psychiatric presentations are rare in the literature. We describe case of a 44-years-old woman presenting with
treatment-resistant depressive disorder with Fahr-type calcification. Inparticular, we noted no previous neurological or psychiatric history.
In the psychiatric examination, headache, vomiting, initial insomnia, irritability, anhedonia, anxiety, depress mood, poor concentration
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and decreased appetite were noted. During the clinical follow-up period of three-year; many drugs, such as fluoxetine, duloxetine,
bupropion, modafinil, venlafaxine and quetiapine, have been tried. But despite treatment her depressive and somatic symptoms has not
passed completely. Brain magnetic resonance images showed bilateral symmetrical calcification in the dentate nuclei of the cerebellum
and basal ganglia. Her neurological examination was normal. Laboratory and endocrinological investigations were all normal. There
was no evidence of hypoparathyroidism and pseudohypoparathyroidism. According to the examination findings and subsequent
investigation exams, present case was diagnosed as FD. Although, extra pyramidal system findings are the most common signs in FD,
purely psychiatric presentations, as demonstrated by our case, are possible.
Consequently, some of the patients with FD might also present treatment-resistant psychiatric symptoms without neurological
examination findings so at these cases only brain imaging allows for diagnosis of this rare disorder. Also, clinicians should consider that
treatment-resistant psychiatric disorders might related to organic etiology.
Keywords: depression, Fahr’s disease, idiopathic basal ganglia calcification
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[Abstract:0340] Neuropsychiatry and behavioral neurology
Development of obsessive compulsive disorder after medullablastoma surgery: can obsessive
compulsive symptoms be part of cerebellar cognitive affective syndrome?
Dilara Demirpence1, Burc Cagri Poyraz2
Department of Child and Adolescence Psychiatry, Istanbul University, Cerrahpasa Faculty of Medicine, Istanbul-Turkiye
1
Department of Psychiatry, Istanbul University, Cerrahpasa Faculty of Medicine, Istanbul-Turkiye
2
e-mail address: [email protected]
The cerebellar cognitive affective syndrome (CCAS) is characterized by the following: Disturbances in executive function such as
deficient planning, set-shifting, abstract reasoning, working memory, and decreased verbal fluency, Impaired spatial cognition, including
visuospatial disorganization and impaired visuospatial memory, Personality changes, characterized by flattening or blunting of affect,
and disinhibited or inappropriate behaviour, impaired language function. In this poster, we present a patient who was referred to our
consultation-lIASon psychiatric clinic for obsessive compulsive symptoms and discuss this case in relation to the cerebellar cognitive
affective syndrome, described recently in literature.
A 21-year-old man whose primary complaints were obsessive compulsive symptoms such as fear of contamination, intrusive sexually
thoughts with irritability was assessed at consultation liaison psychiatry clinic, Cerrahpasa Medical Faculty. The medical history was taken
from his family and himself. The patient’s complaints started after the medullablastoma resection 8 years ago. Medullablastoma tumour
localisation was in right cerebellar hemisphere, it was treated with radiotherapy and chemotherapy after the resection. In addition to
the obsessive compulsive symptoms mentioned above; findings of emotional dysregulation such as fast-changing in mood, feelings
of difficulty in coping with negative emotions and being calm, severe impulsivity like banging doors and hitting objects emerged.
Carbamazepine 400 mg/day and paroxetine 40 mg/day were started. He benefited from pharmacotherapy moderately. On mental status
examination, he was alert and oriented to time, person and place. He was cooperative and communicative. He maintained eye contact.
His mood was depressed and his affect was labile from time to time during the interview. His psychomotor activity was normal. His speech
content was poor and circumstantial in character, his speech rate was fast but with normal quality and volume. He had blockages due
to recalling the names. His sleep and libido were increased. He had thoughts of unworthiness and incompetence related to obsessions
and he also had suicidal and self-mutilative thoughts. On neuropsychological assessment, frontal inhibition was impaired on Luria and
stroop tests. He had difficulties in verbal recall and also had visuospatial difficulties in constructing abilities. On cranial MRI, an area of
encephalomalacia and atrophy on right cerebellum where the tumor was removed, were detected.
Obsessive compulsive findings, psychotic thinking, mood disorders and personality changes can be observed in patients with cerebellar
lesions. In addition to these symptoms, frontal cognitive impairment were also described. In this case, obsessive compulsive symptoms
can be considered as an earliest observable part of the cerebellar cognitive affective syndrome. After patient’s modest recovery from
obsessive compulsive symptoms; emotional, cognitive and affective components of CCAS were observed more clearly.
Keywords: affect, cerebellum, ocd
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[Abstract:0510] Neuropsychiatry and behavioral neurology
Tuberous sclerosis and substance abuse: a case report
Melike Ozdemir1, Fulya Maner2, Ozlem Ceyinkaya2, Derya Ipekcioglu2
Department of Child and Adolescent Psychiatry, Bakirkoy Prof. Dr. Mazhar Osman Training and Research Hospital, Istanbul-Turkey
1
Department of Psychiatry, Bakirkoy Prof. Dr. Mazhar Osman Training and Reseach Hospital, Istanbul-Turkey
2
e-mail address: [email protected]
Tuberous sclerosis is a multi-system-genetic disease characterised by intellectual disability, seizures and hamartomatous lesions in many
organs such as brain, skin, eyes, heart, lungs and kidney. Infantile spasms are most frequently seen among epileptic seizures. Psychiatric
comorbidity especially aggressive/disruptive behavior disorder is very common in tubero sclerosis.
Our case is tuberous sclerosis with multiple organ involvement such as skin, eye, heart, kidney and brain. Psychiatric aspects of intellectual
disability and impulsivity are in the foreground and complicated with epilepsy history and substance abuse that increases criminal tends.
A 20-year-old male whose symptoms reported by his parents to be associated with substance abuse such as cannabis, heroin and bonsai
include increased oppositional behaviors, agitation, irritability, physical aggression and molestation for two months. Before three years, he
was hospitalized in child and adolescent psychiatry inpatient clinic with diagnosis of Mild İntellectual Disability and Epilepsy and disability
report sixty percent. He has not used any regular drug after discharge.
On physical examination, adenoma sebaceum was observed on his face. At psychiatric assessment, it was observed that his self-care
was poor. His psychomotor activity was increased. He was conscious, cooperating and oriented. He had an irritable mood and dysphoric
affect with inappropriate laughing. His thought content was poor and he did not describe any delusions or illusions. He reported auditory
hallucination giving order. He had no insight about his problems. His vital signs were normal. Results of blood work, including complete
blood count, electrolytes, microbiological tests including HIV, HBV, HCV antibodies as well as hepatic and renal function tests were normal.
Tomography and magnetic resonance imaging of the brain indicated tuberous lesions. Echocardiography was revealed bicuspid aorta
and moderate aortic valve insufficiency. Two hamartomatous lesions are observed in fundus examination. In urinary ultrasonography
there was a lesion related with angiomyolipoma in right kidney.
The case was diagnosed substance abuse and mild intellectual disability according to DSM-5 diagnostic criteria and haloperidol (10
mg/day) biperidene (4 mg/day) and topiramate (100 mg/day) PO was started as treatment. After a week haloperidol was changed with
olanzapine (20 mg/day) PO due to extrapyramidal side effects like perioral tremor.
This case includes excessively risky behavior such as intellectual disability and impulsivity that may facilitate use of substance and
encouraging crime such as molestation/abuse individuals. The patients may be prone to interpersonal sensitivity and social alienation due
to the deficits of the disorder. Psychiatric comorbidities are directly proportional with multi-organ involvement.
Tuberosclerosis is a neurocutaneous disorder and associated with neurological and psychiatric conditions. Multidisciplinary clinical
approach is crucial for patients and their families.
Keywords: tuberosclerosis, substance abuse, intellectual disability
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[Abstract:0536] Neuropsychiatry and behavioral neurology
May paliperidone be a new treatment option for tic disorder?
Arif Demirdas, Bilal Tanritanir, Kadir Demirci, Meltem Inci Atay
Department of Psychiatry, Suleyman Demirel University, Faculty of Medicine, Isparta-Turkey
e-mail address: [email protected]
Tics are defined as sudden, fast, repetitious, and arrhythmic motor movements or vocalizations. The most widely approved hypothesis for
tic etiology is the one regarding the dopaminergic system. There are no comprehensive studies regarding the efficacy of paliperidone for
tic disorder. This case report is the first paper demonstrating successful results of paliperidone palmitate in the treatment of this disorder.
Herein we present a patient who has had chronic tic disorder and schizophrenia for 26 years and whose psychotic symptoms and motor
tics resolved after paliperidone palmitate treatment.
Case: A 35-year-old female, who is single and a high school graduate. Her complaints started ten years ago with social withdrawal,
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persecutory delusions against family members, and impaired self-care. She refused to apply to a physician. However, when she declined
to eat and drink, she was t to an internal medicine polyclinic by her family. After having a normal physical examination, she was brought
to a outpatient psychiatric clinic by her family.
Her mental status examination revealed decreased self-care. She had not bathed, brushed her teeth, or changed her clothes for five
months. She had motor tics such as twinkling, moving of the head and neck, and shrugging. Her affect was blunted, her thought
processing was slower, her reaction time had lengthened, and she had a somatic delusion about a disease in her intestines. She was
accepted to the psychiatry clinic with the prediagnosis of schizophrenia. She had had motor tics which had not responded to any therapy
since she was nine year-old. She had been in treatment for obsessive compulsive disorder five years ago. Her laboratory analyses were
within normal limits, and she did not have positive family history for psychiatric diseases.
Haloperidol and amisulpride treatments were administered to the patient. However, since the response to treatment was not adequate
and the compliance with medication was poor, she was given paliperidone palmitate. At the end of the first month, a decrease in both the
psychotic symptoms and the motor tics was observed. Upon the second application of the maintenance dose, her psychotic symptoms
further regressed, and the motor tics resolved completely.
Tic disorder is a rare neuropsychiatric condition in the etiology of which both genetic and environmental factors play a role. The most
widely used agents for the treatment of tic disorder are dopamine antagonists. Pharmaceutical agents for tic disorder are regulated
according to the strength of evidence in the treatment guidelines of the European Society for the Study of Tourette Syndrome. Our patient
had diagnoses of schizophrenia and tic disorder concomitantly. The efficacy of paliperidone in a patient with Tourette’s syndrome and
schizophrenia was also addressed in another case presentation. Comprehensive studies are required to evaluate the effect of paliperidone
and paliperidone palmitate on tic disorder. Placebo-controlled trials on patients having merely tic disorder would help to investigate in
detail the effect of paliperidone and paliperidone palmitate on this disorder.
Keywords: tic disorder, schizophrenia, paliperdidone
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[Abstract:0550] Neuropsychiatry and behavioral neurology
Psychiatric disorders with Huntington’s disease: two case reports
Digdem Goverti, Esra Yurumez, Betul Gursoy Cicek, Hilal Inanir
Department of Psychiatry, Ufuk University, Ankara-Turkey
e-mail address: [email protected]
Huntington‘s disease (HD) is an autosomal, neurodegenerative disorder with midlife onset characterized by psychiatric, cognitive and
motor disturbance. It’s caused by unstable cytosine-adenine-guanine (CAG) repeat expansion on chromosome 4p. The most common
involuntary movement chorea is rapid, elegant, unwanted movement usually in trunk, face, and extremities. Psychiatric features, such as
personality changes, affective disorders, obsessive compulsive disorder (OCD), psychosis and subcortical dementia that are the significant
components of HD occur in 35-73% of patients. In this study, we present the psychiatric problems and the treatment responses of two
consanguineous (first cousin) women with HD.
A 45-year-old female patient applied due to loss of appetite, irritability, feeling guilty, requiring thoughts of suicide, washing her hands
and checking the stove for several times. These complaints occurred approximately 3 years ago. She was thought to behave childish,
inattentive and forgetful.Choreiform movements in her legs and arms had been occurred 8 years ago and aggravated over the past 3
years. She was diagnosed with HD (similar to her father and cousin) and was started on tetrabenazine therapy 2x25 mg 10 months ago
and the choreiform movements were decreased.
Dysarthria, ataxic walking, choreiform movements and motor disability of hands were observed in examination. Depressive mood, suicidal
thoughts, obsessions and compulsions were psychiatric symptoms. There was no abnormality in blood examination except vitamin B-12
deficiency; electrocardiogram and electroencephalogram were normal. Relatively clear T2 hypointensity in the level of globus pallidus
and atrophy of ventricules, subarachnoid space and cisterns were occurred in cranial magnetic resonance imaging (MRG). According to
neuropsychiatric battery; short-term memory and learning were impaired. The patient was diagnosed with comorbid OCD and major
depressive disorder (MDD) with HD and was offered clomipramine 225 mg and quetiapine 25 mg therapy and resumed tetrabenazine.
Choreiform movements were improved particularly and psychiatric symptoms were improved dramatically.
A 57 year-old female patient applied because of loss of interest, inactivity, feeling inadequate and angry over the past 6 months. Depressive
symptoms occurred 35 years ago and had used amitriptyline for a long time. One years ago, she determined choreiform movements on
extremities. Low-penetration CAG repetition was found. She was diagnosed with HD similar with her uncle, aunt and cousin.
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Depressed mood was noticeable. No other psychiatric symptoms were found including thoughts of suicide. There was no abnormality
in blood examination, electrocardiogram and electroencephalogram. CAG repeat number was 17/49. Minimal diffuse cerebral and
cerebellar atrophy in MRG and impairment in attention, short-term memory and learning were realised.
The patient was diagnosed with comorbid MDD with HD. She was started on citalopram 40 mg and amitriptyline 25 mg therapy. She had
been using tetrabenazine for 1 year and the movements were disappeared.
These 2 cases were studied due to the presence of psychiatric symptoms before and after the onset of HD. The prevalence of depressed
mood is in the range of 33-69% and OCD in the range of 20-50%. Psychiatric symptoms contribute to morbidity and early mortality. Thus,
handling of these symptoms can expand the impact of treatment.
Keywords: Huntington’s disease, depressive disorder, obsessive compulsive disorder
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S345-S6
[Abstract:0636] Neuropsychiatry and behavioral neurology
A case report: pre-ictal psychosis
Nergiz Turkegun, Ishak Saygili, Neslisah Atguden, Aysenur Oguz
Erenkoy Training & Research Hospital, Istanbul-Turkey
e-mail address: [email protected]
Relation between epilepsy and psychosis is one of the frequently studied subjects in literature. Psychotic symptoms in epileptic patients
can be observed during both interictal and periictal periods. Peri-ictal psychoses can be divided into following categories i)pre-ictal,
ii)ictal and III) post-ictal. Despite there are numerous case reports on ictal and post-ictal psychosis, there are only limited reports on
pre-ictal psychosis. It is known that there is an inverse correlation between psychotic symptoms and epileptic seizures in some cases,
a phenomenon called “forced normalization”. According to this, psychotic symptoms usually disappear when epileptic seizures appear.
Herein, we report the case of an epileptic patient with pre-ictal psychosis.
A 26-year-old, female, single, student patient who has been diagnosed with epilepsy since 12 years of age, had been applied carbamazepine
monotherapy for the first 6 years. Afterwards, alterations in medications were made in order to control seizures. The last prescribed
treatment was 1200mg/g oxcarbazepine and 1000mg/g valproic acid/sodium valproate. The patient stopped taking drugs 2 weeks ago
due to a travel. After this interruption, patient had insomnia lasted for 3 days, followed by paranoid persecutive delusions. On the 4th day,
patient admitted to ER due to complex partial seizure. The patient then transferred to neurology department. After routine laboratory
tests, biochemistry and hemogram results were normal. The urine test was negative for substance abuse. Neurological exam did not reveal
anything abnormal. However, EEG revealed bioelectrical disorganization in right parietoccipital region. There was no sign of pathology
in Cranial MR. Treatment of haloperidol 10mg / g, lorazepam 2.5mg 3x1/2 and last epileptic medication were initiated. Antipsychotic
medications were ceased gradually when the patient’s psychotic profile improved after 2 days. In previous preictal psychosis case reports,
pathology often has been observed in temporal brain regions, whereas in our case pathologic EEG findings belonged to parietooccipital
area. Since psychotic symptoms began when medications for epilepsy dropped, clinical outcome is evaluated as pre-ictal psychosis rather
than forced normalization. Psychotic symptoms in epileptic patients may be seizure predictor or sign of insufficient epilepsy treatment.
Therefore, sudden appearance of psychotic symptoms in epileptic patients indicates that both neurologic and psychiatric evaluation
should be done jointly.
Keywords: pre-ictal psychosis, forced normalization, epilepsy
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Case Report Abstracts
[Abstract:0673] Neuropsychiatry and behavioral neurology
Role of continuous performance tests in neuropsychological assessment in dementia: a case report
Baris Topcular, Ahmet Yabalak, Aysenur Kaymaz, Ayca Altinkaya, Ebru Altındag, Burcu Altunrende, Ozlem Gungor Tuncer, Zeliha Matur,
Dilek Orken, Gulsen Akman Demir
Department of Neurology, Istanbul Bilim University, Istanbul-Turkey
e-mail address: [email protected]
Continuous performance tests (CPTs) are neuropsychological tests aiming to assess attention and sustained attention in particular.-CPT).
They are used almost solely in diagnosis of Attention Deficit and Hyperactivity Disorder (ADHD). However, attention deficits are evident
not only in ADHD but also in other disorders especially in adult population.
57 year-old right handed man admitted to our outpatient clinic complaining of forgetfulness and decrease in attention in last two years. He
was previously seen in several other centers and was diagnosed as adult onset attention deficit and hyperactivity disorder. He was started
on methylphenidate but showed almost no benefit. He admitted to our outpatient clinic due to no benefit from previous treatment and
progression of his symptoms. Given his previous diagnosis of ADHD he had routine neuropsychological battery for dementia as well as
a continuous performance test (MOXO test). His neuropsychological battery showed very mild frontal signs whereas MOXO test showed
severe impulsivity plus timing problems. A cranial PET-CT imaging showed typical pattern for Alzheimer’s disease. Although continuous
performance tests has a high value in diagnosis of ADHD, their use is not restricted to diagnosis of ADHD. Given the attention and
sustained attention deficits in many other disorders including vascular dementia, epilepsy, multiple sclerosis, it seems feasible to propose
that continuous performance tests should be an essential part of routine neuropsychological testing. Our case supports the view that
continuous performance tests should be a part of routine neuropsychological testing.
Keywords: continuous performance test, Alzheimer’s disease, MOXO
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S347 [Abstract:0688] Neuropsychiatry and behavioral neurology
Is it psychiatric or neurological? in fact neuropsychiatric!
Ardil Bayram Sahin, Pınar Cetinay Aydin, Goksen Yuksel, Ayca Ongel Atar, Nazan Aydin
Department of Psychiatry, Bakirkoy Prof. Dr. Mazhar Osman Training and Research Hospital, Istanbul-Turkey
e-mail address: [email protected]
Central nervous system disorders can emerge themselves as psychiatric complaints.
We present in here a case in which the patient started to show some psychiatric symptoms six years ago but at the end of the process
the patient diagnosed with demyelinating disease. In the case, the patient is 36 year-old woman. It was learnt that firstly 6 years ago,
money stealing behaviors within family and social environment started and then in the last year. She consulted psychiatry clinic. One
month ago some complaint started; crossed eyes then balance lost, meaningless speech, unrecognizing to immediate family members
and nonsense behaviors were realized and the patient was came to emergency clinic. In psychiatric examination, it was stated that she
was conscious, disoriented, her affect was inappropriate. Consultation was asked from Neurology Department. When the patient was not
diagnosed with neurologic pathology, she hospitalized in psychiatry clinic. When the patient was examined in psychiatry clinic, she was
observed as disoriented; she had inappropriate affect and her cooperation was limited. Euphoric mood was defined. She named objects
and individuals differently, her associations were disorganized. There were urinary and stools incontinence. According to information
we receive from patient’s relatives; 3 months ago while there is a relationship full of love with her husband, divorced as a result of her
close relationship with someone else. The results of laboratory investigation were found within normal level. Neurology consultation
was made for the patient who has urinary and stools incontinence and balance disorder in psychiatry clinic. The patient transported to
neurology clinic. Laboratory made in neurology service has antinuclear antibody that is not specific for SLE. In gene mutation scanning,
Methylenetetrahydrofolate reductase gene mutation was confirmed. However, it is stated that this is not significantly in terms of
thrombophilia due to lack of other supporting examination in hematology consultation. IgG,Albumin, Oligoclonal band resulted high
in BOS examination. In the result of CT scan, there observed ischemic differences and concordant common hypodensity in the level of
periventricular white matter and centrum semiovale section. It was learnt that the patient was prediagnosed with demyelinating disease,
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the treatment started with steroid and the patient who respond to treatment came out of neurology clinic one month later. When we
reexamine the patient five month later after the first evaluation; she had no time and place orientation but normal personal orientation.
However, she was emotional when telling about the divorce she is into caused by altered behaviors depending on her neurological
disease. Her recent memory has broken but retrograde memory was stable and there was no psychotic symptom. There was no balance
problem, nonsense speech, urinary and stools incontinence, disorganized behaviors.Mini mental test was applied to the patient and the
result was 12/30.
The case that we presented is about the chronically termed central nervous system demyelinating disease that manifested itself with
psychiatric complaints much longer before time appearance of neurological complaints. The patients are presenting with neuropsychiatric
complaints take into consideration neurological pathology that is important to diagnose in time to start treatment in time and to avoid
more possible loss of psychiatric and neurological symptoms.
Keywords: demyelinating disease, psychiatric symptoms, neuropsychiatric symptoms.
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S347-S8 [Abstract:0757] Neuropsychiatry and behavioral neurology
Extrapyramidal symptoms and psychosis well tolerated with low dose ziprasidone
Halil Ozcan1, Atakan Yucel1, Nermin Yucel2, Mehmet Fatih Ustundag1
Department of Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
1
Department of Child and Adolescent Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
2
e-mail address: [email protected]
Ziprasidone is a second-generation atypical antipsychotic approved for the schizophrenia and acute bipolar affective disorder.
Extrapyramidal symptoms (EPS), parkinsonism, akathisia, acute dystonia and tardive dyskinesia were commonly observed as a side effect
in using especially typical antipsychotics. In here, we report a case with psychosis and EPS accompanied by mental retardation (MR), which
was ameliorated by ziprasidone without other atypical antipsychotics.
17 year-old female patient was admitted to our clinic with complaints such as irritability, excitation, self-mutilation, abundant shooting,
be scared from people, seeing the scary images, restlessness. In her history, the development stages of the patients was underdeveloped
when compared with her peers. She could not learn to read and write, also she needs to help with her personal requirement. In her
psychiatric history, the cooperation was limited. Memory and attention was decreased. Affect and mood were irritable. Hallucinations
and delusions were observed. In the Kent EGY/Porteus maze test was scored as 46 (moderate MR). The diagnosis was compatible with MR
accompanied by psychosis. She was hospitalized. Risperidone 0.5 mg/day was initiated. Cogwheel-like rigidity, limitations in movements
were obtained in the 3th day of treatment. Risperidone was changed to aripiprazole 5 mg/day. Rigidity, akathisia, inappropriate speech
and laughing were arisen with aripiprazole. Then treatment was changed to olanzapine 2.5 mg/day. The difficulty on swallowing and
speech, enuresis weas observed with olanzapine treatment. Thereupon, olanzapine was terminated and ziprasidone 20 mg/day was
initiated also dose titrated up to 40 mg/day. In the 3th week of ziprasidone treatment, the psychotic symptoms decreased. Cooperation
and communication of the other patients and treatment team, adaptation of clinical rule improved. She could eat her food without
help. There were no abnormalities observed in electrocardiography (ECG) during hospitalization. At the end of 5th week of ziprasidone
treatment, she was discharged with improvement in psychotic symptoms. In the periodic outpatient clinic controls, it was observed that
the current well-being continued.
The typical and atypical antipsychotics approximately have identical efficacy for psychotic symptoms. The EPS predominate while using
typical antipsychotic. On the other hand, metabolic and endocrine side effects, weight gain is noticeable in use of atypical antipsychotics.
Ziprasidone may induce EPS side effects, however it is expected to be limited. In our case, we used various atypical antipsychotics for
decreasing the psychotic symptoms without EPS. Ziprasidone surpassed the all other antipsychotics in terms of reducing the psychotic
symptoms and absence of EPS without cardiac abnormalities and another side effect. We emphasize that ziprasidone may be a good
treatment alternative for the psychotic symptoms with checking ECG in patients with sensitive to EPS. This observation need to be
supported with further studies.
Keywords: extrapyramidal symptoms, psychosis, ziprasidone
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[Abstract:0770] Neuropsychiatry and behavioral neurology
Fahr syndrome: a rare neuropsychiatric disorder
Ali Karayagmurlu1, Elif Karayagmurlu2, Gokhan Ozpolat2, Elif Ozcan2, Tuba Ulkevan2, Elif Oral2
Department of Child and Adolescent Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
1
Department of Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
2
e-mail address: [email protected]
The Fahr syndrome is a degenerative neuropsychiatric disorder which is characterized by the idiopathic calcification of the basal ganglia.
It was first described in 1930 by a German neurologist, Karl Theodor. This syndrome may be present neuropsychiatric, extrapyramidal
and cerebellar symptoms, convulsive seizures, Parkinsonian features, dementia and speech disorders. The calcifications can be seen in
the globus pallidus, putamen, caudate nucleus, internal capsule, dentate nucleus, thalamus, cerebellum and cerebral white matter. Fahr
syndrome has a progressive course. Calcium deposition usually begins in the third decade of life and neurological symptoms occur after
two decades so it usually appears between the age of 40-60 years and is uncommon in children. This paper presents Fahr syndrome
in a 34 year-old subject with delusions and agression. K.A. 34 year-old married woman was brought to to our outpatient clinic with
the complaints of quick temper, agression and decline in need for sleep. According to the information obtained from the relatives, the
complaints of patient firstly began with decline in need for sleep, occured of belief that she were a famous woman and others were
engaging in a plan to harm her and therefore suspected people. The Clinical Global Impression Scale (CGIS), Positive and Negative
Syndrome Scale (PANSS) and Young Mania Rating Scale (YMRS) were used during the interview, which gave a score of 6 (severe), 97 and
42, respectively. In the mental status examination revealed the patient to be conscious, full orientated and irritable and to have increased
psychomotor activity, grandiose and persecution delusions in thought content. She underwent lab tests: complete blood counts, ESR,
blood urea and electrolytes, serum AST, ALT, ALP, GGT and serum total bilirubin, random blood sugar, lipid profile, serum T3, T4, and TSH;
serum calcium and phosphorus; and serum vitamin B12. Laboratory tests revealed phosphorus elevation up to 8.2 mg/dL (reference range:
4-7 mg/dL), calcium elevation up to 6.9 mg/dL (reference range: 8-10.4 mg/dL), parathyroid elevation up to 5.3 pg/mL (reference range:
10-55 pg/mL). Other laboratory results were normal. A non-contrast CT brain scanning revealed extensive intra-cerebral calcification. The
patient was diagnosed with Fahr’s syndrome. Fahr’s syndrome is described that symmetric calcifications of basal ganglia independent of
the etiology of the disease. Also Fahr disease is a clinic picture that appeared idiopathic calcification. Many diseases play the role in the
occurence of this syndrome and majority of these diseases affect calcium metabolism. Hypoparathyroidism is an important endocrine
etiologic factor of Fahr’s syndrome. A non-contrast CT brain scanning revealed extensive intra-cerebral calcification. Whereupon she
firstly underwent serum parathyroid to distinguish idiopathic or secondar cause. In laboratory tests, hypocalcemia, hyperphosphatemia
and hypoparathyroidism revealed. Patients was evaluated as Fahr’s Syndrome. Clinicians should note that organic cause may be found in
patients presenting with psychotic and mood symptoms. Determining organic etiology that accompany the psychiatric picture would be
beneficial in terms of diagnosis, treatment and intervention.
Keywords: fahr syndrome, psychosis, calcification
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S349 [Abstract:0781] Neuropsychiatry and behavioral neurology
Migraine associated with methylphenidate: a case report
Nermin Yucel1, Atakan Yucel2, Lutfi Ozel3
1Department of Child and Adolescent Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
2Department of Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
3Department of Neurology, Ataturk University, Faculty of Medicine, Erzurum-Turkey
e-mail address: [email protected]
Migraine, an episodic headache syndrome, is considered that arises from dysfunction of the sympathetic nervous system. Attention
deficit/hyperactivity disorder (ADHD) is one of the most common neurobehavioral disorder in childhood. Both of migraine and ADHD
are common occurred disorders in childhood and adolescent. Methylphenidate, a cornerstone for the treatment of ADHD increases the
amount of norepinephrine and dopamine in synapses by blocking transporters of these neurotransmitters. Migraine type headache
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occurred in our case diagnosed with ADHD after chronic use of psychostimulant treatment that disappeared when we decreased the
methylphenidate daily dose.
A 18 years-old girl applied the outpatient clinic of neurology department with complaints including headache, sensitivity to light and
noise. She told that feels nausea, numbness and tingle on her head before pain and when her headache start she can not tolerate
lights and sounds accompanied by headache persist in 2 days and occur during periods in two months. She declared no any headache
history similar to existence previously, however her mother suffering migraine since 12 years. She seem to a psychiatrist complaints
with forgetfulness, restlessness, impatience, academic failure, shortness of attention span and attention deficit then has diagnosed with
ADHD and had utilized methylphenidate 72 mg/day treatment daily for four months. ADHD symptoms improved with medication but
headache arose in the first week of methylphenidate treatment. Her physical examination was unremarkable expect unilateral throbbing
headache, redness in eyes, nausea and vomiting. Methylphenidate was decreased to 54 mg/day dose and there was no any migraine
attacks observed for 6 months.
Central dopaminergic hyperfunction has determined in patients with migraine which thought to accompany by dysfunction of
noradrenergic sympathetic system. The pathophysiology of ADHD is related with hypoactivity of the prefrontal cortex caused by lack of
the neurotransmitter systems of dopamine and norepinephrine. The mechanism of methylphenidate occurs with blocking of dopamine
and norepinephrine reuptake transporters which cause increased levels of neurotransmitters in the synapses. Researches relevant
with migraine suggest that levels of the neurotransmitters (noradrenaline and dopamine), co-transmitters (dopamine, prostaglandins,
adenosine triphosphate, and adenosine), and neuromodulators (octopamine, synephrine and tyramine,) are determined unbalanced
during migraine attacks and intermediate periods in central nervous system. As a result, these knowledge mentioned in the above may
interpret as chronic use of methylphenidate may cause migraine type headache because of opposed condition of methylphenidate
effect and migraine pathophysiology. Further studies need to be explored the exact mechanism of relationship with methylphenidate
and migraine.
Keywords: methylphenidate, migraine, neuropsychiatry
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S349-S50
[Abstract:0804] Neuropsychiatry and behavioral neurology
A child with ictal psychosis and treatment with valproic acid
Nermin Yucel1, Atakan Yucel2, Mehmet Akif Camkurt3
Department of Child and Adolescent Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
1
Department of Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
2
Department of Dermatology, Afsin State Hospital, Kahramanmaras-Turkey
3
e-mail address: [email protected]
Epilepsy is the widespread neurological disorders that affecting approximately 50 million individuals are affected worldwide. Epilepsy can
be associated with psychotic disorders, personality changes and other psychiatric disorders. In respect of epileptic psychosis have been
described according to temporal relationship with seizures such as before (preictal), during (ictal) or after seizures (postictal). Psychotic
seizures are usually presented as an acute onset with a short symptom duration and complete remission between episodes. In the
literature a very few cases reported that psychosis appears to be ictal. We report a girl with audiovisual and olfactory hallucinations that
diagnosed ictal psychosis and treated with valproic acid.
A 10 year-old girl was brought by the mother to psychiatric outpatient department. Her complaints were including acute audiovisual and
olfactory hallucinations for three months with episodic occurrence. There was history of normal vaginal born at hospital after full-term
pregnancy and neurodevelopmental steps were within normal limits. There was no any family history of psychiatric illness or medical
illness. Examination revealed normal vitals, neurological and other system examination were normal. Mental status examination was
including natural features. However her mother explained that symptoms occur in intervals and she were normal except episodes in
additionally she were feeling tired and falling asleep after hallucinations. All laboratory investigations including count blood cell, liver
function tests, kidney function tests, thyroid function tests and electrolytes were within normal limits. Risperidone suggested 1.5 mg once
a day for 2 weeks but there was no any improvement. EEG showed independent temporal lobe foci predominance on the right during
hallucinations when she consulted neurologist, valproic acid 500 mg twice a day was given and at the same time risperidone decreased
and stopped stepwise. After 3 weeks there was no any symptom with along valproic acid defined as the above.
Complex partial status epilepticus with temporal lobe origin may show similar features and symptoms seen in the primary psychoses.
Temporal relationship between peri-ictal psychosis and seizures are frequently mentioned in the literature as well as psychosis are
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categorized before (preictal), during (ictal) or after seizures (postictal). During preictal psychoses, EEG tracing exhibited seizure activity,
when a comparatively normal EEG tracing was exposed during inter-ictal psychosis. Although combination with antiepileptic and
antipsychotic medication is widely preferred for this condition, there is not any standardized treatment guidelines for epileptic psychosis.
In these cases, the most appropriate option is antiepileptic treatment that antipsychotics is irresponsive.
Keywords: ictal, psychosis, valproic acid
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S350-S1
[Abstract:0826] Neuropsychiatry and behavioral neurology
Herpes simplex encephalitis and mood disorder; a case report
Ibrahim Oner1, Onat Yilmaz2, Alparslan Asil Budakli1, Recep Tutuncu1
Department of Psychiatry, GATA Haydarpasa Training Hospital, Istanbul-Turkey
1
Department of Psychiatry, Kasimpasa Military Hospital, Istanbul-Turkey
2
e-mail address: [email protected]
Herpes simplex encephalitis (HSE) is an uncommon but 70% mortal when remained untreated. Several behavioral and psychiatric
symptoms have been reported during the infection. Here we present a case of HSE with the occurrence of mood disorder symptoms and
symptoms of cognitive decline in a patient.
A 21 year-old male patient was referred for a psychiatric evaluation by neurology department. His parents reported that he was brought
to the emergency service with the complaints of headache, shivers, disturbed speech and memory problems and he was hospitalized with
the diagnosis of encephalitis Magnetic resonance imaging study showed edema resulting in effacement of sulci in uncus, parahypocampal
gyrus, anteroinferior parts of left anterior lobe and T2A-Flair hyperintense signaling in brain cortical regions. Spinal fluid analysis detected
Herpes Simplex Virus by PCR and acyclovir 10 mg/kg treatment was added on. At the 23rd day of the treatment cerebral fluid analysis was
negative for HSV and the antiviral treatment was discontinued. Due to 2 focal epileptic seizures patient started to use levetiracetam 1000
mg per day and discharged. Memory loss, inflated self-esteem, aggressive behavior and decreased need for sleep developed a month
ago and quetiapine treatment was started at a different psychiatric clinic. There was rapid speech, irritability, racing thoughts, inflated
self-esteem, increased drive to achieve goals were observed. The patient was hospitalized with the diagnosis of mood disorder due to
organic causes. Levetiracetam treatment was discontinued and sodium valproate 1000 mg per day and olanzapine 10 mg per day was
started. Addenbrooke Cognitive Examination Test (ACE-R) was applied and mild disturbances in short term memory, immediate memory,
verbal fluency and recall skills was detected. He was able to name 14 items and was able to name 2 items with a stimulus cue and 5 items
with phonemic cues, and the results were consistent with conduction aphasia.
On the 10th day of his admittance he was symptom free and marked improvement in cognitive skills was observed. On his follow-up at 6
month, it was learned that his antipsychotic treatment was discontinued at a different center and he was still symptom free.
Psychiatric and neurological problems such as psychotic behaviors, epileptic seizures, hemiplegia, speech disturbances, amnesia is
not uncommon in HSE. Mood stabilizers are defined as successful treatment options in HSE and sodium valproate might act as a good
therapeutic agent in psychiatric symptoms of HSE.
Keywords: herpes simplex encephalitis, mood disorder, cognitive disorder
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[Abstract:0843] Neuropsychiatry and behavioral neurology
Progressive supranuclear palsy misdiagnosed as catatonic bipolar depression: a case report
Ali Ibis, Atakan Yucel, Mehmet Fatih Ustundag, Elif Oral
Department of Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
e-mail address: [email protected]
Progressive supranuclear palsy (PSP) is a neurodegenerative disease defined as impairment of ocular gaze, postural instability, akineticrigid features, bulbar dysfunction, and cognitive symptoms. It might be unrecognized or misdiagnosed as Alzheimer’s or Parkinson’s
disease (PD) or psychiatric disorders such as apathy, disinhibition, emotional incontinence, mild depression and anxiety are commonly
seen psychiatric symptoms, whereas agitation, irritability, catatonia and psychotic symptoms were rarely reported. In our case, we present
a case of bipolar affective disorder (BAD) -depressive episode with catatonia who was diagnosed as progressive supranuclear palsy.
58 year-old male patient with BAD was admitted to our outpatient psychiatry clinic complaints with weakness, anhedonia, unwillingness,
decrease in movement, sluggishness, insomnia. In his psychiatric examination, he was conscious, oriented, and his speech was
understandable and slow. Intelligence level and memory were observed to be normal. Attention was decreased. Affect and mood were
depressed. There were no hallucinations or delusions. Anhedonia psychomotor retardation, social isolation, impairment of functionality,
loss of insight, lack of appetite were observed. In his physical examination, cogwheel rigidity on his upper extremity and sign of mask face
were found. The imaging and laboratory examination were completely normal. His medication contained with olanzapine 10 mg/day and
biperidene 2 mg/day in admission. The electroconvulsive therapy (10 sessions) was applied with diagnosis of BAD -depressive episode
with catatonia. However there was no remission in his symptoms. The patient was consulted to neurology department, the diagnosis was
compatible with PSP and he was discharged with escitalopram 10 mg/day and L-Dopa 1000 mg/day. His follow-up is going on.
In our case, we would like to emphasize the neurological condition might be masked with psychiatric condition. Therefore profound
search of history, follow-up and treatment response should be take into account by the psychiatrist.
Keywords: bipolar affective disorder, catatonia, progressive supranuclear palsy
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S352
[Abstract:0866] Neuropsychiatry and behavioral neurology
Psychosocial approaches for adolescents with substance use disorder
Ozden S. Uneri
Department of Child and Adolescent Psychiatry, Ankara Pediatric & Pediatric Hematology Oncology Training and Research Hospital, Ankara-Turkey
e-mail address: [email protected]
Substance use disorder (SUD) or drug addiction is the most prevalent neuropsychiatric disorder affecting society today. The social,
medical, and economic costs are enormous, costing the US government alone an estimated $400 billion per year. SUDs are often cronic
disorders requiring ongoing intervention. Psychosocial interventions for treatment of SUDs cover a broad array of treatment interventions.
Psychosocial treatment approaches for adolescents with SUD can be divided two main categories; behavioral approaches and familybased approaches. Behavioral approaches generally focus on teaching and reinforcing new skills, behaviors, and new ways of thinking.
The goal is to reinforce desirable behaviors and to eliminate unwanted or maladaptive ones. Most common behavioral approaches are:
•Motivational Enhancement Therapy (MET)
•Cognitive Behavior Therapy (CBT)
•Twelve-Step Facilitation Therapy
•Contingency Management (CM)
•Adolescent Community Reinforcement Approach (A-CRA)
Family therapy approaches are based on the therapeutic premise that the family has the most profound and long-lasting influence on
child and adoles¬cent development. There are five evidence-based family-based treatments that are in use today:
•Brief Strategic Family Therapy
•Family Behavior Therapy
•Family-Based Therapy (FBT)
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•Multidimensional Family Therapy
•Multisystemic Therapy
Most adolescent substance use treatment programs have used an eclectic treatment approach. Behavioral therapies and family therapies
have been shown to be an effective in SUD treatment for adolescents based on the limited number of comparative studies.
Keywords: neuropsychiatry, substance use disorder, SUD
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S352-S3
[Abstract:0873] Neuropsychiatry and behavioral neurology
Concept, review, and promise of neuroscience based system
Umit Yasar
Department of Pharmacology, Hacettepe University, Faculty of Medicine, Ankara-Turkey
e-mail address: [email protected]
Current nomenclature of neuro- and psycho- pharmacological drugs was introduced in the 1960s. In today’s medicine, it has some
difficulties to implement the recent developments and knowledge into the current classification. It can also cause some confusion to the
health care professions and patients. New pharmacological based classification has been proposed by the collaborative work of European
College of Neuropsychopharmacology (ECNP), the American College of Neuropsychopharmacology (ACNP), the Collegium Internationale
de Neuropsychopharmacologie (CINP), and the Asian College of Neuropsychopharmacology (AsCNP) and International Union of Basic and
Clinical Pharmacology (IUPHAR).
The neuroscience-based classification with five-axis template mainly focuses pharmacological characteristics of the drugs rather than
indication as the primary axis. The project started about 6 years ago with the initiatives of the mentioned neuropsychopharmacology
organizations. The new system neuroscience-based proposal includes 5 axes:
Class: Primary pharmacological target, relevant mechanism
Family: Primary neurotransmitter and relevant mechanism
Neurobiological activity
Efficacy and major side effects and
Indications
As an example of the new system for diazepam:
Axis 1 Class: GABA
Relative mechanism: Positive allosteric modulator
Axis 2 Subclass: GABA-A positive allosteric modulator
Axis 3 Neurobilological description: Benzodiazepine receptor agonist
Axis 4 Efficacy: Anxiolytic; muscle relaxant; anticonvulsant; sleep promoting
Side effects: Sedation, somnolence, ataxia, muscle relaxation
Axis 5 Indications: Anxiety – particularly GAD; muscle spasms; alcohol withdrawal; status epilepticus
As a part of the initial phase of the implementation, a booklet of Neuroscience-Based Nomenclature, and a beta version application
were released at the 27th ECNP Congress in October 2014. A total of 109 drugs used in neuropsychopharmacology have been classified
according to the new proposed system in the booklet.
A recent survey study on physicians (n=1232) evaluated new neuroscience based system (Zohar J et al: A proposal for an updated
neuropsychopharmacological nomenclature, 2014). A significant proportion of the survey participants were positive about the proposed
system and found that it was more preferable to the current system and only about 9% was not favor of it.
The proposed five-axis pharmacology based nomenclature system seems to refresh and reflect the current scientific concepts of
neuropsychopharmacology. The nomenclature committee plans to widen the awareness of the new classification system and to adapt it
into the medical education in the following years.
Keywords: nomenclouture, neuroscience, neuropsychopharmacology
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[Abstract:0852] Neuropsychiatry and behavioral neurology
Pregabaline a drug with abuse potential
Bulent Devrim Akcay1, Beyazit Garip2
Department of Psychiatry, Konya Military Hospital, Konya-Turkey
1
Department of Psychiatry, Sirnak Military Hospital, Sirnak-Turkey
2
e-mail address: [email protected]
Pregabaline has been using commonly to the treatment of neuropathic pain disorders, anxiety disorders, sleep disorder. This drug was
approved by the Turkish drug administer for the treatment of seizure and neuropathic pain and it is not under the control. Pregabaline is a
analog of gama-aminobutirik asit (GABA) and binding voltage dependent calcium channel α²-δ subunit. Pregabaline shows the efficancy
by managing the presynaptic neurotransmitter releasing, pregabaline has not been licensed yet for the treatment of general anxiety
disorders. But it can be prescribed to the treatment of pain that occurs during substance and alcohol dependency treatment. In this case,
we would like to concentrate on pregabaline treatment who have experienced alcohol and substance dependency patient because the
number of these patients have been growing day by day
Male patient age of 21. He has been using cannabinoid and opiod misuse for five years. Patient has been treated suboxane for one years
at the center of AMATEM (Drug Dependency and Treatment Center). To the treatment of the pain that has been complaining by he patient,
pregabaline 300 mg/ day treatment was initiated. After the pregabaline treatment patient’s pain improved and he didn’t go on suboxane
treatment. Patient wanted to continue his clinical improvement so he decided to increase the dose of pregabaline at the 2400 mg/day by
himself. While the he is not on the pregabaline treatment, he had experienced irritability, tremor, increased blood pressure symptoms. So
he was hospitalized to control the symptoms.
Altough the potential of pregabaline dependency and abuse can be described fairly low, after the pregabaline drop out treatment,
some kind of withdrawal symptoms can be seen after drop out period. Altought the certain mechanism of pregabaline dependency
and abuse have not been well understood yet, some of the drug abuse and dependency patient that was on the pregabaline treatment
could be demonstrated pregabaline dependency symptoms. Pregabaline option should be made properly for the treatment of pain that
is occurred substance abuse or dependency patient. It should keep in mind that pregabaline can have dependency and abusing adverse
effect.
Keywords: abuse potential, drug, pregabaline
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OBSESSIVE COMPULSIVE DISORDER
[Abstract:0121] Obsessive compulsive disorder
Treatment of a patient diagnosed with OCD injuring his eyes according to his obsessions: a case
report
Sumeyye Yasemin Kurtulus Calli, Filiz Izci, Yagmur Sever, Murat Yalcin, Rabia Bilici, Medine Gulec
Department of Psychiatry, Erenkoy Training and Research HospitaL, Istanbul-Turkey
E-mail address: [email protected]
Obsessive Compulsive Disorder (OCD) is an anxiety disorder characterized by obsessions and compulsions. Obsessions are mostly contamination,
suspicion, symmetry, preoccupations of religious or sexual thoughts and goes together with intuition of bad things occurrence if specific rituals
not completed. Compulsions are washing, cleaning, controlling, repeating, counting and collecting. We aimed to report a patient diagnosed with
OCD who injuring his eyes with sharp materials according to his preoccupations about obsessions of injuring his eyes.
T.C. is 25 year-old male patient. His symptoms started 8 year ago with frequent hand washing and controlling. His treatment and controls
were irregular. During last 1 year, he started to press table and chairs due to obsessions of pressing these. But, during last months, his
compulsions had become penetrating sharp materials into his eyes due to thoughts of what happens if he injuries his eyes. Also, he
bought some sharp materials according to this obsession. Lastly, he had hospitalized because he could not cope with this obsession and
his eyes were infected also vision started tolost. There was not any feature in medical personal and family history. His mood was anxious
and affect was irritable. He was impulsive. He had damaging and suspicion obsessions and control compulsion and also sleeplessness. His
insight and judgment were adequate. Y-BOCS was 24. The patient’s routine biochemical results, total blood count and thyroid hormone
levels were normal. Clomipramine 75 mg/day, clonazepam 1 mg/day, aripiprazole 5 mg/day were started as pharmacological treatment.
Psychotherapy was tried but he could not cooperate with tasks. During his hospitalization he could not reach sharp materials but this time
he started to press his eyes into some blunt materials such as tap. So clomipramine doses increased up to 225 mg/day and aripiprazole
doses increased 20 mg/day slowly. Due to his eye infection and blurred vision, he was consulted to ophthalmologist. At 6th week of
hospitalization, his symptoms were regressed and he was externalized.
Impulse Control Disorder characterized by damaging itself and OCD are localized in same spectrum. Characteristics of force causing action
separate compulsivity between impulsivity. Compulsive action aims decreasing anxiety while impulsive action aims reaching pleasure
and reward. Patients localized both ends of spectrum cannot keep themselves from repeating actions. Also, in our case, the patient has
difficulty in coping with obsessional thoughts, stopping damaging actions and controlling impulsivity.
Keywords: obsessive-compulsive disorder, obsession, damage to the eye
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[Abstract:0209] Obsessive compulsive disorder
Steroid associated obsessive compulsive disorder in an adolescent: a case report
Gulen Guler, Berna Polat, Veli Yildirim, Fevziye Toros
Department of Child and Adolescent Psychiatry, Mersin University, Faculty of Medicine, Mersin-Turkey
e-mail address: [email protected]
Steroid therapy may cause psychiatric side effects. Depression, mania, psychosis and delirium are the most common clinical presentations
of steroid-associated psychiatric side effects. We will share a case report about an adolescent suffering from steroid-associated obsessive
compulsive disorder (OCD) and her treatment process.
HY, a 17 year-old-girl taking steroid treatment for kidney transplantation, was consulted our Child and Adolescent Psychiatry Clinic
with complaints of strange thoughts, fear of insanity and anxiety. Suffering from chronic kidney disease for 7 years, she had a kidney
transplantation surgery three weeks ago. Following the operation, immunosuppressive therapy was started, consisting off cyclosporine,
mycophenolic acid and prednisolone. She was prescribed of cyclosporine 200 mg, mycophenolic acid 720 mg and prednisolone 40 mg.
No psychological problems were detected at the prescription. It was learned that she was a little worried about her health. In following
two months, major psychiatric symptoms started after the dose of prednisolone had been decreased. She was thinking that she was
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in love with objects such as her shirt button, her pencil, her garbage and even her faeces. As she constantly remembered images of
people that she had seen, she did not want to look at anyone. She experienced very intense distress because of these thoughts. She
recognized these thoughts as absurd and irrational but claimed to be powerless in stopping them. In the psychiatric examination, she
had no delusions and hallucinations. Before this, she had no psychiatric history. Her family’s psychiatric history was unremarkable. She was
diagnosed with drug induced anxiety disorder with obsessive compulsive symptoms. She consulted her pediatrician for reconsideration
of steroid medication. It was learned that discontinuation of prednisolone would be impossible in long term. We started escitalopram 5
mg and risperidone 0.5 mg. She has been taking psychiatric and steroid treatment together. Despite immunosuppressive therapy at low
doses, all psychiatric complaints were improved with psychopharmacological treatment in the first month.
The most common steroid induced psychiatric disturbances are mania, depression, psychotic or mixed affective states, cognitive deficits
and minor psychiatric disturbances. Steroid-associated panic disorder, catatonia and OCD are rarely reported. There is only one case report
about steroid induced OCD in the literature. These psychiatric disturbances are recommended to be treated by a reduction of steroid
dosage or discontinuation of steroid. In this case, unlike the other cases in literature, symptoms occurred after the steroid dosage was
reduced. This case highlights that not only steroid therapy, but also reduction of steroid dosage can lead to OCD. In psychological cases
arise as a result of reduction in steroid dosage -such as steroid-associated OCD- escitalopram and risperidone can be highly effective.
Understanding the pathophysiology of steroid-associated OCD’s development may be an important predictor of treatment factors.
Keywords: adolescent, steroid, transplantation
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[Abstract:0226] Obsessive compulsive disorder
Fracture secondary to compulsion: a case report
Gulen Guler1, Meryem Ozlem Kutuk2, Veli Yildirim1, Fevziye Toros1
Department of Child and Adolescent Psychiatry, Mersin University, Faculty of Medicine, Mersin-Turkey
1
Department of Child and Adolescent Psychiatry, Baskent University, Faculty of Medicine, Ankara-Turkey
2
e-mail address: [email protected]
Obsessive compulsive disorder (OCD) is a chronic psychiatric disorder characterized with obsessions and compulsions. OCD in children
and adolescents is very common. Childhood onset OCD is related to the worst symptoms and prognosis. Dermatitis, gingivitis, anemia,
sight loss, autocastration and rectal prolapse can be observed secondary to OCD. We will discuss about the tibia fracture developed
secondary to OCD in an adolescent. This is the first case of the fracture secondary to OCD.
A 15-year-old female patient was brought to our clinic with complaint of “strange fears” as expressed by her family. From the story of the
patient indicated that she had fear of being gangrene, her hymen being distorted and her photos being uploaded to Facebook. She spent
six hours a day by jumping rope as a precaution against gangrene. She was checking her hands and feet for almost 80-100 times a day to
understand whether she suffered from gangrene or not. Although she was tired of thinking, she couldn’t stop these thoughts. She had
had obsessions since 12 year-old; these obsessions were changing, however, the intensity of the obsessions increased considerably. In
her personal history, there was no medical disease, no alcohol and drug use. She was diagnosed with OCD according to the framework
of DSM-IV and fluoxetine 20 mg and risperidone 1 mg were prescribed. She used the drugs for one month, but the treatment could not
alleviate her symptoms. Fluoxetine was increased to 40 mg and risperidone was continued at the same dosage. Then she was asked to
come to the hospital for the next month. She came to the control with a plaster cast on her leg. We learned that she broke her leg while
jumping rope and her fracture was fixed with surgical operation.
People suffering from OCD have higher sense of responsibility so that it is rare to expect accidents or self-injury behaviors in OCD
patients. It is believed that the difference in anxious individuals’ mental mechanism to evaluate dangers can be beneficial in protection
from accidents. In our case, the security related behavior -jumping rope- against her obsession of being gangrene lead to fracture. Like
externalization disorders, internalization disorders (anxiety and depression) can also raise unwanted injuries in children. Internalization
disorder, by distorting attention control, can increase the probability of accident during possible dangerous actions. Injuries in children
and adolescents are related with impulsivity and hyperactivity. In this case, development of fracture seems to be correlated with increased
activity due to compulsions and also reduced attention as a result of anxiety. Clinicians must be aware that psychiatric disorders may be
the major source of medical conditions.
Keywords: compulsion, fracture, obsession
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[Abstract:0339] Obsessive compulsive disorder
Body dysmorphic disorder in a male and a female adolescent
Sena Saygili, Ozgur Onder, Ilyas Kaya, Murat Coskun
Department of Child and Adolescent Psychiatry, Istanbul University, Faculty of Medicine, Istanbul-Turkey
e-mail address: [email protected]
Body dysmorphic disorder (BDD) is a body-image disorder characterized by persistent and intrusive preoccupations with an imagined or
slight defect in one’s appearance. People with BDD can feel uncomfortable with any part of their body, they often find fault with their skin,
hair, nose, chest, or stomach. BDD that is thought that is associated with obsessive-compulsive disorder, in DSM-5; BDD is a subtitle of the
obsessive-compulsive disorder and related diseases. People with BDD commonly also suffer from anxiety disorders, obsessive-compulsive
disorder or social anxiety disorder, as well as depression and eating disorders.
Here we present two adolescents with body BDD and several comorbidities.
Case-1: A 14-year-old girl, who was admitted to our clinic about one year ago with complaints of severe anxiety symptomatology.
She suffered from anxiety symptoms expressed in school that made her reluctance to go to school and she was afraid of failing at
examinations. Anxiety symptomatology was associated with food restriction with weight loss, skin and hair picking, and unhappiness
with color of her skin and shape of nose. Every time she went out from house,she covered her face with layer of white powder to make
it lighter and tried to hide her nose with her hand. After detailed clinical examination, she was diagnosed with BDD, general anxiety
disorder and anorexia nervosa. We started a medication with fluoxetine 20 mg per day gradually increased up to 80 mg per day. Because
of insufficient effect of decreased, but lasting anxiety and food restriction, we added mirtazapine and N- acetylcystein (NAC) to her
treatment. After this medication in a several days, symptomatology decreased, she was able to go to school without fear, she quit to cover
her face, however she did not change her opinion of her body image and continued in controlling her food income. Now, she is under the
regular psychopharmacotherapy and supportive therapy by our clinicians.
Case-2: A 14-year-old boy, came to our clinic about one year ago by complaining about several fears.He was afraid to go out because of
being teased for his appearance, he felt unsecure with his acnes and he was consistently occupied by them. He spent a lot of time in front
of the mirror to look them and he started to avoid eye contact. After detailed clinical examinatıon he was diagnosed with BDD and general
anxiety disorder, and we started medication with sertraline 50 mg per day, up to 200 mg per day, and augmented this medication with
NAC to control impulsive behavior and automutilation. After remission of anxiety and BDD symptoms, complaints about attention deficit
showed up. We added methylphenidate to his treatment with good response, and In conclusion, patient ended up with medication of
sertraline 200 mg, NAC 1800 mg and methylphenidate 36 mg per day. Follow up of the patient continues in our clinic.
Keywords: body dysmorphic disorder, obsessive-compulsive disorder, social anxiety disorder
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[Abstract:0427] Obsessive compulsive disorder
N-Acetylcysteine augmentation in children and adolescents with treatment-resistant obsessive
compulsive disorder: a case series
Kemal Utku Yazici1, Ipek Percinel2
Department of Child and Adolescent Psychiatry, Firat University Faculty of Medicine, Elazig-Turkey
1
Department of Child and Adolescent Psychiatry, Osmaniye State Hospital, Osmaniye-Turkey
2
e-mail address: [email protected]
Objective: This report discusses the treatment of 5 child and adolescent patients with treatment-resistant obsessive compulsive disorder
(OCD) with n-acetylcysteine (NAC) augmentation.
Methods: The severity of obsessive compulsive symptoms was assessed by Yale Brown Obsessive Compulsive Scale (YBOCS); depressive
symptoms were assessed by Children’s Depression Inventory (CDI); and anxiety symptoms were assessed by Beck Anxiety Inventory
(BAI). At clinical follow-up, the severity of disorder was assessed using the Clinic Global İmpression-Severity Scale (CGI-S); and general
functioning of patients was assessed using the Global Assessment Scale (GAS). Side effects that may occur during treatment were
assessed using the Clinic Global İmpression-Side Effects Scale. The patients were started on NAC 600 mg/day, which was gradually
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increased every two weeks up to 3000 mg/day. All cases were evaluated every 4 weeks during a clinical follow-up period of 6 months, and
improvement was measured primarily by clinical condition and YBOCS scores of the patients.
Results: Two out of 5 patients included in our study had a comorbid diagnosis of major depressive disorder. 4 patients showed a notable
improvement with NAC augmentation. 2 of these patients had a “full response” (a decrease in YBOCS scores of more than 35% or a CSI-S
score of 1 or 2) at the end of six-month follow-up period; while the other 2 achieved “remission” (YBOCS score of <16). No side effect was
reported except for mild gastrointestinal complaints in one case observed during early weeks of NAC treatment.
Conclusion: Recently, glutamatergic agents have been frequently used in the treatment of OCD and OCD spectrum disorders. NAC is an
antioxidant molecule that modulates glutamatergic neurotransmission. It is especially effective in the nucleus accumbens. There are a
limited number of studies in literature on the use of NAC augmentation in treatment-resistant OCD. Most of the current studies present
cases of adult patients and have contradictory results. There is only one case in the child and adolescent age group, which was also
reported by our group. Our findings seem to be compatible with studies reporting the effectiveness of NAC augmentation in treatmentresistant OCD. In this regard, this is the second paper to report the use of NAC augmentation in children and adolescents with treatmentresistant OCD. Our report is considered to be of importance for drawing attention to this gap in literature.
Keywords: children, n-acetylcysteine, obsessive compulsive disorder
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[Abstract:0455] Obsessive compulsive disorder
What is this? late onset, treatment resistant delusion?, obsession?, hallucination? related with
multiple substance use
Halil Ibrahim Tas1, Mehmet Fatih Ustundag2, Naciye Karabulut2, Tuba Ulkevan2
Izmit State Hospital, Kocaeli-Turkey
1
Department of Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
2
e-mail address: [email protected]
Substance usage is a psychiatric disorder which causes a variety of psychiatric symptoms such as hallucinations, delusions, mania,
depression, cognitive disorder, irritability, insomnia, sexual dysfunctions, etc. depending on the substance types. In this case we report a
patient admitted outpatient clinic a few day ago with permanent somatic symptoms posSIBly related with substance use.
A 24-year-old male patient, middle school graduate, single, with no self and family history of any chronic disease including psychiatric
diseases had started smoking 6 years ago and some time later started using ecstasy, cannabis, synthetic cannabinoids such as bonsai
or jamaica and some other drugs which he didn’t know. Irregular substance usage had continued until last year. He has not been using
any substance or alcohol for one year but he still smokes a packet of cigarette in a day. In last two years, he had been feeling urinary
incontinence. This complaint has been increasing when the ambiance was crowded. Besides, he also had been feeling the smell and
the wetness of the urine. But whenever he checked it, he observed that there is nothing. This situation caused some complaints such
as drowning, nervousness, anxiety. Because of this, he had often been checking if he urinated. He has repeatedly admitted to urology,
internal medicine, psychiatry departments with these complaints for one year. No pathology was found. These complaints were explained
as obsession, delusion or hallucination by different clinicians. Although he had used paroxetine, sertraline, olanzapine, aripiprazole
treatments for adequate dosage and time at different time intervals, also hospitalized for five days, but he had no benefit from all. Because
of this complaints, he had leaved his job that he had been working regularly for along time. One year ago he had been experiencing
persecution and reference delusions. After that he had stopped taking drugs because of fear of going mad.
Because of no prior self or family history of any psychiatric or chronic disease before the drug usage we suggested that current symptoms
were related to drug usage. Symptoms such as delusions, hallucinations, anxiety and perception disorders have been reported related to
ecstasy, cannabis, synthetic cannabinoid or other illegal drugs. It was reported that these symptoms may start suddenly or over a long
term interval of the substance usage and may continue even after substance usage is stopped. After the patient was examined it was
thought that the treatment resistant somatic symptoms such as the feelings of urine incontinency, feeling the smell and wetness of the
urine, and persecution and reference delusions might be related with multiple substance usage. Anxiety symptoms might be related
with these complaints or substance usage itself. The clozapine and escitalopram treatment was planned for the treatment of anxiety and
resistant psychotic symptoms. We can not give any further information in this report because of short time follow-up.
Keywords: substance usage, somatic hallucination, delusion
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[Abstract:0461] Obsessive compulsive disorder
Hoarding disorder: diagnosis and treatment update
Cicek Hocaoglu
Department of Psychiatry, Recep Tayyip Erdogan University, Faculty of Medicine, Rize-Turkey
e-mail address: [email protected]
Hoarding disorder (HD) is a persistent difficulty discarding or parting with possessions because of a perceived need to save them. A person
with HD experiences distress at the thought of getting rid of the items. Excessive accumulation of items, regardless of actual value, occurs.
Although it is considered to be a symptom of obsessive-compulsive (O disorder (OCD) in DSM IV- TR, it is thought that HD and OCD may have
different biological, cognitive and behavioral mechanisms and HD may be associated with many other psychological illnesses. In DSM-IVTR, hoarding is listed as one of the diagnostic criteria for obsessive-compulsive personality disorder (OCPD). According to DSM-IV-TR, when
hoarding is extreme, clinicians should consider a diagnosis of OCD and may diagnose both OCPD and OCD if the criteria for both are met.
However, HD seems to frequently be independent from other neurological and psychiatric disorders, including OCD and OCPD. For these
reasons, in DSM-5 HD diagnosis is located under the classification of obsessive-compulsive and related disorders. DSM-5 recognizes HD as
distinct from OCD, codifying a new consensus. Only one previous study prospectively measured response to pharmacotherapy in HD, finding
that hoarders responded as well to paroxetine as did non hoarding OCD patients. Saxena et al. found that compulsive hoarders responded
as well to paroxetine treatment as non-hoarding OCD patients, suggesting that SSRI medications are effective for compulsive hoarding.
However, paroxetine was not tolerated well in that study, and the overall response was moderate. Hoarding disorder was previously classified
as a symptom of OCD and patients received treatments designed for OCD. Treatment of HD can be challenging because many people don’t
recognize the negative impact of hoarding on their lives or don’t believe they need treatment. The literature on HD, including the definition
and manifestations of the problem and a conceptual model for understanding hoarding behavior. The limited research on treatment
provides evidence that current serotonergic medications for OCD are largely ineffective for treating hoarding, but cognitive and behavioral
treatments, especially those focused on deficits identified in the model, have some utility. HD, found in many patients with obsessivecompulsive disorder (OCD), has been associated with poor response to serotonin reuptake inhibitor (SRI) medications in some reports.
Saxena and Sumner suggest that venlafaxine extended-release may be effective for the treatment of hoarding disorder. HD and saving
symptoms, found in many patients with OCD, are part of a clinical syndrome that has been associated with poor response to medications
and cognitive-behavioral therapy (CBT). Symptom improvement from pharmacotherapy of compulsive hoarding appears to be at least as
great as that resulting from CBT. However, the combination of pharmacotherapy and CBT for HD is likely more effective than either treatment
alone. While the compulsive hoarding syndrome appears to be a distinct, more disabling, variant of OCD that does not respond as robustly
to treatment, it may still improve significantly with intensive, multimodal treatment tailored to its specific features and associated deficits.
Future studies should examine the possibility of the predictive factors also identified to be moderators of treatment outcomes.
Keywords: hoarding disorder, classification, treatment
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[Abstract:0599] Obsessive compulsive disorder
Obsessive-compulsive disorder induced by synthetic cannabinoids use: case report
Abdullah Bolu1, Suleyman Akarsu2, Cigdem Aydin3
Aircrew’ s Health Research and Training Center, Eskisehir-Turkey
1
Aksaz Naval Hospital, Mugla-Turkey
2
Department of Psychodermatology, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul-Turkey
3
e-mail address: [email protected]
Synthetic cannabinoids are known to cause a variety of neurological and psychiatric manifestations. These manifestations are agitation
(50-82%), aggression (57%), hallucinations (27-40%), confusion (14-34%), anxiety (15-17%), insomnia (4%), catatonia (1%), anhedonia,
anorexia, depression, increased, libido, panic attacks, self-injurious behavior, suicidality and psychosis. There are also studies about synthetic
cannabinoids can lead to metabolic and cardiac disorders. Cannabinoids are used usually to constitute the addiction. Still, there is no
adequate information about the manifestations that may occur with less frequently use of cannabinoids. In this case report, a patient who
had used three doses synthetic cannabinoids and after that followed-up with the diagnosis of obsessive-compulsive disorder was presented.
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Twenty-eight year-old female patients She admitted to the psychiatric polyclinic with the complaints of doubt obsessions, distress and
anxiety. Detailed psychiatric interview was conducted with patient and the family. Recently, she had used synthetic cannabinoids called
bonsai for three times. She had headaches and doubt obsessions at the next day of the each use of these substances. After about a week,
control compulsions were initiated in addition to the other complaints. She was diagnosed with obsessive-compulsive disorder after
mental examination. Antidepressant + cognitive behavioral therapy treatments began. After about four months of treatment, obsessions
and compulsions in-patient were significantly decreased. Also, patient’s impaired social problems had improved concurrently after the
treatment. Patient treatment and follow-up periods were planned to be monthly.
When disorders associated with substance were classified in DSM-5, substances that can cause obsessive-compulsive and related
disorders had been defined as “stimulants” and “other or unknown”. On the other hand, although occurring of obsessive-compulsive
disorder after using cannabis had been mentioned in the literature, substance abuse was enough to create an addiction. There are very
few identified psychiatric disorders occurred after using a single dose or in substantial doses of cannabis.
Keywords: cannabinoids, obsessive-compulsive disorder, substances
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[Abstract:0785] Obsessive compulsive disorder
Hoarding disorder: a case report
Gamze Akcay, Mahmut Selim Arpacioglu, Erkal Erzincan, Medine Yazici Gulec
Erenkoy Training and Research Hospital, Istanbul-Turkey
e-mail address: [email protected]
Hoarding disorder is a new diagnosis in DSM-5. DSM-IV lists hoarding as one of the possible symptoms of obsessive-compulsive personality
disorder and notes that extreme hoarding may occur in obsessive compulsive disorder. However, available data do not indicate that
hoarding is a variant of obsessive compulsive disorder or another mental disorder. Instead, there is evidence for the diagnostic validity
and clinical utility of a separate diagnosis of hoarding disorder, which reflects persistent difficulty discarding or parting with possessions
due to a perceived need to save the items and distress associated with discarding them. Neuroimaging and neuropsychological studies
indicate that compulsive hoarding is neurobiologically distinct from OCD and implicate dysfunction of the anterior cingulate cortex and
other ventral and medial prefrontal cortical areas that mediate decision-making, attention and emotional regulation. More research will
be required to determine the etiology and pathophysiology of compulsive hoarding, and to develop better treatments for this disorder.
Bulut et al.(2014) reported three cases classified in different diagnostic categories according to DSM-IV-TR and hoarding disorder for DSM-5.
Kanat et al.(2012) presented three different types of dementia cases are in order to emphasize the clinical awareness for hoarding disorder.
In this report, a case diagnosed as hoarding disorder according to DSM-5 will be presented.
53 year-old, married, mid school graduated male patient. He retired from his job 2 years ago and since than he started to hoard
unnecessary items. He had not let others to throw unused staff away, he was getting angry very easily and became more detailer. For
the last year because of unfinished house reparations the house became to be a huge mass. Family often argued about it and these
arguments has become more severe lately and started to include physical violence.
Patient collected about 40-50 big water bottles, lots of bottle tops, shampoo bottles, detergent bottles, yogurt containers, broken
electronic devices, cables, screws, scripts etc. And they were limiting family’s living space.
Mataix-Cols et al.(2010) highlighted that the creation of a new diagnosis in DSM-5 would likely increase public awareness, improve
identification of cases, and stimulate both research and the development of specific treatments for hoarding disorder. The clinical
relevance increased for hoarding disorder after identified as a new diagnosis in DSM-5 as they stated.
This case exhibiting a clinical presentation that can be confused with other diseases such as dementia or psychosis was concluded as
hoarding disorder that is a new diagnosis with epidemiological and clinical appearance. We purposed to emphasize consistency of the
diagnosis and difficulty of differential diagnosis for hoarding disorder.
With this diagnostic criteria many hoarding disorder case will have a place in the DSM-5 classification that forcing inserted under the OCD
and psychotic disorders title before DSM-5.
More research will be required to determine the etiology and pathophysiology of compulsive hoarding, and to develop better treatments
for this disorder.
Keywords: hoarding, compulsive, differential diagnosis
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[Abstract:0812] Obsessive compulsive disorder
The obsessive compulsive symptoms after the operation of the intracranial germinoma: a case
report
Abdullah Atli1, Aslihan Okan Ibiloglu1, Esref Akil2, Mahmut Bulut1, Suleyman Demir1
1Department of Psychiatry, Dicle University, Faculty of Medicine, Diyarbakir-Turkey
2Department of Neurology, Dicle University, Faculty of Medicine, Diyarbakir-Turkey
e-mail address: [email protected]
Intracranial germinoma is a type of germ cell tumor which is the most common location in the pineal or suprasellar regions. Also,
germinomas are most commonly diagnosed between the ages of 12 to 20, predominantly affected young males than female.
Obsessive-Compulsive Disorder (OCD) is a psychiatric condition defined by the presence of obsessions, compulsions or both. Currently,
obsessive-compulsive disorder is viewed as a good example of a neuropsychiatric disorder, mediated by various pathology in specific
neuronal circuits. Recent evidence suggest that OCD patients are exhibited various pathological behaviors within associative dysfunction
of the frontal lobe and/or basal ganglion. We presented here, a case of the Obsessive Compulsive Symptoms after the operation of the
intracranial germinoma.
In this paper, we present the case of a 19 year-old single Turkish man, lower socioeconomic status, living together parents and daughters
who experienced obsessive symptoms, such as related to sexuality and contamination and compulsive complaints, such as wash and
control, since last 6 months. His symptoms are centered on washing and controlling. The patient’s symptoms become gradually worse in
the presence of sexual and contamination thinking. Prior to this he had not been in any psychiatric treatment.
According to the medical records, the germinoma was completely resected. At the psychiatric examination, his mood was severely
anxious with the obsessive and compulsive complaints which characterized by repeated doubts about cleanliness and repeated washing
in addition to anhedonia, unable to stay alone and poor attention span. Especially, with the his symptoms are centered on washing and
controlling. Detailed physical and neurological examinations, including MR images of the brain, were also normal. As in the history of
family, his psychiatric and neurologic history was unremarkable.
Obsessive-compulsive disorder (OCD) is a frequent, chronic, and disabling disorder which may presents in several neurologic disorders,
especially occurs in early adult life. Recently, dysfunction of the cortico-striatal circuits, particularly orbitofrontal cortices and basal
ganglions has been implicated in the pathophysiology of obsessive-compulsive disorder (OCD), characterized by obsessions, ritualistic
behavior, anxiety, and specific cognitive impairments. These features provide a circuit mechanism for adjusting emotional drive in
processes disrupted in various psychiatric disorders, such as phobias and obsessive-compulsive disorder. According to the literature,
some diseases may occurred the OCD symptoms; that can be listed as, head trauma, brain infarct, brain tumors, epilepsy, encephalitis,
developmental disorders, diabetes insipidus, multiple sclerosis and acute intermittent porphyria.
In our opinion, this case showed an interesting relationship between OCD and intracranial tumors, so that complaints of OCD appeared
when the germinoma was detected.
Keywords: intracranial germinoma, obsessive compulsive symptoms, radiotherapy
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[Abstract:0864] Obsessive compulsive disorder
Obsessive compulsive disorder and metabolic syndrome
Oguz Karamustafalioglu
Department of Psychiatry, Uskudar University, Istanbul-Turkey
e-mail address: [email protected]
The prevalence of metabolic syndrome (MetS) in patients with obsessive-compulsive disorder (OCD) is unknown. The use of antipsychotics
in OCD is not rare. The use of antipsychotics in OCD patients may increase the rate of Met S.
A cross-sectional analysis was performed on 58 outpatients with OCD from June 2009 through December 2009. Psychiatric diagnoses
were performed using Structured Clinical Interview for DSM- IV (SCID-I). The metabolic syndrome was defined according to the NCEP
Adult Treatment Protocol III. Subjects having three or more of the NCEP ATP III criteria were defined as having MetS.
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The frequency of MetS was 19% in the whole sample. 15.9% of the female and 28.6% of the male subjects were diagnosed as having
MetS. The patients with MetS were significantly older than the patients without MetS. (p<0.001). Patients using antipsychotics did not
differ for MetS, but had greater waist circumference, higher triglycerides, and significantly lower HDL (p=0.02) levels than those who did
not use antipsychotics.
Higher doses of antidepressants, and use of antipsychotic augmentation are common in OCD compared to the treatment of other anxiety
disorders, Our analyses showed that despite the antipsychotic augmentation and comorbid conditions, the prevalence of MetS in OCD
was relatively low compared to schizophrenia, bipolar disorder, depression, and PTSD.
Keywords: MetS, OCD, PTSD
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PERSONALITY DISORDERS AND ACCENTUATED PERSONALITY
[Abstract:0430] Personality disorders and accentuated personality
Quetiapine induced gall stone: a case report
Hicran Dogru, Gizem Mujdecioglu Demir, Esin Ozatalay
Department of Child and Adolescent Psychiatry, Akdeniz University, Faculty of Medicine, Antalya-Turkey
e-mail address: [email protected]
Borderline personality disorder (BPD) is a serious and chronic mental disorder characterized by affective instability and interpersonal
disturbances. With a lifetime prevalence up to 6%, it is a frequent personality disorder, especially in women. High rates of psychiatric
comorbidities such as posttraumatic stress disorder (PTSD), major depression (MD), and substance abusing disorders have been reported
in BPD patients. Major research on adults with BPD has shown the singularity of the self-image, in which distress, despair, feelings
of inadequacy, and impressions of peer hostility, particularly perceived in group settings. Correlational studies consistently report
relationships between childhood trauma (CT) and most personality disorder (PD) criteria and diagnoses. However, it is not clear whether
childhood trauma is directly related to PDs or whether common familial factors better account for that relationship. CT was significantly
related to Borderline and Antisocial PD. Exposure to potentially traumatic events during childhood has been related to a number of
personality disorder diagnoses and symptoms, with borderline personality disorder receiving the most empirical attention. For example,
individuals with clinical or subclinical Borderline PD symptoms are more likely to endorse having experienced childhood abuse compared
to nonclinical controls. Additionally, etiologic theories of Borderline PD highlight the importance of the role of childhood trauma. Marsha
Linehan cites CT as a “prototypic invalidating experience” contributing to a biosocial model of Borderline PD etiology, with an entire stage
of treatment being devoted to addressing CT and reducing trauma-related behaviors in Dialectical Behavior Therapy.
Patients with BPD often use non-suicidal self-injury (NSSI) as a maladaptive strategy to reduce aversive tension and to feel rapid relief
from corresponding negative emotions. Affective instability is a core feature of borderline personality disorder Several theories consider
other BPD criteria, such as self-injury or substance abuse, to be maladaptive strategies for emotion regulation. The significance of affective
dysregulation is delineated in the DSM-5 and the ICD-10 which both highlight affective instability as an essential criterion for BPD
Borderline and PDs were most strongly predicted by sexual abuse. Here we present a 16 year-old female case with borderline personality,
who lives at home with parents. Multiple (at least 7) previous psychiatric admissions for depression, suicidal ideation and self-injury. She
feels that others do not posSIBly like her. She has few friends. She has had many sexual relationships some of which have been abusive.
Quetiapine was started with a 50 mg per day protocol for her depression and then titrated up to 500 mg. She began to see significant
progress in peer relationships, community involvement and her family affairs. After two years she had an upper right quadrant abdominal
pain and started vomiting. After through clinical assessment gall stone related cholesistitis is found to be the culprit. Gall stone formation
due to quetiapine consumption was reported before.Quetiapine is an atypical antipsychotic that is widely used in the treatment of
schizophrenia and mood disorders. One should keep in mind that abdominal pain when using quetiapine could be from biliary origin.
Keywords: gall stone, personality disorders, quetiapine
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[Abstract:0698] Personality disorders and accentuated personality
Genital self mutilation in a male with erectile dysfunction and hypospadias
Sinan Erenkus1, Zehra Erenkus2, Onur Durmaz3
Van Military Hospital, Van-Turkey
1
Freelance Biostatistician Consultant, Istanbul-Turkey
2
Balikesir Military Hospital, Balikesir-Turkey
3
e-mail address: [email protected]
Genital self-mutilation is a rare medical condition generally reported in psychotic disorders. It can also be observed in religious beliefs,
transsexuality and personality disorders. We report a case of male committed a genital self mutilation diagnosed with cluster B personality
disorder, erectile dysfunction and hypospadias and had no psychotic symptoms.
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21 year-old male referred to outpatient psychiatry clinic for his adjustment problems associated with his mandatory military duty. He
had low socio-economic status and 5 siblings. He had no psychiatric treatment history in his past but he had old self mutilation scars in
his forearms. He described self mutilation to glans penis as circumcision shaped two years before. precipitated by erectile dysfunction
and environmental pressure. He left wound to heal by secondary intention without medical intervention as functional and morphologic
disturbance increasingly continued. He had neither negative perceptions about his sexual and gender identity nor psychotic and
obsessive symptoms.
Although genital self mutilation was generally reported in psychotic patients in literature, we suggest that this case is considerable in
terms of having no psychotic feature, comorbidity of hypospadias and erectile dysfunction. Multidisciplinary approach is warranted for
management of the patient.
Keywords: erectile dysfunction, genital self mutilation, hypospadias
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PHARMACOTHERAPIES
[Abstract:0088] Pharmacotherapies
Olanzapine induced acute hepatotoxicity: a case report and review of the literature
Filiz Sukru Durusoy
Department of Psychiatry, Abant Izzet Baysal Training and Research Hospital, Bolu-Turkey
e-mail address: [email protected]
An atypical antipsychotic, that has been known to be effective in the treatment and management of many psychiatric disorders including
bipolar disorder, schizophrenia and related psychotic disorders, is olanzapine. A few data exist with regard to hepatotoxicity being
associated with olanzapine. In this case report we report on a patient who developed toxic hepatitis in the third week of olanzapine
treatment. To our knowledge, this is the one of the rare reports of serious symptomatic liver enzyme increase and clinical hepatotoxicity
occurred with the treatment with olanzapine.
A-57-year-old man diagnosed with Bipolar Disorder Type II since 2009. Beginning of third week of olanzapine 10mg/day treatment,
patient complained loss of appetite, upper abdominal pain, nausea, malaise and insomnia. His physical examination was normal.
However, initial routine laboratory monitoring revealed increased levels of transaminases enzymes such as; AST:515 IU/L, ALT: 825 IU/L
(N:5–37 IU/L), GGT: 957 IU/L (N:49 IU/L) and cholestasis enzymes such as; ALP: 764 (N:0-129 IU/L), total bilirubin: 3.10 (N:0-1 mg/dL), direct
bilirubin: 2.32 (N:0-0.3 mg/dL). Neither concomitant medical disease nor use of any other medications or natural products was present.
There was no history of ethanol or drug abuse. A series of other laboratory examinations was ordered to exclude other etiological factors.
Serology was negative for viral hepatitis, HIV, acute infection with cytomegalovirus, herpes simplex and Epstein–Barr viruses. Antinuclear
antibody (ANA), liver–kidney microsomal antibody (anti-LKM), anti- mitochondrial antibody (AMA), smooth muscle antibody (SMA) and
perinuclear anti-neutrophil cytoplasmic antibody (p-ANCA) were also negative. Abdominal ultrasonography was normal. Olanzapine was
suspected as the possible causative agent and discontinued immediately. After discontinuation, liver enzymes returned to normal range
within three weeks. Controlled, prospective studies are needed to define better risk factors associated with abnormal hepatic enzyme
elevations related to olanzapine treatment. The clinical significance of mildly elevated hepatic enzyme levels has not been determined.
When olanzapine is used as monotherapy, there is less evidence to support regular monitoring of liver enzyme levels. The short-term
monotherapy trials found only transient elevations in liver functions; however, there have been reports of acute hepatitis possibly due
to a hypersensitivity reaction from olanzapine. Thus, given the lack of long-term safety data with this agent, periodic monitoring seems
prudent. For the drug induced subclinical elevation of liver enzymes treatment dose reduction might be sufficient. If there is a three-fold
increase compared to upper normal limits, most of the physicians prefer to reduce the dose or withdraw the drug. In the decision of
withdrawal, the possibility of switching to other antipsychotics agents, the feasibility of clinical supervision to detect early signs of liver
failure and especially the severity of the hepatic injury and should be taken into account.
Keywords: case, hepatotoxicity, olanzapine
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[Abstract:0115] Pharmacotherapies
Urinary incontinence during sleep associated with extended release form of bupropion HCI: a case
report
Filiz Izci, Murat Yalcin, Merve Setenay Iris Koc, Rabia Bilici, Engin Emrem Bestepe
Department of Psychiatry, Erenkoy Training and Research Hospital, Istanbul-Turkey
e-mail address: [email protected]
Bupropion hydrochloride (HCI) is an antidepressant that acts as a norepinephrine and dopamine reuptake inhibitor. Here, we aimed
to report a case with major depression using extended release form of bupropion hydrochloride who was presented with urinary
incontinence during sleep, an uncommon side effect of bupropion.
F.K, a 42 year old, male patient presented our clinic with a growing feeling of unwillingness, indisposition, anhedonia, boredom, insomnia
and want to cry. The psychiatric examination revealed normal self care, anxiety to interview, depressed, tearful affect and mood,
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decreased speed and amount of speech. Sleep, appetite and sexual desire were decreased. Complete blood count, routine biochemical
parameters, thyroid hormone profile and urinalysis were in normal range. He had a Hamilton Depression Rating Scalewasscored as
24 and a Hamilton Anxiety Rating Scale wasscored as 11. Also Structured Clinical Interview for DSM IV, Axis I was administered to the
patient and major depressive disorder diagnosis was made. Bupropion was started at a dosage of 150 mg/day. At the 15th day of the
treatment patient’s complaints were decreased significantly and it was learned that the patient had urinary incontinence during sleep
after switching to bupropion treatment. Once the patient’s blood and urine test results were normal the patient’s bupropion treatment
was stopped because of the risk of lowering seizure threshold and an electroencephalography (EEG) was recorded at the very same
day. EEG, brain computerized tomography, neurology consultation, urology consultation, upper and lower abdominal ultrasonography,
urine analysis and uroflowmetry were normal. The patient was observed in close room during sleep and during the day. But there wasn’t
observed any epileptic seizures. As a result of the consultations and investigations, it is decided that the patient was not likely to have
any sleep disorder or urological disease. The patient was discharged during the 4th week of admission to be followed as an outpatient.
However, due to continuation of urinary incontinence during outpatient follow-up bupropion was discontinued and following-up with
a selective serotonin reuptake inhibitor was planned. During outpatient follow-up, absence of depressive complaints andno urinary
incontinence was observed.Bupropion is a preferred antidepressant because of its safe side effect profile, however, some rare side effects
such as urinary incontinence may be seen. The most common side effects of bupropion are sleeplessness, headaches and dry mouth. In
our case, urinary incontinence during sleep, which has not been reported in the literature commonly, is observed as a rare side effect.
Consequently, we think that urinary incontinence during sleep associated with extended release form of bupropion in a patient without
any urological pathology is important for its rarity in the literature.
Keywords: bupropion, side effect, urinary incontinence
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[Abstract:0119] Pharmacotherapies
Chlorpromazine in intensive care unit: antipyretic drug resistant hyperthermia case series
Mustafa Karaoglan1, Recep Tutuncu2
1Department of Neurology, GATA Haydarpasa Training Hospital, Istanbul-Turkey
2Department of Psychiatry, GATA Haydarpasa Training Hospital, Istanbul-Turkey
e-mail address: [email protected]
Hyperthermia is defined as an elevated body temperature due to failed thermoregulation. It can occur under physiological conditions
such as intense exercise or due to pathology such as malignant hyperthermia and heat stroke. Hypothalamus regulates body temperature
by integrating thermal input deriving from periphery as well as by sensing directly its own temperatures. Hyperthermia is a risk factor for
brain injuries with inhibits cell proliferation, induces cell oxidative stress
Case 1 is 23 year-old male with no previous medical history who, admitted to Psychiatry Department diagnosed as Conversion Disorder,
began to suffer with subfebrile fever, confusion and epileptic seizures the reason why he was transferred to Neurology Department
prediagnosed as Encephalitis. After transferred, his epileptic seizures recurred for 48 hours even though diazepam and phenytoin
treatment was done so he was accepted as Refractory Status Epilepticus and transferred to Intensive Care Unit (ICU) Department and
treated as continuous intravenosis (iv) infusion of Thiopental. In ICU, his body temperature remained more than 39°C even after whole
body cooling and the antipyretic drug treatment so Chlorpromazine 12.5mg intramuscular(im) injected. After 30 minutes of injection his
body temperature decreased to 36.2°C. Temperature was measured in every hour and did not increase for 12 hour after the injection.
Case 2 is 58 year-old female patient was admitted to Neurology Department with dysarthria, lethargia and slowness of movements. She
had medical history of treatment as Encephalitis. After admission she began to suffer persistent tonic clonic epileptic seizures the reason
why the treatment began with diazepam, phenytoin and was controlled after a continuous infusion of Thiopental. In ICU Department her
body temperature was 40.2°C even after the whole body cooling and antipyretic drugs so Chlorpromazine 12.5mg im was done. After 30
minutes of Chlorpromazine injection her body temperature was decreased to 37.1 degrees. In her vital monitoring her body temperature
did not increase for 8 hours.Thermoregulatory effector sites have been identified in the dorsomedial hypothalamus (DMH). Disinhibition
of neurons in the DMH elevates core temperature. Chlorpromazine was discovered in studies of developing new antihistaminic drugs from
Prometazine, which is a type of phenothiazine derivation. It is one of the eldest and partially used neuroleptic drug in current therapies.
D2 receptors seem to mainly involved in the maintenance of body temperature in euthermia with modulatory influence of D1 systems.
Serotonergic mechanism might be involved as well, Chlorpromazine displaying high 5-HT2A receptor affinity seems to be associated
with hypothermia. Organic brain damage like mental retardation and epilepsy is a risk factor for Chlorpromazine associated hypothermia.
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Chlorpromazine is temporal and potent inhibitor in the chemoreceptor trigger zone so prevents nausea and vomiting. With reducing
secretion binding to anticholinergic effects, it decreases the risk of asphyxiation and aspiration on the intubated patient. Unlike the
barbiturates, it does not reveal lethargia, slowness of movements and ataxia so helps clinicians to follow conscious monitoring. In contrast
of chlorpromazine cause of malign hyperthermia and stimulate epileptic seizures.
Keywords: chlorpromazine, hyperthermia, status epilepticus
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[Abstract:0129] Pharmacotherapies
Improvement of antipsychotic-induced hyperprolactinemia with the addition of aripiprazole: report
of two cases
Memduha Aydin, Bilge Cetin Ilhan, Aslı Seda Kirac, Kubra Kocagoz, Ibrahim Eren
Department of Psychiatry, Konya Training and Research Hospital, Konya-Turkey
e-mail address: [email protected]
Hyperprolactinemia is a frequent and serious side effect of antipsychotic medication. Of all the second-generation antipsychotic drugs
risperidone, paliperidone and amisulpride have been shown to cause marked elevation in serum prolactin levels. Hyperprolactinemia is
known to cause amenorrhea, oligomenorrhea, galactorrhea, gynecomastia, bone loss and sexual dysfunction. These side effects increase
risk of antipsychotic nonadherence, and pose significant problems in the long-term management of women with schizophrenia. A series
of reports and clinical trials have shown that the antipsychotic aripiprazole, a partial dopamine D2 receptor agonist, can lower prolactin
concentrations and potentially reduce prolactin-related effects when given with antipsychotics. We describe two patients who developed
hyperprolactinemia while one of them taking amisulpride and the other paliperidone palmitate long acting antipsychotic treatment
which improved on the introduction of aripiprazole.
A 58-year-old female was diagnosed with schizophrenia for 24 years and received amisulpride 400 mg/day for 5 years. She applied to our
clinic with severe negative symptoms. On admission to hospital, her prolactin level was found to be high (144.8 ng/mL, normal range
4.79-23.3 ng/mL) and aripiprazole was added to amisulpride due to hyperprolactinemia and her negative symptoms. On a stable dose of
amisulpride (400 mg/day), two additional prolactin levels were drawn 1 and 2 months after starting aripiprazole (30 mg/day, gradually
added) and were 102.5 and 89.82 ng/mL, respectively.
B is 47-year-old female, having psychiatric history of 16 years with schizophrenia. She was brought to hospital for her nutritional problems
due to positive symptoms. She also suffered from severe anemia that worsened her negative symptoms. Paliperidone palmitate longacting antipsychotic treatment (1. day, 150 mg; 8. day: 100 mg, 38. day 100 mg and 100 mg injections once every month as maintenance)
was started secondary to a history of noncompliance with oral medication. Serum prolactin levels at baseline were 84 ng/mL. The prolactin
level was found to be elevated at 257.2 ng/mL after 38. day treatment of paliperidone palmitate long-acting injection. Aripiprazole was
added to long-acting injectable antipsychotic (on a stable dose of 100 mg/monthly) due to hyperprolactinemia. Twelve days after the
beginning of aripiprazole (7.5 mg/day), the prolactin level decreased to 56.4 ng/mL.
Brain magnetic resonance imaging of two patients showed no evidence of a pituitary microadenoma. Clinical status of patients and
antipsychotic side effects were assessed by using the Positive and Negative Syndrome Scale (PANSS), the Clinical Global Impression
Severity Scale (CGI-S), Barnes Akathisia Scale (BAS) and Simpson Angus Scale (SAS). Serum prolactin levels were checked at baseline,
week 1, week 2, and monthly after discharge from hospital. We observed a clinically significant improvement in the negative symptoms
subscale scores in both cases. None of the cases experienced any serious adverse effects during the aripiprazole combination treatment.
Adjunctive aripiprazole therapy was generally well tolerated and may be beneficial for reducing negative symptoms and for reducing
hyperprolactinemia induced by antipsychotic drugs. The present findings of our case reports are consistent with previous reports
indicating that aripiprazole reduces elevated prolactin level.
Keywords: antipsychotic-induced, aripiprazole, hyperprolactinemia
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[Abstract:0133] Pharmacotherapies
Acute urinary retention in a female patient on mirtazapine treatment for major depressive disorder
Elif Karayagmurlu1, Ali Karayagmurlu2, Mehmet Fatih Ustundag1, Ece Yazla3
1Department of Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
2Department of Child and Adolescent Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
3Department of Psychiatry, Hitit University, Corum-Turkey
e-mail address: [email protected]
Acute urinary retention (AUR) is defined as the inability to void urine with a retained volume of urine of 200 ml or greater. Female AUR is
a relatively uncommon situation compared to men with a few case reports in the literature. It is estimated that 3 cases per 100.000 occur
per year. The common causes of female AUR are classified into subgroups as anatomical, drugs, operative, neurological and infective
factors. Opiates, antipsychotics and antimuscarinics are known as drugs, which cause urinary retention. Mirtazapine has only very weak
muscarinic anticholinergic effects. Although being rare, urinary retention is a possible adverse event associated with the mirtazapine.
Mirtazapine has potential to induce urinary retention, especially in elderly male patients with benign prostate hypertrophy. But there has
no available reports on mirtazapine’s potential to induce female urinary retention. We present a female patient with the diagnosis of major
depressive disorder in whom initiation of mirtazapine seemed to cause AUR.
A 46-year old married female patient (GK) presented to a psychiatry outpatient clinic in 2011 with major depressive disorder. Her
depressive symptoms were completely remitted with a medication that she could not remember. In the beginning of 2014, she was
hospitalized with MDD again. During two months of hospitalization, electroconvulsive therapy was done for 10 times, because of the
presence of active suicidal ideation. She was discharged with the treatment of quetiapine 300 mg/day, mirtazapine 15 mg/day and
venlafaxine 225 mg/day. After 6 months later she admitted to the outpatient psychiatry clinic of Ataturk University when she was using
venlafaxine and quetiapine with the daily doses of 225 and 325 mg. She was rehospitalized with a diagnosis of MDD. Quetiapine 300 mg/
day was stopped and the 30 mg/day of mirtazapine was started. However, within 48 hours after initiation of mirtazapine treatment, the
patient suffered from acute urinary retention.
Although urinary retention may occur spontaneously in male patients with benign prostate hypertrophy, female AUR is relatively
uncommon. Opiates, antimuscarinics and antipsychotics are common drugs associated with AUR. One possible mechanism of
mirtazapine-induced urinary retention is the dynamic obstruction, which is originated by increase in smooth urethral sphincter muscle
tone. Glutamate appears to be the primary excitatory neurotransmitter for the spinal somatic storage reflex. Glutamate activates somatic
pudendal motor neurons in Onuf’s nucleus to contract the rhabdosphincter, which encloses the mid-urethra. Two important modulatory
systems for establishing the responsiveness of sphincter motor neurons to glutamate are the serotonergic and noradrenergic systems
of the brainstem. Pharmacological studies indicate that 5-HT enhances the guarding reflex by binding to 5-HT2 receptors, while NA
enhances it through α-1 receptors. Although Mirtazapine has only very weak muscarinic anticholinergic effects, it has the potential to
induce acute urinary retention as it was seen in our case. Therefore, mirtazapine should be used cautiously in patients with a history of
urinary retention or when it is used in combination with other agents known to cause urinary retention.
Keywords: female acute urinary retention, major depressive disorder, mirtazapine
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S368
[Abstract:0135] Pharmacotherapies
Olanzapine induced spasmodic dysphonia: a case report
Gokhan Ozpolat, Elif Oral, Elif Ozcan
Department of Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
e-mail address: [email protected]
Spasmodic dysphonia is a rare form of tardive dystonia and characterized by involuntary spasms in the laryngeal muscles, which lead
to uncontrolled voice breaks predominantly during speaking. Olanzapine is serotonin dopamine antagonist, which is reported that it’s
improving effects on the symptoms of tardive dyskinesia. As we know, although there is a few reports of Olanzapine-related TD are
available in literature. This is the first case presentation of spasmodic dysphonia with olanzapine.
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A-19-year old man, admitted to the our inpatient clinic with the diagnose of substance-related psychotic disorder. His symptoms were
inappropriate affect, irritable mood, visual hallucinations, delusions of persecution and reference, disorganized behavior, disorganized
speech, impaired social functions and loss of insight. He had no history of developmental abnormality, medical disease and biochemical
assessment was normal. At the head of the treatment haloperidol 20 mg/day, Biperidene 10 mg/day injection and lorazepam 5 mg/day
was started. Haloperidol was stopped at the 7th day of treatment because of he accepted to the oral medication and risperidone 4 mg/
day was started and increased to 6 mg/day. At the 3th day of risperidone treatment, it was shown that the signs of severe extrapyramidal
symptoms.
To relief the extrapyramidal symptoms, risperidone dosage was decreased to 4 mg/day then 4-6 mg/day Biperidene was added to the
treatment. Because the extrapyramidal symptoms did not improve significantly risperidone treatment was stopped at the 8t day of
risperidone medication, and olanzapine treatment was started with the dosage of 5 mg/day and increased 20 mg/day gradually. After
the medication change to Olanzapine, extrapyramidal symptoms improved significantly, and his psychotic symptoms were significantly
improved. He was discharged with olanzapine 20 mg/day. About 6 months after discharge he began to have difficulty in phonation and
hoarseness. He had no family history of involuntary movement. No focal neurological deficits or involuntary movements over head, trunk
or four limbs were noted during neurological examinations. Physical examination did not reveal any major abnormality. Otolaryngological
examination excluded the possibility of inflammatory or neoplastic change in the larynx and vocal cord or any traumatic injury and
revealed no repetitive abnormal movement in the vocal cords. Blood test results were all within normal range. He had normal neck
ultrasonography. Spasmodic dysphonia induced by olanzapine was diagnosed and olanzapine dosage was decreased to 10 mg/day.
His TDt was diagnosed according to the criteria described by Burke et al. Including presence of chronic dystonia, history of preceding
antipsychotic drug treatment, exclusion of known causes of secondary dystonia and negative family history for dystonia. It has been
suggested that the possible mechanism of spasmodic dysphonia based on the dopaminergic and cholinergic mechanisms, such as
dopamine deficiency and cholinergic excess caused by dopamine antagonists, and on the treatment effect of anticholinergic drugs. In
conclusion, clinicians should be alert regarding this rare side effect with use of olanzapine in clinical practice. Clinicians who prescribe
antipsychotic medication must carefully monitor extrapyramidal symptoms at every follow-up visit and keep up-to-date on the best
methods for dealing with this adverse reaction.
Keywords: dysphonia, dystonia, olanzapine
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S368-S9
[Abstract:0148] Pharmacotherapies
Escitalopram and mirtazapine combination in treatment of psychogenic vomiting
Meral Gunes Coskun, Halil Ozcan, Mehmet Fatih Ustundag, Tuba Ulkevan
Department of Psychiatry, Ataturk University, Faculty OF Medicin, Erzurum-Turkey
e-mail address: [email protected]
Psychogenic vomiting can be described as vomiting without an apparent organic pathology or vomiting accompanied by mental
disorders. Here; we present the successful treatment with escitalopram and mirtazapine of a patient, which is thought to be the origin of
psychogenic vomiting combination.
21-year-old, law school student, male was admitted our clinic with history of recurrent nausea and vomiting that occur 6-7 times a day
for 1 year. His first complaints began when he was preparing for the university entrance exam and intensified by stress. He declared that
he also began to feel sadness, malaise, inability to enjoy life. Medical examinations, detailed laboratory tests were normal. He had been
on escitalopram 20 mg/day and olanzapine 5 mg/day treatment nearly for 1 year without any benefit. Olanzapine treatment was stopped
and mirtazapine 30mg/day added to escitalopram 20mg/day. Meanwhile, he decided to break his training and going to his hometown.
After two weeks he stated that he has vomited only 3 times during two-week period. The supportive-motivational interviewing was
done with patient and continuation of treatment was suggested. Three weeks later he pointed out that he had not vomited since his
last examination. Also his depressive symptoms alleviated and he returned to school. His clinical follow-ups continue in our department.
Psychogenic vomiting is a condition that physicians frequently encounter even it does not have a criteria on DSM-5. Hysterical neurosis,
conversion disorders and major depression are reported to be the most common psychological factors in the onset of psychological
vomiting also five subtypes such as persistent vomiting, habitual- postprandial vomiting, irregular vomiting, nausea, self-induced
vomiting of psychogenic vomiting are defined. Our patient was considered to have the habitual-postprandial type vomiting. Persistent
vomiting type is generally associated with conversion disorder, habitual- postprandial vomiting and irregular vomiting are associated
with depression as similar with our patient. Also there are case reports reporting patients with psychogenic vomiting successfully treated
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by citalopram or escitalopram and olanzapine combination. Weight gain, appetizing and antiemetic effects of mirtazapine are reported
in the literature, but there is no statement on the use primarily in the treatment of psychogenic vomiting. Although the patient that
we present did not have any benefits by olanzapine and escitalopram combination treatment, which is, known to be effective on the
psychogenic vomiting in the literature. With reporting this case we aim to represent escitalopram and mirtazapine combination treatment
as an alternative option in the treatment of psychogenic vomiting.
Keywords: psychogenic vomiting, treatment
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S369-S70
[Abstract:0150] Pharmacotherapies
A case of mania during nicotine cessation treatment with bupropion
Elif Ozcan1, Gokhan Ozpolat1, Elif Karayagmurlu1, Ali Karayagmurlu2, Elif Oral1
1Department of Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
2Department of Child and Adolescent Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
e-mail address: [email protected]
Bupropion XL is a dopamine/norepinephrine reuptake inhibitor antidepressant also licensed for use as a smoking cessation support.
Compared with other antidepressants, bupropion is generally considered to have a lower relative risk of inducing mood shifts in bipolar
depression, but there are no controlled studies specifically showing this risk when prescribed for nicotine dependence treatment.
Secondary mania induction in unipolar depression treatment during depressive episode with bupropion has been rarely reported in
the literature, but little is known about the potential for mood shifts when bupropion is prescribed as a smoking cessation support
in remission. In this case we reported a patient who experienced a first manic episode during the smoking cessation treatment with
bupropion XL.
A 25-year-old woman with nicotine dependence (5 packs-years) who applied to chest diseases outpatient clinic for the treatment of
smoking, bupropion XL 150 mg / day was started three weeks ago. Patient was directed to our psychiatry clinic by chest diseases doctor
with complaints of irritability, euphoria, voluble speech, decreased need for sleep, overactivity, decrease in attention and concentration,
grandiosity, increased sexual attraction and functional decline. Past psychiatric history was significant for single major depressive episode
of remitted spontaneously within 4 months, one year ago. There was no history of else substance misuse or family history of affective
disorder. Scores of Young Mania Rating Scale (YMRS) 17 was found. The patient was diagnosed bipolar disorder I according to DSM-5
criteria. Bupropion treatment was discontinued. Olanzapine (10 mg/day) and lithium treatment (300=>600=>900 mg/day) were started
and lithium blood levels were monitored once a week. Her symptoms were controlled with lithium 900 mg/day and olanzapine 10 mg/
day. She achieved euthymia after 4 weeks and score of YMRS:5 was found. Olanzapine was tapered off gradually, and the patient is in
remission now for the last 2 months.
The timing of symptoms shows an association between bupropion initiation and mood shift in this patient. Bupropion can induce mood
switches in bipolar depression, but possibly less frequently than other antidepressants. There are only a few cases reported of bupropion
induced mood shifts in unipolar disorders and of secondary mania induction.
Although there are several hypotheses for the manic episode, our findings suggest the need to carefully monitor for mood shifts when
bupropion is prescribed as a smoking cessation support, even in unipolar patients or patients who have no psychiatric diagnosis.
Smoking cessation treatment process is a sensitive period for a number of factors for mood changes (e.g. nicotine withdrawal, nicotine
replacement treatment, the stress of quitting smoking).
These factors may change the risk of mood shifts associated with bupropion. Although the benefits of medication assisted smoking
cessation are clear, there is a need for frequent and systematic monitoring of mood symptoms by mental health professionals during
treatment with bupropion in the context of smoking cessation, even in patients not previously diagnosed with bipolar disorder. Before
starting treatment for smoking cessation, possible psychiatric disorders in the patients should be questioned in collaboration with the
mental health professionals.
Keywords: bupropion, mania, nicotine
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[Abstract:0164] Pharmacotherapies
Valproic acid induced pancytopenia in a patient diagnosed with comorbid schizophrenia, mental
retardation, and psychogenic polydipsia
Esra Ozhan Ibis1, Ali Ibis1, Mehmet Fatih Ustundag2, Halil Ozcan2
1Department of Child and Adolescent Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
2Department of Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
e-mail address: [email protected]
Psychogenic polydipsia is a rare clinical condition characterized by excessive water drinking without physiological thirst sensation and
detected in 6-17% of patients with psychiatric illness. Approximately 80% of cases of psychogenic polydipsia are schizophrenic patients.
Valproic acid as a commonly used mood stabilizer and antiepileptic may cause hematological disorders. Thrombocytopenia is the most
common hematological side effect, very rare cases of pancytopenia have also been reported. Here we report a patient, with valproic acid
induced pancytopenia as a potential fatal side effect.
A 43-year-old female patient was admitted to our outpatient clinic with symptoms of malaise, irritability, social withdrawal, mild
persecution ideas, drinking water up to 10 liters a day, insomnia. Her mother declared that she had been on with risperidone depot
injection treatment for 15 years with diagnosis of mild mental retardation and schizophrenia. Almost for last 5 years generally in spring
and autumn psychotic symptoms, irritability, decreased need for sleep had aggravated. In laboratory tests white blood cell count (WBC):
6600 u/ml, neutrophil count (NE): 2600u/ml, red blood cell count (RBC): 4.1X106/mL, platelet count (PLT): 250.000 u/ml, fasting glucose:
95 mg/dL, urea 40 mg/dL, creatinine 0.9 mg/dL, sodium(Na) 131 mmol /L, potassium (K): 4.1 mmol/L, urine density was 1.012 (all results
were between normal ranges). Serum vitamin B12, folic acid levels were normal. Brain MRI and chest X-ray did not reveal any pathology.
She was consulted with internal medicine department. After water deprivation test she was diagnosed with psychogenic polydipsia.
Upon the seasonal pattern of complaints valproic acid 1000mg/day was added to treatment. In the fifth day of sodium valproate-valproic
acid treatment, valproic acid blood level was 120 mg/ml, WBC:3000 u/ml, NE: 900 u/ml, RBC:3,0X106/ml, PLT: 150.000 u/ml. No sign of a
viral infection that might effect laboratory findings was detected. Her physical examination revealed no hepatomegaly or splenomegaly.
Peripheral blood smear revealed no abnormality except pancytopenia. Valproic acid-sodium valproate treatment was discontinued. Two
days later blood valproic acid level was measured as 110 mg/ml and WBC: 3500 u/ml, NE: 1500 u/ ml, RBC: 3.5X106/mL, PLT: 160.000 u/ml.
After 5 days valproic acid blood level was 50 mg/ml and WBC: 4600 u/ml/ NE: 2300 u/ml, RBC: 4.0X106 /mL, PLT: 200,000 u/ ml.
The etiopathogenesis of effect of sodium valproate-valproic acid on blood cells is unknown, it is suggested as a side effect in bone marrow.
Keywords: pancytopenia, psychogenic polydipsia, valproic acid
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S371
[Abstract:0172] Pharmacotherapies
Hyperglycemia may reduce plasma levels of lithium: a case report
Gokhan Ozpolat1, Elif Ozcan1, Elif Karayagmurlu1, Ali Karayagmurlu2, Elif Oral1
1Department of Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
2Department of Child and Adolescent Psychiatry Ataturk University, Faculty of Medicine, Erzurum-Turkey
e-mail address: [email protected]
Lithium has been used as a mood stabilizing agent in the treatment of bipolar disorder. Lithium is almost completely absorbed after
oral administration, distributes into total body water and is eliminated almost entirely by renal elimination. After filtration, lithium
reabsorption occurs from the proximal tubule. Alterations of proximal tubular function may affect the renal elimination of lithium.
Excreting of glucose to proximal tubule called as glycosuria and this condition may cause to osmotic diuresis which would increase the
renal clearance of lithium in hyperglycemic patients. The following case suggests that persistent hyperglycemia can result in a clinically
relevant increase in the renal clearance of lithium.
A 51-year-old man presented to the emergency department with elevated mood, grandiosity, decreased need for sleep, more talkative
than usual, increased energy, spending money excessively. These symptoms had been ongoing for a month. The man had a 10-year
history of bipolar disorder. He had been noncompliant with lithium therapy for a year prior to hospitalization. He was diagnosed with
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bipolar disorder manic episode and admitted to our clinic. Laboratory tests were significant for 4+ glucose and no trace ketones in the
urine and a blood glucose concentration of 410 mg/dL. Admission lithium plasma concentration was 0.2 mEq/L. Oral lithium carbonate
900 mg/d and quetiapine xr 400 mg/d was started. The following day, fasting glucose was 309 mg/dL and he was started on insulin aspart
3*8 unit and insulin glargine 1*24 unit and was given to diabetic diet. On day 3, lithium dosage was increased to 1200mg/d. On day 9
lithium plasma concentration was 0.4 mEq/L and lithium dosage was increased to 1500 mg/d and quetiapine xr dosage was increased to
600 mg/d. Blood glucose concentrations remained elevated, so on day 10 insulin aspart dosage was increased to 3*10 unit and insulin
glargine dosage was increased to 1*30 unit. On day 15, the lithium plasma concentration was still 0.4 mEq/L; the lithium dosage was
increased to 1800 mg/d the next day. On day 18 blood glucose concentrations were still higher and insulin aspart dosage was increased
to 3*12 unit and insulin glargine dosage was increased to 1*36 unit. Then blood glucose concentrations started to decrease. 10 days later,
the lithium plasma concentration was 0.6 mEq/L and lithium dosage was not increased. On day 36 the lithium plasma concentration was
0.8 mEq/L. The lithium dosage was still 1800 mg/d at this time. After blood glucose levels dropped, the lithium plasma concentrations
began to rise.
Glycosuria associated with hyperglycemia induces an osmotic diuresis that increases the renal clearance of lithium. In such a situation,
higher doses are needed to reach therapeutic plasma levels. Lithium has a very narrow therapeutic window that predisposes patients on
lithium maintenance treatment to poisoning with relatively minor changes in medications or health status so it is important to maintain
lithium plasma concentrations within a specific range for each individual to achieve a balance between efficacy and safety.
Keywords: hyperglycemia, lithium, osmotic dieresis
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S371-S2
[Abstract:0173] Pharmacotherapies
Bupropion-induced hyperprolactinemia: a case report
Alperen Kilic, Ahmet Ozturk, Ismet Kirpinar
Department of Psychiatry, Bezmialem University, Istanbul-Turkey
e-mail address: [email protected]
Hyperprolactinemia is a state which is characterized by abnormally increased levels of prolactin. Physiologically seen in pregnancy and
lactation, hyperprolactinemia may be caused by hypophysial adenomas, trauma, renal and hepatic pathologies, thyroid disorders, and
also by the use of some drugs such as antipsychotics, serotonin reuptake inhibitors, tricyclic antidepressants. There are also some cases
reported hyperprolactinemia cases caused by venlafaxine. Bupropion is a dopamine and norepinephrine reuptake inhibitor. Bupropion
acts as a non-competitive antagonist for some neural acetylcholine receptors. Hyperprolactinemia and menstrual irregularities have been
attributed mostly to antipsychotic use but hyperprolactinemia can also be seen in conjunction with SSRI use.In this study we reported a
case developed prolactinemia and oligomenorrhea after the use of bupropion and had normal prolactin levels after the discontinuation
of the drug.
Our case is a 32 year-old female, married and had children. She was on venlafaxine treatment for one year due to some depressive
complaints, she was using the drug regularly and benefit from it, she did not have menstrual irregularities at that moment (oligomenorrhea
or amenorrhea). She did not have any organic disease, chronic use of any drug, a history of any operation. She had usual menstrual cycles.
She was not pregnant and was not using oral contraceptives. At the time she applied to our center she complained of nervousness,
head ache, apathy, misery and insomnia; 75 mg of venlafaxine and 50 mg trazodone were planned. Later on, venlafaxine was gradually
increased up to 225 mg and since the patient still had depressive complaints 150 mg bupropion was planned. In the following month,
the patient started to have menstrual irregularities (oligomenorrhea). There was no significance reported in the hemogram, lipid profile,
hepatic enzymes, urea, creatinine or thyroid function tests of the patient. The prolactin level of the patient was 200 and a week later it was
202 ng/ml. The history of the patient did not reveal any history of increased levels of prolactin. To exclude the organic causes, cranial MRI
and hypophysial MRI were performed and there was not any pathologies related to the clinic. Bupropion treatment was discontinued and
in the control blood test after a week prolactin level was found to be decreased to
16 ng/ml. The previous treatment was continued.
In literature it is claimed that bupropion which is an atypical antidepressant was neutral by means of the effect on prolactin levels,
furthermore it is also suggested that bupropion may decrease the levels of prolactin in the way it increases the reuptake of dopamine.
In our opinion, prolactin levels may increase during the use of bupropion because of the metabolites. It is possible that the release of
dopamine may be inhibited and nicotinic receptors may be blocked either by bupropion or its metabolites. However the mechanism
of action is unclear. Clinicians must be alerted to hyperprolactinemia and menstrual irregularities during the course of antidepressant
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treatment and the mechanism of action playing role in the adverse events needs to be enlightened by further research.
Keywords: bupropion, hyperprolactinemia, prolactin
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S372-S3
[Abstract:0174] Pharmacotherapies
Tardive oculogyric crisis during treatment with clozapine
Duygu Kubra Gocmen Yigit1, Gamze Akcay1, Selma Bozkurt Zincir1, Sermin Kesebir2
1Department of Psychiatry, Erenkoy Training and Research Hospital, Istanbul-Turkey
2Department of Psychiatry, Uskudar University, Istanbul-Turkey
e-mail address: [email protected]
Tardive oculogyric crisis (OGC) is a dystonic syndrome that starts after long term use of dopamine receptor antagonists. Atypical
antipsychotic have reduced liability for inducing tardive dystonia. Clozapine is an atypical antipsychotic drug, and that clozapine may be
an effective treatment for tardive dystonia. Here we presented a case of tardive OGC while taking clozapine treatment and discussed the
possible relationship between tardive OGC and clozapine monotherapy.
The patient is a 44-year-old single male with a diagnosis of schizophrenia, who was unemployed and living with his family caregiver.
The patient had been treated continuously with various typical antipsychotic medications without any significant improvement since
1986. At the same time, he had also been given anticholinergic medications for extrapyramidal adverse effects. When he was referred to
our psychiatry outpatient unit, in 2006, he was switched to clozapine treatment. Daily 400 mg Clozapine was effective in controlling all
psychotic symptoms and he had not complained any extrapyramidal side effects during 8-year follow-up period. Despite the lack of any
dose changes, he began to tardive OGC seen in case of episodes have emerged in patient within the last 3 months. The OGC episodes
were resistant to treatment of intramuscular biperidene. However, oculogyric crisis signs spontaneously remitted after 3-4 hours and
recurred within 2-4 days. The patient had no history of substance abuse, head trauma or any other neurological problems. There was no
family history of dystonia. Complete blood count and routine blood biochemistry profile tests for the patient were all in normal ranges.
Electroencephalography and brain MRI images were also reported as normal. Clozapine therapy was continued in this patient.Clozapine
is generally considered to have little or no potential to cause tardive syndromes. There are case reports that clozapine may be an effective
treatment for tardive dystonia. In the literature, there are very scarce case reports on clozapine use-related tardive dystonia or OGC. In
our case, oculogyric crisis signs continued for 3-4 hours and disappeared spontaneously. This clinical picture and EEG -taken soon after
OGC emerged- was not suggestive of an epileptic state. This paper describes a patient with schizophrenia who developed episodes of
ocular dystonia (OGC) as a delayed adverse effect of clozapine. Although the relationship between tardive OGC and clozapine is still
unknown, there are some explanations about this discrepancy. It is possible that the previous long-term exposure to numerous typical
antipsychotic medications resulted in dopamine receptor dysfunctions because of permanent dopamine receptor blockade. This might
have created a sensitizing or priming effect on this patient’s striatum. The other explanation is that some patients with schizophrenia
are more susceptible to extrapyramidal signs even they are antipsychotic-naive. At least in some patients this may posSIBly reflect basal
ganglia pathology or genetic predisposition.
Keywords: clozapine, tardive oculogyric crisis, schizophrenia
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S373
[Abstract:0184] Pharmacotherapies
Suicidal behaviors during the efavirenz treatment in HIV positive patients; a case report
Fatih Baz, Omer Yanartas, Zeynep Senkal, Anil Gunduz, Volkan Topcuoglu
Department of Psychiatry, Marmara University, Faculty of Medicine, Istanbul-Turkey
e-mail address: [email protected]
Major depressive disorder is quite common in patients with HIV positive. Both the direct effects of disease perception, and the side effects
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of the anti-HIV drugs may be related to this condition. The non-nucleoside analog reverse transcriptase inhibitor (NNRTI) efavirenz is
commonly used in combination treatment of HIV. The neuropsychiatric side effects of an efavirenz, such as; insomnia, fatigue, depression,
suicide attempt, headache and dizziness, has been reported between 20-40%. Although the neuropsychiatric side effects generally may
be observed in the initiation period, it also may be observed in the long term treatment period. In this study we present a case, who has
recurrent suicide attempt during the EFV combination treatment period, for the clinicians’ draw attention.
A 54-year-old, male, living with his family. He attended to the dermatologist due to the lesions on his skin and after his serologic
examination, the HIV + was detected in his laboratory test results. The efavirenz (600 mg) and emtrisitabin - tenofovir (245 mg+200 mg)
combination treatment was started and sufficient response was taken to this treatment. After the first year of this treatment depressive
symptoms such as; anhedonia, insomnia, nightmare, lack of appetite, sexual dysfunction and suicidal ideas initiated. Due to these
symptoms the patient went to his cottage for attempting suicide. He attempted suicide by taking too much alcoholic beverage and pills
(two box antibiotic and two box analgesic drugs). Since he could not commit suicide he returned back his home and he took his gun
for suicide attempt. His wife realized and prevented his suicide attempt and persuaded him for applying to our outpatient clinic and
the patient was hospitalized to our inpatient clinic. After the mental examination the patient diagnosed as major depressive disorder
according to DSM IV-TR criteria and the symptom severity was detected according to the Hamilton Depression Rating Scale (HDRS)
and the test score was correlated to severe depression (47 point). The escitalopram treatment 5mg/day was given and after the clinical
microbiology infectious diseases consultation EFV treatment was discontinued and lopinavir-ritonavir (800mg) combination treatment
was given. After 10 days of treatment depressive symptoms and especially suicidal ideations decreased clearly and the HDRS score was 3
point and then the patient returned back to his job and his occupational functionality was well.
People with HIV have an elevated rate of depression. Poor mental health conditions are related to reduced adherence, poorer outcome,
elevated mortality in this group of patients. Efavirenz has long term neuropsychiatric side effects such as; sadness, mood changes,
irritability, nervousness and in the follow up study these side effects were observed higher with the efavirenz than protease inhibitor
containing regimen. Since patients’ symptom reduced dramatically after discontinuation of the efavirenz we associated depression
with efavirenz as a side effect. In this case we started escitalopram due to possible drug interaction with other antidepressants and we
observed improved clinical progress and occupational functionality with this agent.
Keywords: depression, efavirenz, suicidal behavior
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S373-S4
[Abstract:0187] Pharmacotherapies
Galactorrhea induced by separately use of venlafaxine and duloxetine: a case report
Murat Mutlu1, Mehmet Fatih Ustundag2, Halil Ozcan2
1Department of Psychiatry, Sinop Ataturk State Hospital, Sinop-Turkey
2Department of Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
e-mail address: [email protected]
Galactorrhea is a medical condition that may be associated with many medical disorders and use of medications including antidepressants.
In the literature, is as and serotonin norepinephrine reuptake inhibitors is of venlafaxine with Cases having hyperprolactinemia and
galactorrhea have been reported associated with the use of selective serotonin reuptake inhibitors such as sertraline, fluoxetine. The
number of cases having hyperprolactinemia and galactorrhea associated with serotonin-noradrenaline reuptake inhibitors such as
venlafaxine and duloxetine are quite limited
Galactorrhea induced by serotonergic system effecting drugs is explained by two mechanisms. First is the effects of activated serotonergic
system by blocking the dopamine on tuberoinfundibular pathway and leading to hyperprolactinemia and galactorrhea. The other
mechanism is the stimulation of serotonergic receptors in the hypothalamic postsynaptic region causing hyperprolactinemia and
galactorrhea. Here we report a case having hyperprolactinemia and galactorrhea associated with separately use of venlafaxine and
duloxetine. A 34-year-old female patient was admitted to our outpatient clinic with symptoms of fatigue, malaise, loss of enjoyment of
life, sleep and appetite problems. She scored 17 in Hamilton depression rating scale. Venlafaxine 37.5 mg/day was started and increased
to 75 mg/day increased. In the third week of treatment she complained about galactorrhea. Her serum prolactin level was 95 ng/ml. Brain
magnetic resonance imaging according to the doubt of an existing pituitary adenoma revealed no pathology. Venlafaxine was stopped
and duloxetine 30 mg/day was started instead. On 15th day of duloxetine treatment serum prolactin level was 42 ng/ml. Duloxetine
dosage was increased to 60mg/day because of inadequate treatment response. Three weeks later the patient came to clinic with
complaints of galactorrhea again, the measured serum prolactin level was 75ng/ml. We gradually cut duloxetine treatment, agomelatine
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25 mg/day was initiated. At the end of the first month of the agomelatine depressive symptoms partially reduced. She scored 10 on
Hamilton depression rating scale, serum prolactin level was 31 ng/ml. Her follow-ups continue in our clinic.
Normal levels of serum prolactin is 2-25 ng/ml. Prolactin levels in patients with galactorrhea due to drugs are in normal ranges or below
100 ng/ml. In our case, the serum prolactin level below 100 ng/ml suggests the effect of a medicine rather than a hypophysis tumor. Also
the detection of hyperprolactinemia and galactorrhea with the increased dose of venlafaxine and duloxetine suggests that this is a most
likely dose-dependent side effect. With this case presentation we aim to draw attention to the hyperprolactinemia and galactorrhea
side effects of antidepressant agents (venlafaxine and duloxetine) those are commonly used in treatment of many psychiatric disorders,
migraine, fibromyalgia, etc.
Keywords: duloxetine, galactorrhea, venlafaxine
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S374-S5
[Abstract:0189] Pharmacotherapies
Resistant depressive disorder in a patient treated with antiretroviral drugs for HIV: a case report
Filiz Izci, Merve Setenay Iris Koc, Rabia Bilici, Murat Yalcin, Sumeyye Yasemin Kurtulus Calli, Yagmur Sever, Engin Emrem Bestepe
Department of Psychiatry, Erenkoy Training and Research Hospital, Istanbul-Turkey
e-mail address: [email protected]
Some antiviral drugs used for the treatment of infection diseases like HIV may cause mood disorders such as depression and resistance
to treatment. Here we aimed to discuss a case with treatment resistant depression who was receiving antiretroviral therapy (tenofovir
disoproxil + emtricitabine, efavirenz).
A 39-year-old male patient admitted with reluctance, malaise, anhedoina, insomnia, loss of appetite. His complaints were ongoing for 8
months. It was learned that the patient had been receiving regular psychiatric treatment for 6 months but his complaints were increased
fort he past 1 month and he had started to make suicide plans. The patient was hospitalized with a preliminary diagnosis of depressive
disorder. According to history taken from the patient and his family the patient had been using cannabinoids occasionally fort he past
13 years and he was hospitalized in a psychiatry clinic for 3 times but no regular medication use. He had stopped using cannabinoids
when he was diagnosed with HIV 1 year ago. Treatment with emtricitabine + tenofovir disoproxil and efavirenz was administered to
the patient. There was no special finding other than this in the patient and family history. In the psychiatric examination, self care was
moderate, he was reluctant to communicate, speed of his speech and intonation was low, psychomotor activity was decreased, his mood
and affect were depressive, anhedonia, insomnia, anorexia, anxiety, energy, avolition and suicidal thoughts were present. Insight was
present and judgment was preserved. HAM-D and HAM-A scores were 24 and 14, respectively. Paroxetine 20 mg/day, lorazepam 1 mg/
day, quetiapine 200 mg/day was administered. Blood biochemistry, complete blood count and thyroid hormones were at normal range.
Substance metabolites were negative in urine analysis. Because there was no significant decrease in HAM-D scores during the 1st and 2nd
week of treatment paroxetine dose was increased up to 30 mg/day and quetiapine dose was increased up to 300 mg/day and because his
insomnia was still present zopiclone 7.5 mg/day was added. During the 4th week of the treatment it is thought that the current anti-HIV
drugs were increasing his depressive symptoms and the patient was consulted to infectious diseases department for drug selection. It
was said that continuation of current drugs was required. Partial improvement was seen in the patient’s complaints during the 6 th week
of the treatment. Lamotrigine 25 mg/day was added and increased up to 100 mg/day. The patient was discharged with partial recovery
at his own request. In the outpatient follow up lamotrigine was increased up to 200 mg/day, paroxetine was increased up to 40 mg/day
and quetiapine was continued as 300 mg/day. HAM-D scores were decreased to 8 and remission was achieved.
Mood disorders, anxiety, and substance use disorders can be seen in HIV (+) patients undergoing antiretroviral therapy. Antiretroviral
treatment can exacerbate depressive symptoms and complicate treatment response. In our patient and in this group of patients it should
be considered that drugs used fort he treatment of infectious diseases may complicate treatment response.
Keywords: antiviral, depression, HIV
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[Abstract:0194] Pharmacotherapies
Carbamazepine-induced probable drug reaction with eosinophilia and systemic symptoms (dress)
syndrome:a case report
Cana Aksoy Poyraz, Eser Aydin, Senol Turan, Alaattin Duran
Department of Psychiatry, Istanbul University, Cerrahpasa Faculty of Medicine, Istanbul-Turkiye
e-mail address: [email protected]
Carbamazepine (CBZ) is a widely used drug in psychiatric practice. The most severe reaction occurs as part of a generalised hypersensitivity
reaction, also known as drug reaction with eosinophilia and systemic symptoms (DRESS). We report here a probable case of a young adult
who presented with DRESS. Clinicians should be aware of such an association, as the most effective treatment is cessation of the offending
drug.
A 27-year-old male adult with antisocial personality disorder was admitted to our psychiatry service. Recently he had severe marital
conflicts with his wife and subsequently he had homicidal thoughts toward his wife that he presented to the emergency room and
he was recommended hospitalization. Carbamazepin 400 mg daily was started, and increased to 800 mg daily at day 4, and to 1200
mg daily at day 8. At day 13 his body was covered in a maculopapular rash and he was febrile (39oC). Initial investigations revealed an
inflammatory reaction and liver dysfunction. C-reactive protein was 65 (normal range<5) Liver transaminase levels were mildly elevated,
aspartate transferase 103 I U/l, alanine transferase 146 IU/l. Serological tests for hepatitis A and B were negative. Initial full blood count
showed severe thrombocytopenia (plt: 9700 µL) and eosinophilia (0.6x103/mm3). Serum amylase, urea, and electrolytes were normal.
Urinalysis by dipstick showed protein 1+and occult blood 3+. The patient was diagnosed with probable case of DRESS syndrome based
on clinical and laboratory findings and his CBZ was immediately stopped, he was placed on broad-spectrum antibiotics for possible sepsis.
Parenteral methyl prednisolone treatment at a dose 60 mg/day was started. At day 3 his platelet counts raised to 27.000 and to 76 000 at
day 4 and 203.000 at the end of the first week. Fever and rash disappeared in 7 days and symptoms completely resolved, laboratory tests
were normal in 10 days. DRESS syndrome is a severe idiosyncratic drug reaction characterised by a papulo–pustular or erythematous skin
eruption, fever, lymphadenopathy and involvement of organ systems. The clinical symptoms of DRESS are not immediate and usually
occur 2–8 weeks after first administration of the drug. The aromatic anticonvulsants (CBZ, phenytoin and phenobarbitone) are amongst
the drugs most likely to cause DRESS syndrome. Diagnosis is largely clinical, based on knowledge of the temporal relationship between
the onset of a drug and symptoms, and exclusion of other conditions. DRESS syndrome can be difficult to differentiate form other diseases.
In our case differential diagnosis included drug-induced thrombocytopenic purpura, severe trombocytopenia is not common in DRESS
syndrome, the lack of lymphadenopathy and atypical lymphocytes and eosinophilia (>0.7x103/mm3) are other findings incompatible with
DRESS. However the presence of organ involvement (mild hepatitis), fever and skin rash covering >50% body surface area and skin rash
type suggesting DRESS along with the rapid resolution were the supportive findings of DRESS.
The DRESS syndrome must be recognised promptly and the causative drug withdrawn. Earlier withdrawal of the offending agents is
associated with a better prognosis. Supportive and symptomatic treatments are indicated; corticosteroids are often used.
Keywords: carbamazepine, DRESS syndrome, hypersensitivity
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S376
[Abstract:0195] Pharmacotherapies
Mirtazapine induced acute angle closure: a case report
Nilay Kahraman1, Onur Durmaz2
1Department of Psychiatry, Cerkezkoy State Hospital, Istanbul-Turkey
2Department of Psychiatry, Balikesir Military Hospital, Balikesir-Turkey
e-mail address: [email protected]
Acute angle closure (AAC) is an ocular emergency with symptoms including blurred vision, eye pain, headache, nausea, vomiting
and reddening of the eye result in increased intraocular pressure. This clinical condition can lead to permanent damage in vision and
blindness by progressive and irreversible optic neuropathy if left untreated. There are several reasons of AAC including several classes of
local and systemic medications, mainly sympathomimetics, cholinergics, anti-cholinergics, mydriatics, anti-histamines, antiepileptics like
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topiramate, tricyclic and tetra cyclic antidepressants, serotonin reuptake inhibitors, antipsychotics, sulpha-based drugs and anticoagulants.
Mirtazapine, a noradrenergic and specific serotonergic antidepressant, is an atypical antidepressant with a complex pharmacological
profile. This case report describes a patient with major depressive disorder, who experienced AAC after the first dosage of mirtazapine
treatment. A 27-year-old woman referred to the outpatient clinic with depressive symptoms including unhappiness, unwillingness, sleep
problems. She had no history of psychiatric treatment. She was diagnosed with MDD and escitalopram was started 10 mg/day. During the
3rd day of treatment, she reported serious sleep disturbance, and mirtazapine 15 mg/day was intitated as add-on treatment. About one
hour after the first dose of mirtazapine, she reported nausea and severe headache with pain, blurred vision, and reddening on the right
eye. Her neurological examination was intact and vital signs were found to be normal while she did not have any chronic diseases or any
other medications. Ophtalmological consultation was planned due to her ophtalmic complaints. In her ophtalmic examination, the best
corrected visual acuities were 8/10 and 10/10 while IOP was found to be 26 mmHg and 12 mmHg in the right and left eyes respectively. A
slit-lamp examination revealed mild corneal edema and conjuntival injection of the right eye, a shallow anterior chamber, while her left eye
examination was normal. Her right pupil was mid-dilated and unreactive to light stimulus. Gonioscopy revealed a closed angle on her right
eye while it was wide open on the left side. A diagnosis of right ACC was made and 450 ml of intravenous mannitol 20% was administered
as indicated by the ophthalmologist in order to reduce IOP. Mirtazapine treatment was stopped and she was kept in short stay unit. Her
ophtalmic symptoms resolved dramatically after mannitol administration and her ophtalmic examination including IOP measurementfound 12 mmHg in both eyes- was normal one day after cessation of mirtazapine. Her fundus examination was normal and corrected visual
acuity was 10/10 in both eyes. Her ophtalmological examination remained unremarkable at one week and one month follow-up visits. To
our knowledge, this is the first report of unilateral AAC case following administration of mirtazapine add-on treatment This case emphasizes
the importance of close monitoring of individuals under antidepressant treatment particularly immidiately after initiation of the drug.
Keywords: glaucoma, mirtazapine, side-effects
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S376-S7
[Abstract:0203] Pharmacotherapies
Acute myopathy on single eye caused by aripirazole: a case report
Mehmet Gunes, Suleyman Demir, Mahmut Bulut, M. Cemal Kaya, Abdullah Atli, Aslıhan Okan Ibiloglu
Department of Psychiatry, Dicle University, Faculty of Medicine, Diyarbakir-Turkey
e-mail address: [email protected]
Objective: Aripirazole is a new atypical antipsychotic agent with partial agonist effect which is more reliable in terms of side effect profile.
Acute myopathy on single eye is a rare condition which generally appears due to the drugs. Therefore, we want to present in this report
a case of acute transient unilateral myopia related to the addition of Aripiprazole to the use of Fluoxetine.
Case: A 34-year-old female patient, a nurse, has been seen and treated in our clinic for two years with a diagnosis of obsessive-compulsive
disorder and major depression (DSM-5). The patient was taking Fluoxetine 80 mg/day, but the response to the treatment was insufficient,
hence Aripiprazole 10 mg/day was added. While the patient had previously not suffered from any visual disturbances, 3 days after the
addition of Aripiprazole vision defects set in. Due to blurred vision, when reading a book, words would slide above one another. Distance
vision became difficult. Because of the visual problems after Aripiprazole use, the patient interrupted the intake of the drug for two days
without consultation with the doctor. The visual problems receded but returned after restarting the use of Aripiprazole. For this reason,
the patient came to our clinic, where the required tests were administered. Neurological examination did not yield any pathological
results. An ophthalmological assessment was made, during which the patient’s visual acuity was found to be complete in the right eye,
20/40 in the left eye. A refraction test established myopia of -2.00 diopters in the left eye. As it was assumed that the visual disturbance
was connected with the use of Aripiprazole, the drug was withdrawn while Fluoxetine was continued. The patient’s visual complaints
improved 3-4 days after stopping the drug. She was again assessed ophthalmologically. Visual acuity on both sides was found to be
perfect. It is assumed that the addition of Aripiprazole to the use of Fluoxetine was the cause for the unilateral acute transient myopia
episode.
Conclusions: Therefore we have come to the opinion that the unilateral myopia linked to the addition of Aripiprazole to the use of
Fluoxetine emerged idiopathically. Therefore attention has to be given to the possibility that unilateral myopia can be observed among
visual complaints developing after starting on Aripiprazole or adding Aripiprazole to the use of Fluoxetine
Keywords: aripiprazole, myopathy on single eye triggered by drug, drug side effect
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[Abstract:0216] Pharmacotherapies
Mania induced by aripiprazole use: a case presentation
Demet Saglam Aykut, Ahmet Tiryaki, Evrim Ozkorumak
Department of Psychiatry, Karadeniz Technical University, Faculty of Medicine, Trabzon-Turkey
e-mail address: [email protected]
Number of researches concerning effectiveness of atypical antipsychotics in treatment of BAD is increasing. For the treatment of bipolar
depression, olanzapine quetiapine aripiprazole have been shown to be effective. However induction of manic and depressive episodes
during treatment with atypical antipsychotics has also been described as a risk. Aripiprazole has been approved by the FDA for the
maintenance treatment of BAD and also for the treatment of acute bipolar mania. Furthermore, the benefits of aripiprazole in the
treatment of bipolar depression augmentation treatment has been shown. Although the antidepressant effect of partial agonism at D2
and antagonism at 5HT2a of aripiprazole facilitating manic shift has been reported in the literature. In this report, a case who has shifted
to manic episode with 30 mg/day of the aripiprazole is discussed.
A 35-year-old female graduated from elementary school, lives with his family, came with her sister. She is followed with the diagnosis of
BAD-I for 12 years, taking paliperidone 9 mg/day and lithium 1200mg/day for the last 14 months. Past 2 weeks, she was feeling weakness,
fatigue, taking less pleasure in life, thinking that she is guilty, siner ad she was suspected about being spell on her. She was internalized
with the diagnosis of BAD- depressive episode with psychotic features Aripiprazole 30 mg/day was added to current treatment regime
Afterwards increase in behavior, inappropriate smilings, decreased need for sleep, accepting the doctors and health officers as being
‘God’ and herself as ‘the wife of God’ and as an angel from heaven, feeling of superiority were observed. The symptoms of mania were
considered to be induced by aripiprazole and dose was decreased to 10 mg/day. After the dose reduction, patient’s symptoms improved
in 2 weeks.
Aripiprazole was approved by the FDA for the treatment of acute bipolar mania and maintenance treatment in BAD Also the benefits of
aripiprazole has been shown in augmentation of bipolar depression. Although partial agonism of D2 and antagonism of 5HT2a effect
of aripiprazole causes the antidepressant effect may also may facilitate manic shift has been reported in the literature. So far, mania/
hypomania with aripiprazole was published in 5 reports, aripiprazole dose was between 5 to 15 mg/day. In our case, manic shift has
emerged with dose of 30 mg/dl unlike the literature reporting 5-15 mg\day. Although the studies reporting that high doses of aripiprazole
cause antimanic effect, there is still uncertainty about the optimal dose. In contrary to the literature mania was induced with high doses
of aripiprazole treatment. Disappearance of symptoms after dose reduction and shorter mania than the previous episodes may imply
dose dependent induction of mania with aripiprazole also it may be a part of the natural course of the disease. Fort the aim of clarifying
the role of aripiprazole in mood disorders and the evaluation of the appropriate dose range there is a need of controlled trials with large
samples in this area.
Keywords: aripiprazole, bipolar depression, manic attack
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S378
[Abstract:0237] Pharmacotherapies
Effect of olanzapine treatment on INR in a patient receiving warfarin therapy
Derya Arslan, Taha Can Tuman, Ugur Cakir, Osman Yildirim
Department of Psychiatry, Abant Izzet Baysal University, Faculty of Medicine, Bolu-Turkey
e-mail address: [email protected]
Olanzapine’s an atypical antipsychotic drug, commonly used in the management of psychotic symptoms in patients with schizophrenia
and bipolar affective disorder. There’re a number of reported side effects of olanzapine treatment such as weight-gain, sedation and
anti-muscarinic effects. Deep venous thrombosis (DVT) is a manifestation of venous thromboembolism (VTE). VTE’s associated with
immobility, malignancy, surgery and hypercoagulable states. It’s very well known that use of antipsychotic drugs increase the risk of
thrombosis in patients with schizophrenia. Many studies has reported the effects of olanzapine on thrombosis but there isn’t any report
about the effect of olanzapine on INR in the medical literature. In this paper, it has been aimed to report the effect of olanzapine treatment
on INR by a patient with schizophrenia and also family history of DVT who had referred our psychiatry clinic because there isn’t a rise on
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INR with anticoagulant treatment by warfarin while the olanzapine treatment goes on.
Follow-up for 20 years with a diagnosis of schizophrenia, 46 year-old male patient was started on olanzapine and olanzapine dose was
adjusted to 30 mg per a day before. The patient is vulnerable because he had a family history of DVT. The patient had a DVT episode
ten days later from the start of olanzapine treatment. Than cardiovascular surgeon was consulted but not informed about the patient’s
olanzapine treatment so it was continued at the same dose. The warfarin treatment was started 5mg per a day and fluid intake increased
by the cardiovascular surgeon’s advise. The patient’s INR value was found of 1,67 after a week. After two weeks INR value was detected
0,97. The patient had referred our psychiatry clinic because there isn’t a rise on INR with anticoagulant treatment by warfarin while the
olanzapine treatment goes on. Olanzapine treatment was stopped and amisulpride 400 mg per a day was started in our psychiatric ward.
After a week, INR level was found to be 3.69 (Therapeutic dose for DVT) and amisulpride treatment was continued at the same dose.
In the literature, in three patients who developed DVT with olanzapine treatment had risk factors of medical illness and senility. Another
case report, 27 year old male had a DVT episode with olanzapine overdose. Atypical antipsychotic drugs increase platelet aggregation
by 5-HT2A antagonism, sedation, obesity, lethargy, hyperprolactinemia such as long-term side effects of atypical antipsychotics play a
role in the pathogenesis of DVT. In our case report the patient had a family history of DVT, senility and lack of movement as risk factors
He had a DVT episode with a therapeutic dose of olanzapine (30 mg per day). INR level did not rise after started warfarin treatment.
When olanzapine switched with amisulpride INR level rapidly increased after a week. Finally, in patients started olanzapine treatment,
in the early stages we should be careful about DVT, even there’s no risk factor. Also in schizophrenia patients who developed DVT after
olanzapine treatment and patients with schizophrenia who had risk factors for DVT, as in our case, amisulpride may be a possible choice.
Keywords: DVT, INR, olanzapine
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S378-S9
[Abstract:0241] Pharmacotherapies
Chlorpromazine induced priapism: a case report
Demet Saglam Aykut1, Evrim Ozkorumak1, Ersagun Karaguzel2
1Department of Psychiatry, Karadeniz Technical University, Faculty of Medicine, Trabzon-Turkey
2Department of Urology, Karadeniz Technical University, Faculty of Medicine, Trabzon-Turkey
e-mail address: [email protected]
Priapism is an urologic emergency characterized by painful erection lasting 4-6 hours and irrelevant from libido and coitus. The mechanism
of priapism due to drug use is unknown but % 15- 26 of them related to antipsychotics. Besides; alpha blocker activity or central serotonin
like activity of psychotrops is considered to be responsible for priapism. Chlorpromazine is a conventional antipsychotic which has high
alpha1 antagonist activity and it has been used for it’s sedative effects. In chlorpromazine related priapism; dose of the drug or duration
of use could not be shown and cases were reported with different doses and duration of use in chlorpromazine. In this case; recurrent
priapism is associated with only one dose of intramuscular Chlorpromazine and by this case report the related literature was reviewed.
A 22-year-old man with the diagnosis of schizoaffective disorder for 8 years was hospitalized in the clinic because of abusive speech and
destructive behaviors for 2 weeks. He had stopped using his treatment for a month. In the mental state examination his self care was bad,
was irrelevant to the interview and was getting angry to the questions. His speech was loud and stuttering. Stuttering was increasing
with excitement and was having trouble with spelling the last syllable of the words. His affect and mood was elevated, irritable, angry
and nervous. His associations were loose and fast. There was grandiose and perspective delusions in the thought content. He was getting
angry very fast, he was restless and agitated. Physical examination, vital signs, complete blood count and biochemistry and urinary
examinations were within normal limits.
Chlorpromazine induced secondary priapism is the most commonly reported reason in the literature. The dose of chlorpromazine which
causes priapism is controversial but it is not considered as a dose depended complication.
Priapism is an urologic emergency and has to be examined and treated immediately. Using antipsychotics like chlorpromazine is related
with low but definite increased risk of priapism. Early diagnosis and appropriate treatment reduces the morbidity and may prevent the
permanent impotence. For this reason, patient’s medical story has to be taken carefully and also we should be alert to predisposing factors
like history of elongated erection, blood dyscrasia especially sickle cell anemia and warn the patients and families about it.
Keywords: chlorpromazine, erectile dysfunction, priapism
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[Abstract:0249] Pharmacotherapies
Olanzapine induced urinary incontinence
Taha Can Tuman, Ugur Cakir, Osman Yildirim
Department of Psychiatry, Abant Izzet Baysal Training and Research Hospital, Bolu-Turkey
e-mail address: [email protected]
Olanzapine is one of the atypical antipsychotics that commonly used. Olanzapine cause frequently metabolic side effects like
weight gain, hyperglycemia, an increase in blood lipid levels in patients. Olanzapine also often causes sedation but rarely cause
urinary incontinence. In this case presentation we reported a case of psychiatric patient who developing urinary incontinence
after started olanzapine. A 30-year-old woman was admitted the outpatient unit with complaints of insomnia, loss of appetite,
malaise, meaningless speeches, self talking, obsessions, disorganized behavior for two weeks. In her past psychiatric history she
used venlafaxine 75 mg per day for a diagnosis of adjustment disorder. Because of her daughters health problems she felt anxious
one year ago. We diagnosed atypical psychosis so venlafaxine stopped and olanzapine 10 mg per day started to the patient. After
starting olanzapine the patient had urinary incontinence three consecutive days. In her past medical history there was no urinary
incontinence and we consulted this problem with urology. They didn’t find any urologic problem will lead to urinary incontinence.
Her urinalysis was normal. She didn’t use any other medicine. The neurological examination did not reveal any thing about urinary
incontinence. And we thought that urinary incontinence may be due to olanzapine medication and we stopped olanzapine
and started aripiprazole to the patient. Urinary incontinence disappeared. The patient had 6 point with Naranjo Adverse Drug
Reaction Probability Scale. In the literature Sagar et al. reported a case of double incontinence following started of 20 mg per
day olanzapine. Vernon et al. treated the urinary incontinence with ephedrine which induced by olanzapine. Of M1 muscarinic
receptor blockade of olanzapine may cause urinary incontinence via urine overflow. The other mechanism is that adrenergic
receptor blockade cause decrease the bladders’ sphincter contraction resulting incontinence. Clinicians should be aware of this
rare side effect of olanzapine.
Keywords: incontinence, olanzapine, urinary
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S380
[Abstract:0258] Pharmacotherapies
Acute psychosis developed due to vitamin B12 deficiency: a case report
Yasemin Gorucu1, Hasan Mayda2, Halil Ibrahim Guzel3, Fatima Karakaya Colak4, Erman Bagcioglu1
1Department of Psychiatry, Faculty of Medicine, Afyon Kocatepe University, Afyon-Turkey
2Department of Psychiatry, Mardin Kiziltepe State Hospital, Mardin-Turkey
3Department of Psychiatry, Konya Aksehir State Hospital, Konya-Turkey
4Department of Neurology, Isparta State Hospital, Isparta-Turkey
e-mail address: [email protected]
Patients with vitamin B12 deficiency may apply with hematological, gastrointestinal, neurological, and psychiatric complaints. Clinical
picture of acute psychosis due to vitamin B12 deficiency is rarely encountered. Mood disorder, personality change, and dementia are
psychiatric conditions observed due to this vitamin D eficiency. The basic treatment in psychosis developed due to vitamin B12 deficiency
is replacement of deficient vitamin, which will rapidly recover psychotic symptoms. Its diagnosis and treatment are easy, so vitamin B12
level should be examined in all cases applying with psychiatric complaints.
In the present article, we aimed to present a 87-year-old male patient who was brought to neurology clinic with complaints of there
would be harmful behaviors to his relatives, auditory and visual hallucinations, and anxiety. Laboratory test revealed no abnormality
other than vitamin B12 deficiency. Dementia and delirium were ruled out in differential diagnosis. The patient had no previous
psychiatric disease history. He was hospitalized into psychiatry clinic, and vitamin B12 replacement was started with low dose
alprazolam for 2 weeks. The patient was successfully treated without using any antipsychotic, and was discharged. He attended
the control visits, and was observed well. Therefore, we would like to present this acute psychosis case which was developed due
to vitamin B deficiency.
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This case indicates importance of tests for underlying etiology and of ruling out organic causes in patients who apply to the psychosis
clinic for the first time.
Keywords: psychosis, vitamin B12 deficiency, treatment
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S380-S1
[Abstract:0275] Pharmacotherapies
A notable interaction between venlafaxine and diazepam: a case report
Pelin Dag, Kemal Yazici, Eda Aslan Uckardesler
Department of Psychiatry, Mersin University, Faculty of Medicine, Mersin-Turkey
e-mail address: [email protected]
We describe a patient who developed orthostatic hypotension related to combination of diazepam and venlafaxine. A literature search
revealed only three cases published to date.
A 48-year-old woman with a diagnosis of major depression was admitted to hospital because of suicidal thoughts. The patient was started
on venlafaxine 75 mg/day. Two weeks later, the dose of venlafaxine was increased to 150 mg/day and diazepam 30 mg/day was added to
relieve anxiety symptoms. Venlafaxine was titrated up to 300 mg/day while dose of diazepam was decreased gradually. At the 20th day of
treatment with venlafaxine 300 mg/day plus diazepam 10 mg/day, she started experiencing episodes of severe dizziness and blackouts
on getting up and even had a fall on one occasion. Although her blood pressure was 130/80 mm/Hg in the supine position, she showed
a significant postural drop to 90/50 mm/Hg. Diazepam was discontinued and she had no significant orthostatic hypotension symptoms
thereafter. Because she started to complain of uneasiness, tension and difficulty falling asleep 5 days after the cessation of diazepam, she
was restarted on low dose diazepam (2.5 mg/day). One week later, she suffered same hypotensive symptoms again. Eventually, diazepam
treatment was stopped and patient’s blood pressure improved.
Venlafaxine induced orthostatic hypotension is a rare event and usually occurs on early period of treatment. In our case, there was no
orthostatic hypotension with neither venlafaxine monotherapy nor in combination with diazepam as long as the dose of venlafaxine
stayed below 300 mg/day. Orthostatic hypotension developed when venlafaxine dose was increased to 300 mg/day in combination
with diazepam. Even a low dose of diazepam (2.5 mg/day) added to venlafaxine, caused significant orthostatic hypotension. Our case
and the three cases reported previously, suggest that combining venlafaxine and benzodiazepines may cause orthostatic hypotension
in some patients. Although the mechanism of interaction is not clear, this effect may arise from a drug-drug interaction or may be due
to raising of serum benzodiazepine levels by venlafaxine. Venlafaxine is metabolized in liver by cytochrome P450 enzymes (CYP). In
vitro studies reported that O-demethylation pathway of venlafaxine is mediated primarily by CYP isoenzyme 2D6 and N-demethylation
pathway is mediated by CYP isoenzyme 3A4. Further elimination of O-desmethyl-venlafaxine (ODV), the major metabolite of venlafaxine,
is dependent on CYP3A4. Diazepam is also metabolized by CYP3A4. Previous studies showed that venlafaxine only weakly inhibits the
activity of CYP1A2, CYP2C9, CYP2C19, CYP2D6 and CYP3A4. CYP2D6 deficiency that results in an increase in the ratio of venlafaxine to
ODV leads to the inhibition of CYP3A3/4. Inhibition of CYP3A3/4 leads to a significant increase in venlafaxine and ODV plasma levels which
may inhibit the metabolism of diazepam by CYP3A3/4.
In conclusion, the addition of benzodiazepines to venlafaxine may be associated with substantial risks, one of which may be falls
due to orthostatic hypotension. This may develop even with a low dose of benzodiazepines. Thus, when combining venlafaxine and
benzodiazepines, the clinicians should be aware of such hypotensive effects and also warn the patient about the risk of orthostatic
hypotension.
Keywords: CYP isoenzymes, hypotension, venlafaxine
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[Abstract:0289] Pharmacotherapies
Topiramate-induced stuttering: a case report
Sevgi Cicek, Recep Bostan, Veli Yildirim, Fevziye Toros
Department of Child and Adolescent Psychiatry, Mersin University, Mersin-Turkey
e-mail address: [email protected]
Topiramate is an antiepileptic drug with multiple mechanisms of action that has been shown to be effective in a number of
neuropsychiatric disorders. However, cognitive dysfunction is frequently observed in such cases, often representing a relevant challenge
in their management. Stuttering is understood as a disturbance in the normal fluency and pattern of speech, in which a person tends to
repeat sound and syllables or has sound prolongations and broken words. There are two types of stuttering: developmental and iatrogenic.
Iatrogenic stuttering has frequently been described as a drug side effect, more so in cases with developmental disorder or family history of
stuttering. There are few case reports which have implicated topiramate, phenothiazines, clozapine, olanzapine and risperidone as a cause
of stuttering. We describe here a child who developed topiramate-induced stuttering that resolved after discontinuation of topiramate.
A 14-year-girl applied to our clinic with the diagnosis of epilepsy and mental retardation. Her first generalized seizure appeared at the
age of 1 year. She had been maintained with 1000 mg/day sodium valproate and 1000 mg/day levetiracetam for seizure episode. She had
self-mutilation, so topiramate 1 mg/kg dose was started. Fifteen days after starting topiramate, her stuttering and speech problems was
developed. After that, topiramate was stopped gradually (over a 1-month period). As a result her stuttering and languages deterorations
improved.
The exact mechanism underlying stuttering is unknown. However, pharmacologic studies have implicated dopamine in the
pathophysiology of stuttering. In our case, the language deterioration was manifested by reduced expressive output, stuttering, wordfinding problems, grammatical and semantic problems and telegraphic speech treatment-emergent adverse effect that necessitated
stopping topiramate or reducing its dosage. Topiramate modulates neurotransmitters such as glutamate and dopamine, both of which
have been implicated in the evolution of speech-related disorders.
Keywords: antiepileptic, topiramate, stuttering
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S382
[Abstract:0294] Pharmacotherapies
Fulminant neuroleptic malignant syndrome induced by low doses of quetiapine in a patient with
possible dementia with lewy bodies: a rare case
Tuba Ozcan1, Nilay Tas2, Esra Yancar Demir3, Dogan Iscanli4, Ozlem Ozdemir5, Osman Bektas6, Arzu Altuncekic Yildirim7
1Department of Neurology, Ordu University, Faculty of Medicine, Ordu-Turkey
2Department of Anesthesiology and Reanimation, Ordu University, Faculty of Medicine, Ordu-Turkey
3Department of Psychiatry, Ordu University, Faculty of Medicine, Ordu-Turkey
4Department of Emergency Medicine, Ordu University, Faculty of Medicine, Ordu-Turkey
5Department of Internal Medicine, Ordu University, Faculty of Medicine, Ordu-Turkey
6Department of Cardiology, Ordu University, Faculty of Medicine, Ordu-Turkey
7Department of Infectious Diseases and Clinical Microbiology, Ordu University, Training and Research Hospital, Ordu-Turkey
e-mail address: [email protected]
Neuroleptic malignant syndrome (NMS), a rare but life-threatening idiosyncratic adverse reaction to antipsychotic medication. NMS is
commonly seen with typical antipsychotics, that also reported with atypical antipsychotic drugs.
A 81-year-old man was presented to emergency department of our hospital due to altered mental state. He had been taking quetiapine
for 3 days for management of aggressive behavior. Just after treatment with 50 mg/day quetiapine at the previous hospital, he developed
hyperthermia, altered mental status and akinetic-rigid parkinsonism, and he had been transferred to our hospital. He was diagnosed with
possible NMS based on history, altered mental state, rigidity, leukocytosis, hyperthermia, and increased blood level of CK. So, he was
admitted to the intensive care unit immediately.
This paper reports a rare fulminant NMS induced by low doses of quetiapine. The clinical manifestations and laboratory test results
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corresponded to the diagnostic criteria of NMS. It must be kept in mind that even low doses of atypic antipsychotic drugs such as
quetiapine can trigger NMS.
Keywords: atypical antipsychotic, neuroleptic malignant syndrome, quetiapine
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S382-S3
[Abstract:0342] Pharmacotherapies
Pharmacogenetics in Psychiatry: Neurobiology
Isil Gogcegoz Gul
Department of Psychiatry, Uskudar University, NPIstanbul Hospital, Istanbul-Turkey
e-mail address: [email protected]
Drug treatment of psychiatric disorders is troubled by severe adverse effects, low compliance and lack of efficacy in a lot of patients.
Pharmacogenetics, the science dedicated to the identification of genes influencing response to pharmacotherapy. Pharmacogenetics
holds some promise for improving the treatment of disorders by utilizing information about genetic polymorphisms to match patients
to the drug therapy that is the most effective with the fewest side effects. There are high expectations about the capabilities of
pharmacogenetics to tailor psychotropic treatment and “personalize” treatment. The activity of psychiatric drugs can also be influenced
by genetic alterations affecting the drug target molecule. Association studies investigating the relation between genetic polymorphisms
in metabolic enzymes and neurotransmitter receptors on psychiatric treatment outcome provide a step towards the individualization of
psychiatric treatment through enabling the selection of the most beneficial drug according to the individual’s genetic background. In this
presentation pharmacogenetic applications in psychiatry has been revised.
Keywords: psychiatry, psychopharmacology, pharmacogenetics
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S383
[Abstract:0343] Pharmacotherapies
Do pharmacogenetics methods work in resistant cases?
Gul Eryilmaz
Department of Psychiatry, Uskudar University, NPIstanbul Hospital, Istanbul-Turkey
e-mail address: [email protected]
While 35-45% of treated psychiatric patients respond to treatment, 30-50% do not respond or are exposed to severe side effects.
Pharmacokinetics is defined drug absorption, distribution, metabolism and excretion. Clinical pharmacokinetics is the relationship
between drug concentration at the site of action and the resulting effect, including the time course and intensity of therapeutic and
adverse effects. Pharmacokinetic genotyping and pharmacodynamic genotyping are the current analysis methods for personalizing
treatment. Pharmacokinetic genotyping analysis yields polymorphisms in the genes encoding the CYP enzymes that are responsible for
the metabolism of various drugs. In order to improve the efficacy and safety and to understand the disposition and clinical consequences
of drugs, two rapidly developing fields pharmacogenetics (focus is on single genes) and pharmacogenomics (focus is on many genes)
have undertaken studies on the genetic personalization of drug response. In a CYP2D6 genotyping study on Turkish psychiatric patients
poor metabolizer frequency has been reported as 1.45%, and ultra-rapid metabolizer 10.29 %. The sum of the frequency of poor and rapid
metabolizers in terms of CYP2D6 activity is about 12.7%. Hence, 12.7% of Turkish population is at risk for CYP2D6. Pharmacodynamic
genotyping yields polymorphisms in certain proteins such as carrier proteins, receptors etc. In slow metabolizers, side effects of drugs
occur more, while the drug ineffectiveness arises in fast metabolizers. In evaluation of CYP2D6 enzyme activity, genotyping, phenotyping
by prop medication and Therapeutic drug monitoring (TDM) are methods that are used.
Keywords: pharmacogenetic, pharmacokinetic, treatment resistant
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[Abstract:0344] Pharmacotherapies
Treatment difficulties in geriatric patients group: the importance of pharmacodynamic and
pharmacokinetic parameters
Isil Gogcegoz Gul, Gul Eryilmaz
Department of Psychiatry, Uskudar University, NPIstanbul Hospital, Istanbul-Turkey
e-mail address: [email protected]
Geriatric patients often suffer from co-morbidity and use of multiple drugs. Polypharmacy is a problem in geriatrics populations. This
may lead to an increase in drug-drug interactions and incidence of adverse events. Pharmacokinetic and pharmacodynamic changes
related to aging and age-associated disorders influence the choice and dosage of psychotropic drugs in the treatment of the elderly.
physiologic changes during aging, including hepatic or renal function changes, contribute to pharmacokinetic differences. Geriatric
patients vulnerable to pharmacokinetic and pharmacodynamic interactions with severe clinical consequences. Pharmacokinetic
genotyping analysis yields polymorphisms in the genes encoding the CYP2D6, CYP 2C9, CYP 2C19, CYP1A2 and CYP3A4 enzymes that
are responsible for the metabolism of various drugs. Pharmacodynamic genotyping yields polymorphisms in certain proteins such as
carrier proteins, receptors etc. On the other hand, therapeutic drug monitoring (TDM) will provide information on pharmacokinetics by
showing the drug plasma concentration. Genotyping is recommended, if a substrate that has quite different metabolism is being used, if
the drugs a have narrow therapeutic range (if it has the toxic effects due to genetic differences in metabolism), if the drug or metabolite
has an unusual plasma concentration and if genetic factors thought to be responsible, if there is a chronic disorder that needs a lifelong
treatment. Additionally, as the enzyme activity can be also affected by environmental factors in addition to genotyping factors, the most
effective method for current enzyme activity of the individual is phenotyping. The measurement of plasma level is justified only when
the information provided is of potential therapeutic benefit. The clinical value of plasma level monitoring depends on how precisely the
treatment outcome can be defined.
Keywords: geriatric patients, pharmacodynamic, pharmacokinetic
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S384
[Abstract:0346] Pharmacotherapies
Widespread ecchymosis associated with the use of fluoxetine: a case report
Hakan Karas1, Muzaffer Kaser2
1Department of Psychiatry, Sisli Kolan International Hospital, Istanbul-Turkey
2Department of psychiatry, University of Cambridge, London-England; Department of Psychiatry, Bahcesehir University, Istanbul-Turkey
e-mail address: [email protected]
Selective Serotonin Reuptake Inhibitors (SSRI) are known to have relatively a favorable side effect profile. Besides, in recent years especially
there has been an emphasis on the risk of upper gastrointestinal bleeding in patients taking SSRI antidepressants. Although they may
have some effects on coagulation profile, bleeding under the skin is known as a rare clinical manifestation of these effects.
We report a case of a 25-year-old female patient who was diagnosed with depressive disorder according to DSM-IV criteria and manifested
spontaneous widespread ecchymosis on her legs rapidly following fluoxetine use. Her complete blood cell count, prothrombin time,
partial thromboplastin time, bleeding time and other hematologic screening tests were within the normal limits. After discontinuation of
fluoxetine, her ecchymosis was resolved in two weeks.
Spontaneous ecchymosis is not a well-known side effect but can occur rarely during fluoxetine use. Clinicians should be vigilant about
the skin lesions while prescribing this drug.
Keywords: ecchymosis, fluoxetine, side effect
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[Abstract:0363] Pharmacotherapies
Valproate induced hiperammonemic encephalopathy and substance withdrawal: a case report
Taner Oznur1, Abdullah Bolu2, Suleyman Akarsu3, Ozge Demircan Tulaci1, Adem Balikci1
1Department of Psychiatry, Gulhane Military Medical Academy, Ankara-Turkey
2Aircrew’ s Health Research and Training Center, Eskisehir-Turkey
3Aksaz Naval Hospital, Mugla-Turkey
e-mail address: [email protected]
Psychotic disorder related to substance abuse is gradually increasing especially in young people. Variables such as premorbid
characteristics, kinds of substances used, concomitant diseases lead to occurrence of different clinical conditions. A patient with persistent
vomiting after using valproic acid and diagnosed as psychotic disorder related to due substance abuse is presented in this case report.
A 21-year-old male patient. He had a history of multiple substance abuse and received a treatment of substance addiction for two
times in a psychiatric clinic. Patient was hospitalized due to the behavior abnormalities (masturbation in the community, eating
garbage, kissing the walls). According to the anamnesis taken from his family, recently, he was using synthetic cannabinoids intensely.
Electroencephalography, brain tomography, complete blood count, routine biochemical tests were made in order to evaluate the
organic pathology. Test results were found to be within normal limits. Treatment of quetiapine 400 mg/day and valproate 500 mg/day
was started and edited as quetiapine 800 mg/day and valproate 1500 mg/day gradually within three days. Vomiting began on the fifth
day of the hospitalization. Direct abdominal radiogram, abdominal ultrasonography and routine biochemical tests were performed
and internal medicine consultation was requested. No abnormality was detected. When spontaneous vomitings were 3-4 units per day,
confusion began and behavioral pathologies were increased. Monitoring for the behavior of feeding garbage was increased and taken
under control. Vomiting continued on the seventh day of the hospitalization. Routine biochemical tests and blood valproate levels
were examined. Blood ammonia level was higher than the normal range. Blood level of valproate was 131.09 µg/mL. Valproate dosage
was edited as 1000 mg/day and frequency of vomiting was decreased. Valproate blood levels were 124.12 µg/mL on the tenth day of
hospitalization. Valproate treatment was terminated. Treatment of patient was continued as quetiapine 800 mg/day. He was delivered
to his family and discharged on the 24th day of hospitalization because of good drug compliance and improvement of the symptoms.
Valproate-induced hyperammonemiac encephalopathy is typically manifested by vomiting, impairment of consciousness and lethargy.
Sometimes, focal neurological signs are also added to the symptoms. Ammonium is eliminated by the urea cycle whose first rate-limiting
step is mediated by carbamylphosphate synthetase1 (CPS1). CPS1 take a part in the formation carbamoyl phosphate by the combination
of carbon dioxide and ammoniac. Also it is involved in the regulation of the urea synthesis rate. It is activated by N-acetylglutamate.
Propionyl Co-A and valproyl Co-A are formed by the mitochondrial oxidation of valproate. They inhibit N-acetylglutamate synthetase so
level of N-acetylglutamate level decreases. This leads to the inhibition of CPS1 resulting in decreased clearance of ammonia.
Keywords: ammonium, encephalopathy, valproate
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S385
[Abstract:0365] Pharmacotherapies
Tardive oculogyric crisis associated with risperidone long acting injection
Ikbal Inanli, Yusuf Emre Yilmaz, Ali Metehan Caliskan, Ibrahim Eren
Konya Training and Research Hospital, Konya-Turkey
e-mail address: [email protected]
Tardive oculogyric crisis is one of the extrapyramidal syndromes who chronically antipsychotic-treated patients and usually reported as a
subtype of tardive dystonia. Tardive dystonia occurs in about 3% of patients during long-term antipsychotic treatment. Tardive oculogyric
crisis is rarer than tardive dystonia and characterized by spasmodic deviation of eyes mostly up-wards. Additionally, they would define
restlessness, agitation and malaise.
A 56-year-old, female living with her family. She was met the DSM-IV criteria for paranoid schizophrenia. The persecutory delusion had
been begun since his age 26. Risperidone long action injection was begun at 37.5 mg/2 week. It was effective in controlling her psychosis
and remained her exclusive antipsychotic treatment for one years. After that, she began to develop reverSIBle and repeater oculogyric
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crisis, had reported feelings of anxiety and restlessness during crisis. She was diagnosed tardive oculogyric crisis. There was no familial
history of movement disorder. A thorough neurological examination and brain imaging revealed no other abnormalities. Risperidone
dosage had been reduced and the frequency and duration of the dystonic symptoms decreased.
Tardive oculogyric crisis is side-effect of long-term antipsychotic treatment and can easily be overlooked. Most reports of tardive dystonia
have been originated in cases with typical antipsychotics as well as with atypical antipsychotics. To our knowledge, this is the first in the
literature.
Keywords: tardive oculogyric crisis, risperidone, dystonia
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S385-S6
[Abstract:0366] Pharmacotherapies
Amnesia after sildenafil use
Fatih Kayhan
Department of Psychiatry, Mevlana University, Faculty of Medicine, Konya-Turkey
e-mail address: [email protected]
Amnesia may result from medical conditions such as trauma, anoxia, hypoxia. In addition, amnesia may occur upon using some drugs. The
current case report represents a 62-year-old male patient developing amnesia due to the sildenafil use. He was admitted to the psychiatry
clinic with the help of his relatives with complaints such as confusion and inability to perceive what was happening around. He had been
already admitted to neurology clinics on the first day that these complaints started. Some laboratory tests were performed in order to
assess the whole blood count, serum biochemistry, TSH hormone and vitamin B12. There was no abnormality in laboratory tests. Brain
magnetic resonance imaging (MRI), diffusion MRI and electroencephalogram were also performed. There were also no any abnormalities
in brain imaging. He did not have a complaint regarding the mental and psychological aspects earlier and he did not use psychotropic
agents before. Lately, he did not have a psychological problem or traumatic situation as well as he did not complain about perception or
comprehension problems till he used sildenafil. He did not have a history of illness and use any drug continuously in his life. He had used
sildenafil 100 mg one day before the complaints started. According to the mental state examination, he showed the decreased self-care,
scattered attention and he was responding to questions with short sentences consisting of a few words. There was no delusion and his
thoughts were mixed as well as he was confused. Affectivity was apathetic. As a result of his mental state examination, global amnesia
was diagnosed according to DSM-IV diagnosis criteria and it has been understood that it was developed secondary to sildenafil use. He
was followed up without prescribing any drug. Improvement in the symptoms was partially observed in the first month of the followup. The affective apathy was improved whereas he still had distractibility in the second month of the follow-up. It should be noted that
sildenafil can lead to alterations in cerebral blood stream, transient ischemic attacks and stroke since it can cause the expansions of the
cerebral vessels except corpus cavernosum, even in individuals without a history of illness. Especially as it is in our case, sildenafil use can
cause amnesia, even though there is no history of illness. Clinicians should consider that sildenafil can lead to alterations in the vascular
structure, even there is no disease due to this deterioration. It should be kept in mind that advanced age can be the risk factor for sildenafil
treatment. There should be more comprehensive studies that can examine the effects of sildenafil on cerebrovascular system.
Keywords: amnesia, sildenafil, adverse effect
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[Abstract:0367] Pharmacotherapies
Metoclopramide induced akathisia of five cases
Murat Eren Ozen1, Mehmet Mustafa Ozkose2
1Department of Psychiatry, Adana Private Hospital, Adana-Turkey
2Department of Psychiatry, Hendek State Hospital, Sakarya-Turkey
e-mail address: [email protected]
Metoclopramide (MET), procaine derivative, dopamine-2 receptor antagonist, an antiemetic, is associated with psychomotor adverse
effects, including akathisia. Recognition of drug-induced akathisia (DİA) is based on the clinical basis and experience, no laboratory test
exists. Case series reports their admission, diagnosis and management.
1: After psychiatric admission, Paroxetine use caused nausea, need to use MET, induced akathisia, treated with Biperidene.
2: Referred from Urology, Urinary tract infection leading nausea made use MET, caused akathisia,
treated with Propranolol.
3: Referred from gastroenterology, treatment resistant reflux-gastritis made use MET, caused
akathisia, treated with Diazepam.
4: Referred from Internal Medicine for vertigo and nausea, after MET use caused akathisia, treated with iv Diphenhydramine in emergency
service.
5: Referred from Internal Medicine for loss appetite, treatment resistant nausea led to use MET, caused akathisia, treated with IV
diphenhydramine. DIA is often difficult to diagnose, may present varying grades of severity. Defined as a psychoneuromotor phenomenon
in which the patient may describe an unpleasant feeling of inner restlessness most commonly to the lower limbs, with a desire to walk and
a feeling of anxiety. Most common offending agents are neuroleptic anti-psychotic medication or withdrawal from any physical addiction,
e.g. benzodiazepine withdrawal syndrome.
The objective motor components include restlessness of the lower limbs in the form of rocking foot to foot, crossing and uncrossing
of legs, and pacing. Positron Emission Topography studies show D2 receptor occupancy in the striatum plays a role and noradrenergic
and serotonergic systems also appear to be involved. Interestingly, metoclopramide acts, in part, via presynaptic dopamine receptor
antagonism, and an overactive adrenergic system secondary to presynaptic dopamine receptor block in key parts of the brain and
spinal cord may be the possible mechanism of DIA. Metoclopramide has been linked to akathisia in many reports and the incidence of
restlessness reported after IV administration of drug is 20–25%. The diagnosis of DIA is largely clinical. There are no relevant laboratory
tests in making the diagnosis. After diagnosis, the offending drug should be promptly withdrawn. Benzodiazepines, β-blockers,
α2-agonists, opioids, and anti-cholinergics have all been used to treat akathisia. Benzodiazepines are more effective, but associated with
higher sedation rates.
Keywords: akathisia, drug induced, metoclopramide
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S387
[Abstract:0376] Pharmacotherapies
A case report of Kleine Levin syndrome: followed with escitalopram for 4 years
Mehmet Akif Camkurt1, Mahmut Sami Metin1
1Afsin State Hospital, Kahramanmaras-Turkey
e-mail address: [email protected]
Kleine Levin syndrome is rare syndrome represents with episodes of hypersomnia, hyperphagia and disinhibition. It is more common
in males. Dysregulation in hypothalamus is known to be related with Kleine Levin syndrome. During episodes patients experience
irritability, depression, euphoria, loss of concentration, apathy and lethargy. Between episodes patients are normal. Physical examination
and laboratory results are usually normal. In this case report we spotted Kleine Levin syndrome in a patient who came to our clinic for
repetition of prescription. Clinicians should evaluate every patient carefully whether they admitted for repetition of prescription.
A 23-year-old male patient, high school graduate, single, unemployed. He admitted to our clinic for prescription of escitalopram he is
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taking for depression. During psychiatric interview patient said he is experiencing episodes of hypersomnia (19 hours), eating 5-6 times
per day (between episodes he eats 3 times per day), increased sexual desire and increased numbers of masturbation. Between episodes
patient feels a little bit depressed. He didn’t experienced any psychotic symptom like hallucination, delusion, disorganized behavior or
thought. In 4 years patient experienced 8 attacks. Attacks lasted for 2 weeks. During attacks he was sleeping in most of the day, he was
waking up to eat and to go to lavatory. Patient has been followed up for 4 years with escitalopram 10 mg treatment. Between attacks
his functionality was normal. Cranial CT and MR, EEG results were normal. Patient referred to a neurologist and internist. They didn’t find
any pathology related with these symptoms. Patient and his parents didn’t define previous manic or hypomanic episode. As a result of
psychiatric interview and medical examination patient diagnosed as Kleine Levin syndrome. We stopped escitalopram treatment and
started valproic acid 1000 mg per day treatment. During psychiatric evaluation patient were stable so we didn’t started any stimulant.
Kleine Levin syndrome should be differentiated from depression, bipolar disorder and schizophrenia. In our case, patient experienced
short term depressed episodes and inter-episodic wellness accepted as drug response, because of this escitalopram treatment continued
for 4 years. Also increased sexual desire should be differentiated from bipolar manic episode. Patients should be evaluated carefully and
differential diagnosis should be done conscientiously. This syndrome rarely diagnosed at first episode. Patients should be followed up
carefully. During episodes psychostimulants are used. Between episodes, mood stabilizers like lithium, valproic acid and carbamazepine
could be beneficial. We started valproic acid in our case. Clinicians should be aware of patients who admit for prescription repetition,
psychiatric evaluation and interview must be done with all patients to reveal misdiagnosed psychiatric pathologies.
Keywords: kleine levin syndrome, escitalopram, misdiagnosis
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S387-S8
[Abstract:0377] Pharmacotherapies
Two case reports of physical and psychological hot chili addiction
Mehmet Akif Camkurt1, Mahmut Sami Metin2
1Department of Psychiatry, Afsin State Hospital, Kahramanmaras-Turkey
2Department of Dermatology, Afsin State Hospital, Kahramanmaras-Turkey
e-mail address: [email protected]
Hot chili originates from Americas, its’ use is known to be starting from B.C. 7000s. It is a part of traditional diet in countries like Africa,
China, İndia and Korea. Inappropriate usage of hot chili is so common in society for weight loss. Additionally, capsaicin stimulates
endogenous opioid and cannabinoid receptors and creates feeling of pleasure. In this regard, because of mentioned pathways above we
think that hot chili has the potential for addiction and abuse. We aimed to demonstrate this rare and interesting type of addiction with
two case reports who are related to each other.
A 49-year-old, male, high school graduate, married, public servant patient. Patient stated that he consumes hot chili since he was 6 year-old,
first times he was consuming about 100-200 grmas of hot chili but now he eats 500 grams of hot chili per day. He is eating hot chili every
day starting from breakfast and he always take hot chili with himself when he takes the road. He always eats hot chili with meals and he
consumes hot chili as snacs. He keeps hot chili at work, in the car and at his home. He asks his friends to bring hot chili and hot sausages who
goes to abroad. He travels to Sanliurfa to buy hot chili from there. He demonstrates physical effects of hot chili like nasal flow, rubor, mouth
burn,constipations and relux lighter than usual people. He enjosy comsuming hot chili and when he doesn’t eat hot chili he demostrates
seeking behaviour and withdrawal symptoms.we didn’ recomend any medication for this situation. We recommenden patient to stop
consuming hot chili. During his evaluation in policlinic he refused our suggestion. 1 month later at control examination he stated that he
stopped consuming hot chili for two days and after that he started sweating, felt depressed, experienced anhedonia and tremor
According to our knowledge it is the first case report for hot chili addiction. It is important to keep in mind that hot chili contains capsaicin
which has the potential to stimulate cannabinoid and opioid receptors. Consuming hot chili is accepted as a normal behavior in society.
This acceptance may cause hot chili addiction getting unnoticed by both clinicians and society. Future studies focusing on capsaicin could
help us to understand new possible pathways for opioid and cannabis addiction
27 year-old male, high school graduate, married, laborer. Patient admitted with recommendations of his relatives. He consumes hot chili
starting from childhood. Amount of chili he consumed increased by years. He brings himself extra hot chili and sausages from abroad,
Hatay and Sanliurfa. When he wakes up he eats hot chili first. His relatives warn him to decrease consumption of hot chili but he doesn’t
care. He admitted to dermatology clinic for acne. He was told to stop comsuming chili but he still keeps comsuming although he has
medical problems. When he doesn’t eat hot chili for 1-2 days he feels depressed and experienced anhedonia and unwillingness. He always
asks for hot chili wherever he goes. The longest period he didn’t concume hot chili was two days. Patient refused to decrease amount of
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hot chili he comsumed per day. We didn’t find any additional medical or psychiatric condition.
We performed database search with keywords “hot pepper addiction”, “hot chili addiction”, “case report”, and we didn’t find any result
relevant. Our case report is important because it is the first case report of hot chili addiction with our other poster. Feeling of pleasure
after eating hot chili is known to be caused by capsaicin. Capsaicin relieves morphine withdrawal symptoms, stimulates vanilloid and
cannabinoid receptors. This acting mechanism of capsaicin could be related with addiction. Being a part of daily meals and socio-cultural
acceptance of consuming hot chili increases risk for development of addiction. We believe focusing on acting mechanisms of capsaicin
could yield for possible new pharmacotherapies and increase our understandings of addiction.
Keywords: hot chili, addiction, abuse
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S388-S9
[Abstract:0379] Pharmacotherapies
Spontaneous ejaculation; caused by venlafaxine, reverted by mirtazapine
Mehmet Akif Camkurt
Afsin State Hospital, Kahramanmaras-Turkey
e-mail address: [email protected]
Antidepressants cause sexual side effects frequently. It could be overlooked by factors arising from clinicians and patients. Most frequent
side effects are loss in sexual desire and arousal, delayed ejaculation. Spontaneous ejaculation is a rare side effect, reported previously
by noradrenergic drugs like reboxetine. Spontaneous ejaculation usually occurs without sexual arousal and could follow micturition and
defecation. Spontaneous ejaculation happens without orgasm. We aimed to present a case report of spontaneous ejaculation caused by
venlafaxine reverted by mirtazapine.
A 29-year-old male, complaining of headache and neck ache, spasm in shoulders, feeling anxious and worried about all fields of life.
When he admitted to our clinic he was on a venlafaxine 75 mg/d treatment. Patient stated that he was feeling well with venlafaxine, his
symptoms were gone, but he was experiencing loss of sexual desire and spontaneous ejaculation following micturition and defecation.
We started mirtazapine 30 mg/d, at the visit 2 weeks after starting mirtazapine patient stated frequency of spontaneous ejaculation
decreased apparently. At the visit after 6 weeks, spontaneous ejaculation ended up and loss of sexual desire relieved.
Exact mechanism of spontaneous ejaculation is still unknown. It is a complicated process including monoamines like serotonin,
noradrenaline anatomical structures like brain and spine. In our case venlafaxine caused a rare side effect, spontaneous ejaculation
and mirtazapine solved this situation. In the light of this case report we recommend clinicians to be more aware of side effects caused
by antidepressant, also to ask sexual side effects to every patient. New case reports implying use of mirtazapine to treat spontaneous
ejaculation could help patients who benefits from antidepressants but experiences this side effect.
Keywords: mirtazapine, spontaneous ejaculation, venlafaxine
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S389
[Abstract:0387] Pharmacotherapies
Hypomania soon after agomelatine adjunctive therapy
Elif Nurgul Sungur, Ayse Nur Inci Kenar
Department of Psychiatry, Pamukkale University, Denizli-Turkey
e-mail address: [email protected]
Agomelatine has an antidepressant effect by stimulating melatonin 1 (MT1), melatonin 2 (MT2) receptors and blocking 5HT2c receptors
in the central nervous system. Hypomanic or manic episodes have been reported to be induced by multiple classes of antidepressant
agents, but there are only a few case report about agomelatine- induced hypomania or mania in literature. Here; we report a case who
presented hypomanic symptoms after addition of agomelatine to treatment.
A 44-year-old female patient. Her main symptoms included depressed mood, irritability, head shaking and mouth slipping, insomnia,
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loss of interest, timidity, shyness for about 15 months. She had no diagnosed psychiatric and major systemic diseases and there is no
history of bipolarity in her family. She was diagnosed major depression, social phobia and tic disorder according to DSM-IV criteria,
and the treatment has been arranged as fluoxetine 20 mg/ day, risperidone 0.5 mg/ day, trazadone 50 mg/ day and aripiprazole 5 mg/
day. After a while dosage of fluoxetine was increased from 20 mg/ day to 40 mg/ day and aripiprazole from 5 mg/ day to 10 mg/day,
risperidone and trazadone was stopped. By the time tic symptoms were regressed, depressive symptoms were partially regressed, social
phobia symptoms persisted. On the 8. month of the treatment, her anxiety symptoms appeared and we added escitalopram 10 mg/
day to treatment. On the 9. month of the treatment, escitalopram dosage was increased to 15 mg/day. Finally, her anxiety symptoms
regressed but her depressive symptoms resisted, thus agomelatine 25 mg/day was added to her treatment. One week later, the patient
reported hypomanic symptoms such as distractibility, more talkative than usual, flighting of ideas, racing thoughts, euphoria, Social
phobia symptoms regressed significantly.
Hence, the temporal relation between the appearance of the hypomania symptoms and agomelatine use supported the diagnosis of
agomelatine- induced hypomania diagnosis. Developing hypomanic symptoms was found a remarkable while using aripiprazole 15
mg/g. Agomelatine combines 5HT2C antagonism with melatonin 1 (MT1) and melatonin 2 (MT2) agonism, thus striking potentiation of
dopamine and norepinephrine release occurs in the prefrontal cortex. It has been thought that increased dopamine transmission can play
one important role in the pathophysiology of mania. Increased dopamine transmission caused by agomelatine may particularly explain
the hypomania symptoms in this patient. In conclusion, physicians should be attentive about the possible appearance of hypomania or
mania when using agomelatine, as using other antidepressants.
Keywords: agomelatine, hypomania, antidepressant
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S389-S90
[Abstract:0390] Pharmacotherapies
Understanding the metabolic side effects of antipsychotic drug treatment
Gavin P. Reynolds
BMRC, Sheffield Hallam University, Sheffield-UK
e-mail address: [email protected]
The past two decades have seen an increasing awareness of the association between metabolic disturbances and severe mental illness. These
metabolic disturbances may manifest as obesity and metabolic syndrome, resulting in a greater incidence of diabetes and cardiovascular
disease, the latter being a major contributor to reduced life expectancy in schizophrenia. There is evidence that psychiatric disease itself
can predispose to metabolic syndrome through a variety of mechanisms that may include inflammatory processes, stress, poor diet and
sedentary lifestyle. However, a major contributory factor is that of treatment with the antipsychotic drugs. Many, but not all, of these
drugs increase body weight, and two, olanzapine and clozapine, can induce particularly profound weight gain. Type 2 diabetes may be a
consequence of the development of metabolic syndrome, while there are other pathogenic factors contributing to diabetes, including a
rapid-onset antipsychotic-induced disorder that may result in ketoacidosis, as well as a genetic relationship with schizophrenia.
Exercise and dietary advice have been shown to ameliorate drug-induced weight gain, although their effects are eventually lost if the
regime is discontinued. There are also some pharmaceutical approaches to the avoidance or treatment of antipsychotic weight gain.
Switching to a less problematic antipsychotic, or adding aripiprazole, can be valuable. A variety of other drugs as protective or weight loss
agents have been tested, with the strongest evidence being for adjunctive use of metformin.
The underlying receptor mechanisms are not fully understood and may vary between drugs, but are likely to include 5-HT2C receptor
antagonism which may interfere with hypothalamic signaling mechanisms of hormones, such as leptin, important in the control of body
weight. Other possible pharmacological mechanisms include antagonism at histamine H1 and dopamine D2 receptors. Acetylcholine M3
receptor blockade may also contribute, particularly to the development of diabetes. Some of the drugs with little effect on body weight
may have pharmacological actions that offer protection against weight gain.
Interestingly there is large individual variation in antipsychotic drug-induced weight gain. This is beginning to be understood as
associated with variability in several genes involved in the hypothalamic control of food intake, including the gene for the 5-HT2C
receptor. Thus genetics may soon contribute to a predictive test for drug-induced weight gain, a first step towards personalized medicine
in these vulnerable patients.
Keywords: antipsychotic drugs, weight, metabolic syndrome
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[Abstract:0393] Pharmacotherapies
Menorrhagia probably associated with sertraline: a case report
Havva Sert, Kadir Demirci, Abdullah Akpinar, Arif Demirdas
Department of Psychiatry, Suleyman Demirel University, Faculty of Medicine, Isparta-Turkey
e-mail address: [email protected]
Antidepressant drugs may lead to bleeding abnormalities. There are case reports describing patients with various bleeding problems (e.g.
purpura, hematuria, ecchymosis, epistaxis, gastrointestinal, or vaginal bleeding) associated with selective serotonin reuptake inhibitors
(SSRI) treatment. Menorrhagia is defined as excessive or prolonged uterine bleeding that exceeds 80 mL of blood loss per menstruation
and lasting more than seven days. We here report a case, presenting with menorrhagia after using sertraline treatment.
A 35-year-old female presented with complaints of demoralization, decreased appetite, reluctance, weakness, insomnia, and fatigue. She
had no previously documented psychiatric history and family history. The physical and neurological examination were normal. A complete
blood count, serum electrolyte, vitamin B12, folic acid, kidney, liver, and thyroid function tests were normal. Hamilton depression scale
score was 20. The patient was diagnosed as a major depressive disorder according to DSM-IV. She was prescribed sertraline 50 mg/day
for depression treatment. Depressive symptoms improved within the next two months. But she reported menorrhagia, continuing for 15
days in the last 2 menstrual cycles. She had no personal or family history of a bleeding disorder, trauma, or self-injurious behavior. The
patient did not take any other medication except sertraline. She had previously a regular menstrual period lasting 7 days. She was referred
to hematology and gynecology. Her genital ultrasound was normal. Repeated laboratory tests including a complete blood cell count, liver
function tests, total iron binding capacity, serum ferritin, erythrocyte sedimentation rate, glucose, and serum coagulation panel assay;
bleeding time, prothrombin time (PT), partial PT, activated partial PT, international normalized ration, clotting time, and fibrinogen level
were normal. As a result of these investigations we concluded that the menorrhagia was associated with sertraline and the patient’s
sertraline was discontinued. Two days after stopping the sertraline the menorrhagia diminished. According to Naranjo causality scale
(the scale was 7) the adverse effect was probably caused by sertraline. Later, he was prescribed duloxetine 30 mg/day for depression
treatment. The one- and three- month follow ups indicated that the patients maintained well on duloxetine, there were no menorrhagia
and depression.
Menorrhagia is attributed to the use of sertraline in our patient, after excluding other etiologies of bleeding. SSRIs are thought to cause a
decrease of serotonin levels in platelets, which causes impaired platelet aggregation and bleeding abnormalities. Drug-induced immune
thrombocytopenia, inhibition of nitric oxide synthase, and blockade of calcium activation are also the mechanisms being attributed to
SSRI-related bleeding diathesis. Consequently, this case demonstrates that the use of sertraline may rarely lead to menorrhagia.
Keywords: menorrhagia, sertraline, bleeding
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S391
[Abstract:0419] Pharmacotherapies
Acute urinary retention following a single dose of duloxetine: a case report
Ozgun Karaer Karapicak
Department of Psychiatry, Baskent University, Faculty of Medicine, Ankara-Turkey
e-mail address: [email protected]
Duloxetine, a dual acting potent serotonin-norepinephrine reuptake inhibitor, may cause urinary retention as a rare side effect. The
foregoing is a case report about a patient who experienced acute urinary retention after one single use of 60 mg duloxetine.
A 49-year-old female patient presented to Psychiatry Department of Baskent University Hospital with hopelessness, anxiousness,
anhedonia, inability to complete daily chores and loss of appetite. She was given fluoxetine during her first depressive episode that
occurred 15 years ago after a stressful life event and other antidepressants such as citalopram, sertraline, trazodone, venlafaxine and
clomipramine during following depressive episodes for optimum dose and duration. She was antidepressant free for seven months as
she presented to our clinic. Her medical history was positive only for hyperlipidemia and she had been using atorvastatin 10 mg per
day for three years. The patient was put on duloxetine 60 mg/day considering its safe interaction profile with atorvastatine and prior
antidepressant treatments during the past depression episodes. She reported that she was unable to urinate with a disturbing sense of
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Case Report Abstracts
full bladder four hours after taking the first dose of duloxetine and thereupon took one of her acetazolamide tablets (250 mg) in order
to urinate that she was using for her Meniere’s disease. Four or five hours later she voided a few drops of urine by straining and applying
suprapubic pressure and following morning her urination was back to normal. She presented to an emergency service that day and
performed urine test, total blood count, renal function test revealed no pathology. Due to absence of an underlying organic pathology,
duloxetine was thought to be responsible for urinary retention responsible for urinary retention of patient and medication was switched
from duloxetine to escitalopram. At follow-ups no side effects other than mild mouth drying was reported.
Urinary retention, a potential side effect of SSRI and SNRI antidepressants, is uncommon. Several urinary retention cases were reported
with use of sertraline, escitalopram, mirtazapine and milnacipran. An urinary retention case with use of paliperidone, an antipsychotic,
was also reported. Combination of antidepressants and antipsychotics may also lead to urinary retention by controlling voiding with their
effects on central serotonergic and dopaminergic pathways. To our knowledge this is the first reported case of urinary retention with only
or single dose of duloxetine use. In literature a patient who was taking olanzapine was reported to develop urinary retention one week
after duloxetine 60 mg/day was added to pharmacotherapy regimen to treat post-psychotic depression and resolved one week after
cessation of duloxetine. Patients have to be informed by clinicians about possible side effects of duloxetine and other antidepressants
including urinary retention. Also it is important for clinicians to consider this painful and disturbing condition while prescribing duloxetine
to patients having underlying obstructive urinary conditions.
Keywords: acute urinary retention, duloxetine, single dose use
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[Abstract:0431] Pharmacotherapies
Treatment of attention deficit and hyperactivity disorder in visually impaired children: case series
Mustafa Yasin Irmak, Nagehan Ucok Demir, Duygu Murat, Gulseda Ayranci, Ayse Rodopman Arman
Departman of Child and Adolescent Psychiatry, Marmara University, Faculty of Medicine, Istanbul-Turkey
e-mail address: [email protected]
Attention-deficit/hyperactivity disorder (ADHD) is an early occuring neurodevelopmental disorder that persists into teenage period.
Problems of focusing and maintaining attention can also be seen in the visually impaired children. There is no information concerning the
association of visual impairment and treatment of attention deficit and hyperactivity disorder in the literature. Methylphenidate (MPH) is
the most common drug treatment of ADHD in childhood.
A 8-year and 9-month-old boy which is visually impaired (congenital) admitted to the Childhood Psychiatry Outpatient Clinics of Marmara
Medical School with the complaints of school failure, inability to concentrate, rocking and bed-wetting. An 8 years, 9 months old female
case who is visually impaired (congenital) was referred to the clinic with the symptoms of hyperactivity and behavioral problems was
also taken into psychiatric evaluation. Both cases were clinically evaluated based on DSM–IV and they were diagnosed as ADHD. A
dramatic improvement in the symptoms of school failure, difficulty in concentrating and rocking has been observed in cases treated with
methylphenidate.
In this article, informing the clinicians on not to overlook of attention problems in visually impaired cases and proper treatment of these
cases are aimed.
Keywords: attention deficit and hyperactivity disorder, metylphenidate, visual impaired children
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[Abstract:0436] Pharmacotherapies
Decreased prolactin levels in two weeks after adding aripiprazole to the treatment in an antipsychotic
induced hyperprolactinemia: a case report
Ayse Nur Inci Kenar, Burcu Albuz, Didem Tezcan
Department of Psychiatry, Pamukkale University, Faculty of Medicine, Denizli-Turkey
e-mail address: [email protected]
Aripiprazole is a partial agonist of presynaptic and postsynaptic dopamine D2 receptors and has a strong affinity for D3 receptors and
moderate affinity for D4 receptors. It also acts as a partial agonist of serotonin 5HT-1A and 5HT-2C receptors, and an antagonist of 5HT2A receptors. Because of the receptor binding profile of aripiprazole, it does not affect serum prolactin levels and it may even stabilize
these levels. In this case report, we present a female patient, using risperidone long-acting injection for psychosis, who developed
hyperprolactinemia after adding aripiprazole to the treatment and thereafter, high prolactin levels decreased in two weeks. A 45-yearold female was diagnosed with “psychotic disorder” ten years ago. She was referred to many psychiatry clinics, but has used medications
with short periods and irregularly. In the psychiatric examination; defensive attitude, reduction in self-care, reference and persecution
delusions were noted and risperidone long-acting injection 37.5 mg every 15 days intramuscular and risperidone 3 mg/day per oral was
started as a treatment. After 15 days, in outpatient control, impairment of gradual muscle adjustment during wrist circumduction was
detected and Biperidene 2 mg/day was added to the treatment. Her complaints were decreased, psychotic symptoms disappeared and
her functionality increased. By the three weeks of the treatment, oral risperidone was discontinued. On the 45th day of the treatment, we
detected that prolactin level was 115.7 ng/ml (normal range 4.04-15.2 ng/ml) in laboratory tests. Increased level of serum prolactin was
thought to be related to the antipsychotic drug (risperidone) by the endocrinology clinic. Twenty days after the first test of the prolactin
levels, we repeated the test, and in the second test, her prolactin level was increased to 141.9 ng/ml. Aripiprazole 5 mg/day was added
to the treatment. By 15th day of the aripiprazole addition to the treatment, prolactin levels decreased to 57.5 ng/ml. Aripiprazole is
known as a dopamine stabilizing agent. It has D2 receptor agonist and 5HT2A receptor antagonist activity. Although there are a few case
reports of hyperprolactinemia with aripiprazole, based on these properties, it is reported that aripiprazole does not increase prolactin
levels and may even decrease high prolactin levels associated with the use of other antipsychotics. The addition of a fixed dose of daily 5
mg of aripiprazole to hyperprolactinemia induced by risperidone long-acting injectable (RLAI) treatment in patients results in decreased
prolactin levels. But, the decrease of prolactin levels is usually seen at least six weeks after aripiprazole addition to the treatment. In
the present case, although prolactin levels were very high, a marked decrease in prolactin levels was seen after 15 days from addition
of aripiprazole to the treatment. Adjunctive aripiprazole is both safe and effective as a reasonable choice treatment for patients with
antipsychotic-induced hyperprolactinemia. The appropriate dose of adjunctive aripiprazole may be 5 mg/day. Finally, even though
prolactin levels are very high, before changing the present medication that the patients benefit, it can be thought as a good option to
add aripiprazole to the treatment.
Keywords: aripiprazole, hyperprolactinemia, antipsychotic
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[Abstract:0442] Pharmacotherapies
Rapid-onset hyponatremia induced by duloxetine in an elderly patient
Seden Demirci1, Kadir Demirci2, Atilla Altuntas3, Ali Soylemez1, Suleyman Kutluhan1
1Department of Neurology, Suleyman Demirel University, Faculty of Medicine, Isparta-Turkey
2Department of Psychiatry, Suleyman Demirel University, Faculty of Medicine, Isparta-Turkey
3Department of Internal Medicine, Division of Nephrology, Suleyman Demirel University, Faculty of Medicine, Isparta-Turkey
E-mail address: [email protected]
Duloxetine is a balanced serotonin and noradrenaline re-uptake inhibitor which is known to be effective in major depressive disorder
and diabetic neuropathic pain. The most common adverse effects with duloxetine are nausea, dry mouth, fatigue, dizziness, somnolence,
anorexia, constipation, and hyperhidrosis. Hyponatremia induced by duloxetine has been reported in rare cases. Here, we report a 75
year-old male who developed rapid-onset and severe hyponatremia after low-dose duloxetine treatment.
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A 75-year-old male patient with previously documented sensorimotor polyneuropathy was admitted to neurology department
complaining of numbness, tingling sense, pain, and weakness in both legs that had lasted approximately three months. His medical
history revealed that he had been treated pregabalin 150 mg/day for neuropathic pain but the patient had stopped pregabalin treatment
due to severe dizziness. He did not use any medications for two months before being admitted to the neurology department. There
was no history of any known disease except for sensorimotor polyneuropathy. Neurological examination showed mild weakness of feet
dorsiflexion bilaterally and reduced deep tendon reflexes in both lower extremities. On psychiatric examination he had depressed mood
and insomnia. His vital signs and detailed laboratory investigations were normal. Duloxetine 30 mg daily was initiated for neuropathic
pain and depressive symptoms. His serum sodium level on that day was 138 mmol/L. Three days following initiating the duloxetine,
because patients complained of lethargy, headache and nausea, his laboratory investigation was made before third dose of duloxetine
administration and it revealed hyponatremia. His serum sodium level was 118 mmol/L. The urine osmolarity was 578.3 mOsm/L, urine
sodium was 154 mmol/L, with the serum osmolarity of 245.7 mOsm/L. Renal, adrenal, thyroid, hepatic, and cardiac functions, and brain
magnetic resonance imaging were normal. Tumor markers were also normal. Fluid intake was normal. The patient appeared euvolemic
by examination. In the result of investigations, the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) was diagnosed.
It was thought that SİADH was related to duloxetine treatment and then duloxetine was stopped. Treatment with intravenous hypertonic
saline was initiated. Serum sodium normalized within 5 days (137 mmol/L). According to the Naranjo causality scale (the score was 7) the
hyponatremia was probably because of duloxetine. During six months of follow-up, his serum sodium levels were within normal range.
Our patient developed severe and rapid-onset hyponatremia after 2 doses of duloxetine treatment only 30 mg per day. Hyponatremia
is attributed to duloxetine in this case because there was no other discoverable reason that may cause hyponatremia. Moreover,
hyponatremia resolved after discontinuation of duloxetine and was not observed in the control examination. Because the wide use of
serotonin and noradrenaline re-uptake inhibitors in the population, it is significant to consider hyponatremia as avoidable adverse effect.
Clinicians should be awareness of the hyponatremia while treating their elderly patients with lower duloxetine dosages. Laboratory
controls of the patient’s serum sodium prior to and during duloxetine treatment might be required.
Keywords: adverse effect, duloxetine, hyponatremia
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[Abstract:0445] Pharmacotherapies
Marked liver enzyme elevation related to clozapine use
Keziban Turgut, Nazmiye Kaya
Department of Psychiatry, Necmettin Erbakan University, Meram Faculty of Medicine, Konya-Turkey
e-mail address: [email protected]
Here we report a case of asymptomatic marked liver enzyme elevation related to clozapine use.
A 17-year-old boy referred to emergency room with negativism, mutism, insomnia, disorganized behavior, social withdrawal, catalepsy
and reference delusions. He was hospitalized with a prediagnosis of schizophrenia. He had a history of complex partial epilepsy
characterized with laughing. On admission, his biochemical tests, ECG and EEG were normal. During his hospitalization and outpatient
follow up various atypical antipsychotic agents were used. Because of insufficient efficacy and adverse effects (tardive dyskinesia related
to risperidone) aripiprazole treatment combined with clozapine by taking informed consent from his relatives. Biochemical tests were
repeated and were normal. In the fifth week of treatment when clozapine dose was 100 mg/day, he had nausea and abdominal pain,
AST:37 U/L, ALT:70 U/L, other tests were normal, physical examination was normal. During 3 weeks time they were decreased slightly
and were normal at the end of 3 weeks. After titrating Clozapine dose to 200 mg/day, in the tenth week of clozapine treatment with
aripiprazole 15 mg/day, his oral dyskinetic movements decreased significantly, he had no positive symptoms and social functioning was
almost normal. But routine laboratory monitoring revealed increased levels of ALT at 76 U/L, AST at 38 U/L. During next 7 weeks, AST
and ALT levels continued to increase slightly, his physical examination was normal, serology was negative for hepatitis B and C. At the
fourth week of enzyme elevation, aripiprazole dose was decreased to 10 mg/day because of enzyme elevationpersistence. At the end
of seventh week AST:151 U/L, ALT:323 U/L, clozapine treatment was stopped and aripiprazole was continued at 5 mg/day dose. After
this change AST and ALT levels decreased slightly and was normal at the end of six weeks. While he was taking aripiprazole 5 mg/day,
he started to complain about visual and auditory hallucinations and social withdrawal. Aripiprazole dose increased to 30 mg/day and
amisulpirid 300 mg/day was added to treatment. However he experienced akathisia and his visual hallucinations continued. 4 weeks
after the normalization of transaminase levels, aripiprazole dose decreased to 20 mg/day and clozapine was restarted at the dosage of 25
mg daily. In the third day of clozapine rechallenge ALT: 85 U/L, AST:44 U/L, clozapine was stopped. After 2 weeks AST and ALT levels were
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normal. Aripiprazole was stopped because of insufficient efficacy and side effects and Amisulpirid dose increased to 600 mg/day. With
amisulpirid treatment he is on remission.
Usually liver function disturbances related to Clozapine are mild and transient. Despite routine monitoring of liver function tests
during clozapine treatment is not mandatory, should be cautious especially at the beginning of the clozapine treatment. It should be
discontinued if enzyme elevation persists.
Keywords: clozapine, liver enzymes, schizophrenia
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S394-S5
[Abstract:0459] Pharmacotherapies
Glutamatergic agents in the treatment of children and adolescents with trichotillomania: report of
six cases and discussion on the administration of topiramate augmentation
Ipek Percinel1, Kemal Utku Yazici2
1Department of Child and Adolescent Psychiatry, Osmaniye State Hospital, Osmaniye-Turkey
2Department of Child and Adolescent Psychiatry, Firat University, Faculty of Medicine, Elazig-Turkey
e-mail address: [email protected]
Objective: This report discusses the treatment and follow-up process of six patients with trichotillomania treated with the addition of
topiramate to their medication regimen.
Methods: The patients’ hair pulling behaviors were assessed using the Massachusetts General Hospital Hair Pulling Scale (MGH-HPS),
depressive symptoms were assessed using Children’s Depression Inventory (CDI); and anxiety symptoms were assessed using Beck
Anxiety Inventory (BAI). At clinical follow-up, the severity of disorder was assessed using the Clinic Global Impression-Severity Scale
(CGI-S); and general functioning of patients was assessed using the Global Assessment Scale (GAS). Side effects that may occur during
treatment were assessed using the Clinic Global İmpression-Side Effects Scale (CGI-SE). The patients were started on topiramate 25 mg/
day, which was gradually increased every two weeks up to 200 mg/day/max. All cases were evaluated every 4 weeks during a clinical
follow-up period of six months, and improvement was measured primarily by clinical condition and CGI-S scale; and changes in symptom
severity were assessed based on MGH-HPS scores.
Results: Two out of 6 patients included in our study had a comorbid diagnosis of anxiety disorder. 4 patients showed a notable
improvement with topiramate augmentation, while the other 2 did not have a meaningful improvement. 3 patients had an irregular
appetite, which was considered to be associated with topiramate, but no weight change was observed.
Conclusion: Trichotillomania is classified under “Obsessive Compulsive (OCD) and Related Disorders” in the DSM-5. Various psychotropic
agents from different groups are used in treatment, however there is no specific pharmacological molecule proven to be effective.
Recently, glutamatergic agents have been frequently used in the treatment of OCD and OCD spectrum disorders. Topiramate is an
antiepileptic drug, which is involved in the modulation of glutamatergic activity in the brain. In literature, we have found only one openlabel study on trichotillomania which conducted with adult patients. We have not found any study conducted on the use of topiramate
in the treatment of children and adolescents with trichotillomania. Our study is considered to be of importance for being the first report
on this subject as far as we are aware, and drawing attention to this gap in literature.
Keywords: children, topiramate, trichotillomania
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[Abstract:0460] Pharmacotherapies
Escitalopram treatment in preschool-aged children with obsessive compulsive disorder: a discussion
on the treatment and six-month follow-up period of a 3.5-year-old girl
Kemal Utku Yazici1, Ipek Percinel2
1Department of Child and Adolescent Psychiatry, Firat University, Faculty of Medicine, Elazig-Turkey
2Department of Child and Adolescent Psychiatry, Osmaniye State Hospital, Osmaniye-Turkey
e-mail address: [email protected]
This report discusses the escitalopram treatment and six-month follow-up period of a 3.5-year-old girl, who was diagnosed with obsessive
compulsive disorder (OCD).
A 3.5-year-old girl presented to our clinic with the concern that she would get sick from someone touching her and increasingly repeated
hand washing and cleaning behaviors. No previous psychiatric admission was reported. The patient was diagnosed with OCD. She didn’t
respond to behavioral methods because of her young age. The patient was then started on fluoxetine 5mg/day and a controlled dose
increase was planned. On the second day of the treatment, the patient was brought to our clinic with skin rashes spread throughout the
body. After a detailed anamnesis, skin rashes were considered to be associated with fluoxetine. Fluoxetine treatment was ceased, and
skin rashes completely disappeared in two days. Tablet medication could not be used, because of her age. Escitalopram was suggested
for the patient. The patient was started on escitalopram 5 drops/day. The first evaluation was made two weeks later. No side-effects were
observed and the dose was increased to 10 drops/day. Evaluations were then performed in 4 week intervals. At clinical follow-up, YaleBrown Obsessive Compulsive Scale (Y-BOCS), Clinical Global Impression-Severity Scale (CGI-S), Clinical Global İmpression-İmprovement
Scale (CGI-I), and Clinical Global Impression-Side Effects Scale (CGI-SE) were used.
The patient’s Y-BOCS score was 34 and CGI-S score was 5 (markedly ill) at admission. After six months of treatment, a notable improvement
was observed in her symptoms. Maintenance treatment with escitalopram 5 mg/day was well tolerated. No side effects were observed. At
the end of 6 months, the patient’s Y-BOCS score was 13; CGI-S score was 1 (normal, not at all ill); CGI-I score was 1 (very much improved).
This report aimed to discuss six-month clinical follow-up of a 3.5 year-old girl with OCD who developed allergic reaction to fluoxetine
and was treated with escitalopram. The selective serotonin reuptake inhibitors (SSRIs) are considered to be first-line drugs for the
psychopharmacological treatment of OCD. Examining the literature, we have observed that there are a limited number of studies
on pharmacological treatment of preschool-aged children with OCD and most of these studies report cases treated with fluoxetine
and sertraline. We have found only one study reporting the use of escitalopram. Based on a retrospective analysis of 11 patients, this
case report describes improvement in symptoms in 5 out of 6 patients with OCD. Fluid drugs are primarily suggested for young aged
patients, considering possible difficulties in swallowing pills. Fluoxetine and escitalopram are the SSRIs available in liquid form in Turkey.
Escitalopram can be suggested as a second alternative for early age children, who cannot use fluoxetine for any reason. Therefore, the
patient was started on escitalopram and showed a notable improvement with no side effects that may be associated with the medication
in the course of treatment. To our knowledge, our case describes the youngest patient in literature reporting the use and effectiveness of
escitalopram in preschool age children with OCD.
Keywords: escitalopram, obsessive compulsive disorder, preschool age
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S396
[Abstract:0465] Pharmacotherapies
Pregabalin dependence: a case report
Gulay Oguz1, Mukerrem Guven2
1Canik Basari University, Samsun-Turkey
2Akdeniz University, Antalya-Turkey
e-mail address: [email protected]
Pregabalin is a structural analogue of δ-aminobutyric acid (GABA). It is a ligand that exerts anticonvulsant, analgesic and anxiolytic effects
in animal models and has high potent for alpha-2-delta” subunits of “voltage-sensitive calcium channels” (VGCC). However, despite the
broad utilization range thereof, the number of case reports on the abuse potential and dependence of pregabalin have increased recently.
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A 27-year-old, male works as a marketer. The parents of the patient, who applied on 05/12/2014 for treatment, divorced when he was
five year-old. His mother, who settled in Istanbul after the divorce, remarried when he was eight year-old. His father was shot dead by a
relative when he was 17 year-old. He went to his mother living in Istanbul to work and established a business with his childhood friend
following the completion of his military service. After two years he left this business because they could not get on with each other.
He declares that he could not bear his friend’s selfishness and became frustrated. His uncle, a few year-older than him, was also taking
narcotic drugs and jailed for this reason. Upon his imprisonment, he became obliged to support his uncle. He having 2 sisters and one
half-brother, married 3 years ago and has a one-year-old daughter. The patient, who started to take narcotic drugs when he was 17
year-old and alcohol later, began taking Jamaica two years ago and took Jamaica for eight months. Upon this, he began to take Lyrica
(Pregabalin) with the suggestion of a friend. He began to use 300 mg firstly and then increased the take thereof up to 2100 mg. He says
that he feels cheerful, extremely strong and happy but he is disturbed due to trembling, sweating and muscle pains. And when he does
not take the drug he has problems such as irritability, insomnia, loss of appetite, heartburn, inertia, desire of being away from people and
not working, and therefore he does not want to quit the drug. He cannot resist not taking pregabalin more than 2 days. The patient, who
could obtain pregabalin from the pharmacies until 2013 without the need for prescription and take it easily, currently obtains the drug
through illegal ways. The patient stated that he decided to receive help in this regard due to the presence of his daughter and if his life
continues in this way he will not be able to work in the future. The patient also mentioned that he currently takes 2100 mg of pregabalin,
marijuana and alcohol.
Pregabalin poses a risk due to its euphoria effect. Euphoria effect of pregabalin (1-10%) is expressed by more patients compared with
placebo (0.5%). There are some studies on pregabalin dependence in the literature. Although it has been shown that pregabalin is
effective in the treatment of some psychiatric disorders except epilepsy, it should be used with caution particularly in patients with
alcohol and drug addiction in terms of abuse.
Keywords: pregabalin, dependence, GABA
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S396-S7
[Abstract:0467] Pharmacotherapies
Psychotic relapse due to topiramate
Gulay Oguz1, Saime Cagli2
1Canik Basari University, Samsun-Turkey
2Psychologist, Samsun-Turkey
e-mail address: [email protected]
Topiramate is an antiepileptic employed in the treatment of many psychiatric disorders in addition to epilepsy. Topiramate exerts
the antiepileptic effect thereof through different mechanisms such as by blockage of sodium channels, increasing GABAergic
neurotransmission, antagonizing excitatory amino acid receptors (glutamate) or blockage of calcium channels. Its employment in
psychiatric diseases has increased in recent years and psychotic symptom development due to usage of topiramate has been observed in
some studies. As such, it is essential to evaluate psychotic symptoms while using topiramate. This article presents a case report of 37 year
old woman who has depression, anxiety and auditory hallucinations after taking 150mg topiramate. After stoping topiramate olanzapine
5 mg 2x1 was started for the patiend and the symptoms were gradually decreased and disappeared.
A 37-year-old female, who has 3 children and who has been using topiramate 150 mg/day since 3 years due to migraine, applied with
complaints of restlessness, irritability and hearing strange sounds on 17.11.2014. Topiramate was discontinued by reducing by contacting
a neurology expert. The patient was very upset due to hearing strange sounds. She told that especially her neighbors were accusing her
to be immoral. She was hearing sounds like “You’re bad, you’re cheating on your husband” and “you’re immoral”. The patient could not do
her houseworks because of these sounds, she had complaints like insomnia, loss of appetite and shivering and she could not go out of
her house. The patient explained that she thought 6 months ago her neighbor’s husband looked at her and his wife suspected her and
these people told bad words about her. She was hearing voices like “God damn you” and “go out” and then the patient went out. In her
mental examination, irritability, restlessness and inability to focus attention were observed in addition to her repeating “There is nothing
like that, isn’t it?” Her Beck Depression Inventory score was 42 and her Beck Anxiety Inventory score was 48. Olanzapine 5 mg 2x1 was
started to the patient. It was observed after two weeks that anxiety and frequency of auditory hallucinations the patient decreased and
she heard only sounds looking like her father in law’s voice. She heard voices like “You cannot do anything”, “You do not take care of
children” and “Men are running after you”.It was observed in her examination after one month that the patient did not hear any voice and
her depressive symptoms decreased.
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Topiramate, which has indications in treatment of many diseases, is used frequently in psychiatric diseases. In addition to obtaining
positive effects it was observed that frequency of psychotic symptoms was 1% 5 and therefore it should be used with caution and it is
important to inquire psychotic symptoms.
Keywords: topiramate, psychotic symptoms, auditory hallucinations
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[Abstract:0479] Pharmacotherapies
Diarrhea due to clozapine treatment: a case report
Zeynep Anil Sahin, Ahmet Inel, Ibrahim Taymur, Rustem Askin
Department of Psychiatry, Sevket Yilmaz Training and Research Hospital, Bursa-Turkey
e-mail address: [email protected]
Clozapine is an atypical antipsychotic drug, as distinct from typical antipsychotic drugs, used for resistant schizophrenia treatment
and more efficient also with low extrapyramidal side effects. Clozapine’s most common gastro-intestinal side affect is constipation but
diarrhea, colitis and eosinophilic colitis are also observed rarely. Eosinophilic colitis cases due to clozapine treatment are observed with
diarrhea, fever and eosinophilia.
A 34-years-old male patient was followed up with schizophrenia for 10 years. Due to progression of paranoid-persecutive delusions,
auditory hallucinations and self- destructive behavior in last 2 weeks, he was hospitalized in our clinic for treatment regulation. Clozapine
treatment was started and drug dose was gradually increased. Constipation was observed in clozapine 75mg/day treatment; fever and
nausea-vomiting symptoms were observed and eosinophilia was determined after in clozapine 200 mg/day treatment. After all, with
dosage decreaseament, diarrhea was regressed. In the sametime; blood, throat and fecal specimens were examined and no microorganism
was determined but ceftriaxone treatment was started empirically. After all symptoms were regressed, dosage of clozapine gradually
increased again but with the dosage increasement, bloody diarrhea was observed. With dosage decreasement and finishing of clozapine
treatment, symptoms were disappeared. Because of not performed colonoscopy and biopsy; diagnosis of eosinophilic colitis was not
eliminated.
With this case, we take attention to eosinophilic colitis which is rarely but one of clozapine’s gastro-intestinal side affects.
Keywords: clozapine, side affects of antipsychotics, eosinophilic colitis
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S398
[Abstract:0487] Pharmacotherapies
Venlafaxine induced hair loss: a case report
Esra Yancar Demir
Department of Psychiatry, Ordu University, Faculty of Medicine, Ordu-Turkey
e-mail address: [email protected]
Objective: Hairloss is a common side effect caused by medical treatment such as chemotherapeutic drugs, antithyroid drugs,
anticoagulants, triparonol, lithium, antiepileptics or vitamin combinations. It is reversible when the drug is discontinued. The mechanism
of drug-induced alopecia is not exactly understood. Agents within antidepressants which are the most commonly associated with hairloss
are tricyclic antidepressants. However, hairloss side-effect due to SNRIs are limited to case reports.
Case: We wanted to present this article as a case of a 33-year-old female patient who had venlafaxine-induced general hairloss recovering
after its discontinuation. E is a 33 years old married female patient with two children. Since her twenties, she suffers from symptoms
of depression and anxiety like anhedonia, insomnia once or twice a year. This time she had been suffering from depressive mood,
unwillingness, pessimism, aggresiveness, impatience, anxiousness and constant feeling of fatigue for 4 months and she appealed to our
clinic as she felt that her symptoms were worsening. She had a history of different anti-depressant usage like fluoxetine, essitalopram,
duloxetine, venlafaxine and reboxetine. As she had thought she benefited only from venlafaxine she was using it with periouds of 2-3
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months without clinician control. She was diognosed as major depression reccurrent type according to DSM-4 and venlafaxine 75
mg/day treatment was started. At the first month her symptoms were decreased % 50 without any report of side effect except slight
increase in appetite. She was continued with same treatment. At the end of second month she reported witht he complaint of hair-loss.
Her laborotuary findings including thyroid function tests, vitamin B-12 and D were all normal. Dermathology consultation found no
dermathological pathology and hairloss was accepted as seasonal. Thetreatment had been continued as usual and at the end of the 4th
month the hairloss complain was intolerable. As the organic reasons that might have caused the problem were sidelined, it was thought
that venlafaxine might be the cause and it was discontinued after gradually decreasing the dosage. Patient didn’t want to use any other
anti-depressant agent as she thought she was in no need. At the first month control after discontinuation hairloss had clearly been
decreased and at the end of the second month it was found out to be completely stopped.
Conclusion: Clinicians should be aware that hairloss dueto venlafaxine,even rare, might be seen and such a complaint of a patient using
venlafaxine shouldn’t be over looked
Keywords: venlafaxine, alopecia, side effect
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S398-S9
[Abstract:0495] Pharmacotherapies
Gingival hyperplasia due to sodium valproate: a case report
Ozlem Kahraman, Zejneb Lushi, Didem Behice Oztop
Department of Child and Adolescent Psychiatry, Erciyes University, Faculty of Medicine, Kayseri-Turkey
e-mail address: [email protected]
Bipolar disorder (BP), characterized by impulsivity, risky behavior, interpersonal problems, and mood dysregulation, is a recurrent and
often chronic psychiatric illness. Sodium Valproate is an anticonvulsant drug that has been shown to be effective in acute mania. Valproic
acid (VPA), a mood stabilizer frequently prescribed for patients with BP When the acceptability of long-term treatment is considered,
together with efficacy, the adverse event profile of a medication is also important. One of the rare side effects of valproic acid is gingival
hyperplasia. Gingival hyperplasia is defined as an excessive growth of periodontal tissue. Causes of congenital gingival enlargement
include hereditary and metabolic disorders. Drug-induced gingival enlargement has also been well-known for a long time, and it has been
traditionally associated with the use of phenytoin, cyclosporine and Ca channel blockers.
A 14-year-old boy had been followed in our outpatient clinic with a diagnosis of bipolar affective disorder over one year. He had border
mental development. As the patient initially using risperidone had frequent manic episodes, it was planned to add valproic acid.
Complete blood count, liver and renal function tests were within normal range. Thus, 500 mg/day valproic acid was prescribed to patient,
which then up-titrated to 750 mg/day by achieving optimal blood level. Remission was obtained by valproic acid. No adverse effect other
than weight gain was observed. The patient using valproic acid for 7 months referred to periodontology clinic of faculty of dentistry with
progressive gingival hyperplasia which was more prominent at maxilla and anterior teeth. He was considered as gingival hyperplasia and
referred to our outpatient clinic. The patient was considered as gingival hyperplasia due to valproic acid; thus, valproic acid was tapered
and discontinued although patient experienced beneficial effects. Marked regression was observed in gingival complaints in the patients.
It was planned to initiate another mood stabilizer to control bipolar disorder. The patient is still attending follow-up examinations in our
clinic.
Several complications of sodium valproate are known but gingival hyperplasia is rare than other complications. Sodium valproate carries a
relatively low risk for development of gingival enlargement other anticonvulsant agents. Significant correlations between the occurrence
and/or severity of drug-induced gingival overgrowth and the presence of plaque and calculus accumulation have been reported in
numerous studies. Bacterial plaque has been causally linked to gingival and periodontal disease and has provided a logical focus for
efforts directed at preventing or containing the process of gingival overgrowth. Oral hygiene represents the risk factor most likely to be
controlled by the patient, dental hygienist and dentist. As our patient, for mentally impaired patients, such care is dependent on others,
and consequently often deficient.
Keywords: gingival hyperplasia, sodium valproate, bipolar disorder
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[Abstract:0500] Pharmacotherapies
Neuroleptic malignant syndrome with paliperidone palmitate
Yakup Yilan, Cem Oge, Recep Tutuncu, Hakan Balibey, Ayhan Algul, Alpay Ates, Cengiz Basoglu
GATA Haydarpasa Training Hospital, Istanbul-Turkey
e-mail address: [email protected]
Neuroleptic malignant syndrome (NMS) is a rare, but life-threatening, idiosyncratic reaction to neuroleptic medications that is
characterized by fever, muscular rigidity, altered mental status, and autonomic dysfunction. NMS often occurs shortly after the initiation of
neuroleptic treatment, or after dose increases. Herein we present a case of Neuroleptic malignant syndrome with Paliperidone Palmitate.
A 21-year-old male patient was admitted by his family to emergency clinic with the complaints of irritability, muscular rigidity. His speech
was blurred. His diagnosis was bipolar disorder and he was being treated with Paliperidon palmitate and lithium. Blood tests showed
elevated plasma creatine phosphokinase level (1447 U/L, n=10-190). AST levels were also increased (53, n=0-31). After five days in the
intensive care unit, patient was transferred to the psychiatry clinic. Recovery of his symptoms lasted as long as one month which was so
difficult for the patient and the parents to deal with.
We still need a cautious approach regarding paliperidone palmitate and lithium combination should be avoided or monitored closely
due to the possibility of NMS occurrence.
Keywords: lithium, neuroleptic malignant syndrome, paliperidone palmitate
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[Abstract:0507] Pharmacotherapies
Atypical drug eruption limited in the face related with mirtazapine
Ersan On1, Mustafa Karaoglan2, Hakan Kullakci3, Recep Tutuncu3, Bilal Dogan1
1Department of Dermatology, GATA Haydarpasa Training Hospital, Istanbul-Turkey
2Department of Neurology, GATA Haydarpasa Training Hospital, Istanbul-Turkey
3Department of Psychiatry GATA Haydarpasa Training Hospital, Istanbul-Turkey
e-mail address: [email protected]
Mirtazapine, an antidepressant, increases noradrenergic and serotonergic neurotransmission in the central nervous system. Increased
appetite, vivid dream, weight gain, drowsiness, dizziness and headache are known adverse drug reactions due to the mirtazapine.
However cutaneous drug reaction induced by mirtazapine is extremely rare. In this case; Mirtazapine treatment in depression and
insomnia after stroke caused atypical drug eruption with erythematous desquamation limited in the face.
An 85-year-old male with depression and insomnia followed by stroke 1 month ago on his left upper and lower extremities taking
mirtazapine (15mg per day) On 12th day of Mirtazapine treatment; he started to suffer seborrheic eruptions; red, scaling rash on his
face. After dermatology consultation, mirtazapine treatment stopped and methylprednisolone aceponate ointment 0.1% (twice daily)
started. On the 4th day of methylprednisolone aceponate ointment 0.1%, seborrheic symptoms relieved. Patient’s relative started to
give him mirtazapine (15mg per day) daily for insomnia symptoms and after 7 days, seborrheic symptoms flared up. After neurology
clinic admission, mirtazapine treatment stopped instead venlafaxine (75 mg per day) and methylprednisolone aceponate ointment 0.1%
started. On the 5th day of treatment his dermatological symptoms totally relieved and no recurrence after 6 months.
Mirtazapine is an antidepressant which increases noradrenergic and serotonergic neurotransmission in the central nervous system. The
intrinsic score of imputability of mirtazapine, according to the French pharmacovigilance criteria was C2S2 with a suggestive causal link.
Mirtazapine is derived from mianserin and shows chemical structural similarities with other psychotropic drugs, such as clozapine, and
certain tricyclic antidepressants. Thus, the patient should avoid using the casual agent, mirtazapine as well as its structural congeners such
as mianserin, clozapine and tricyclic antidepressants.
Keywords: drug eruption, mirtazapine, erythematous desquamation limited in the face
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[Abstract:0511] Pharmacotherapies
A rare case of oculogyric crisis under ziprasidone therapy
Mehmet Celal Kefeli, Abdullah Yildirim, Hulya Cecen, Pinar Guzel Ozdemir
Department of Psychiatry, Van Yuzuncu Yil University, Faculty of Medicine, Van-Turkey
e-mail address: [email protected]
Extrapyramidal effects of antipsychotic drugs are frequently encountered and may result in lower compliance to medical therapy. These
side effects, compared to first generation antipsychotics, are relatively rare with second generation pharmaceuticals. Oculogyric crisis is
a type of dystonic reaction. This particular extrapyramidal side effect develops more rapidly when than other adverse reactions and is
quite worrisome for the patient and the patient’s family. A case of oculogyric crisis under ziprasidone, which is considered as quite safe
regarding extrapyramidal side effects, is presented.
A 30-year-old female patient with the diagnosis of schizoaffective disorder and a history of recurrent attacks during the last six years
was admitted to our inpatient clinic. The patient was conscious, fully oriented and cooperative; her affect was minimally flattened and
her mood dysphoric with loosened associations between expressed ideas. She lacked insight and had persecutory, mystic, grandiose
delusions as well as delusions of reference; she also had auditory and visual hallucinations. Patient had a history of low compliance to
treatment with quetiapine, risperidone, olanzapine, haloperidol, zuclopenthixole and aripiprazole, all without full remission. Seven months
previously, the patient had extrapyramidal side effects, in the form of an oculogyric crisis and rigidity of the arms, due to 150 mg/month
im haloperidol decanoate which lead to considerable loss of compliance to medications. On her last outpatient visit, she was prescribed
valproic acid – sodium valproate 1250 mg/day and quetiapine 150 mg/day. During admission her therapy regimen was readjusted as
ziprasidone, a potent dopamine D2 receptor agonist with a low extrapyramidal side effect profile, 80mg/day and valproic acid – sodium
valproate 1250 mg/day in divided doses. During the seventh day of admission the patient developed oculogyric crisis which was resolved
twenty minutes after administering biperiden 5mg IM. Therapy was continued with the addition of biperiden 4mg/day and ziprasidone
dose was increased to 160mg/day after one week. A second attack of oculogyric crisis which lasted five minutes was encountered one day
after increasing biperiden dosage. Weekly QTc measurements during her medical therapy of five weeks were 400ms, 420 ms, 390 ms, 410
ms and 440 ms, respectively. Despite effective dosage and optimal time period of medical therapy, the patient’s response to treatment
was poor and her hostility did not subside. Thus, her medication was stopped and electroconvulsive therapy was planned.
Extrapyramidal side effects are frequently encountered during antipsychotic drug therapy and lead to substantial decrease in the quality
of life which is the main factor in discontinuation of therapy by the patients. Oculogyric crisis is one such extrapyramidal effect which
develops rather rapidly and is of great concern for the patient and his/her caretakers. Although ziprasidone is considered as quite safe
regarding extrapyramidal side effects, oculogyric crisis may also be encountered during therapy with this particular drug. This case
underlines the fact that extrapyramidal side effects may be experienced with any antipsychotic medications. It must be emphasized that
informing and educating the patient and his/her caretakers on potential extrapyramidal side effects of these drugs would lead to higher
compliance with medications.
Keywords: oculogyric crisis, extrapyramidal side effects, ziprasidone
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[Abstract:0527] Pharmacotherapies
Eosinophilia due to duloxetine: a case report
Ebru Sekmen1, Berker Duman2, Ebru Cobanoglu3, Selami Kocak Toprak4, Hakan Kumbasar5
1Department of Child Psychiatry, Ankara Pediatric Hematology Oncology Training and Research Hospital, Ankara-Turkey
2Department of Psychiatry, Ankara University, Faculty of Medicine, Ankara-Turkey
3Department of Psychiatry, Ankara University, Faculty of Medicine, Ankara-Turkey
4Department of Hematology, Ankara University, Faculty of Medicine, Ankara-Turkey
5Department of Psychiatry, Ankara University, Faculty of Medicine, Ankara-Turkey
e-mail address: [email protected]
Eosinophilia is defined by an eosinophil count of >600/mm3; it may be primary or secondary due to the underlying cause. End-organ
damage may develop in drug induced form as well as primary or other secondary eosinophilia and it may also develop regardless of a
specific cause in severe or mild eosinophilia.
Antidepressants induced eosinophilia is a rare clinical entity reported with tricyclic antidepressants, venlafaxine, fluoxetine, clomipramine,
paroxetine, sertraline, trazodone and bupropion. Recently, Espeleta et al. reported a case of duloxetine induced eosinophilic pneumonia.
We present a case of an outpatient who developed eosinophilia during duloxetine therapy.
Case: A 53-year-old male who was referred for psychiatric consultation by hematology department with eosinophilia of unexplained
etiology probably associated with duloxetine administration. He was formerly evaluated by allergy-immunology and dermatology
departments. He had been treated for recurrent depression with trazodone 50 mg/day for 10 years and duloxetine 60 mg/day had
been added 5 years ago for depressive symptoms. Previous treatment trials included fluoxetine, venlafaxine, moclobemide but were
discontinued because of lack of response. Mental status examination revealed mild anxiety symptoms and irritability with no other
significant psychopathology. Medical records showed eosinophilia had been detected four years ago but no detailed examination had
been carried out. Duloxetine was tapered and discontinued. 3 weeks later blood eosinophil count was decreased from 800/mm3 (10.8%)
to 400/mm3 (7.4%).
Duloxetine is an antidepressant which classified as Selective Noradrenaline Reuptake İnhibitor (SNRI). Its frequent side effects include
nausea, vomiting, dry mouth, headache, constipation, diarrhea, anorexia, abdominal pain, insomnia, dizziness, somnolence and
hyperhidrosis. Hepatotoxicity, hypertensive crisis, arrhythmia, seizures, severe skin reactions are uncommonly seen dangerous adverse
effects. To our knowledge only one case of duloxetine induced eosinophilia presented with eosinophilic pneumonia has been published
so far. In our case, other possible causes of eosinophilia were excluded and eosinophilia can be attributed to duloxetine therapy because
of the temporal association of eosinophilia and duloxetine usage and decrease in eosinophil levels after drug discontinuation. Druginduced eosinophilia is an important clinical finding that can cause end-organ damage. End-organ damage is more common in moderate
to severe eosinophilia (Eosinophilia is classified as mild when the blood eosinophil count is between 600-1500/mm3, moderate when
1500-5000/mm3 and severe when >5000/mm3), which is consistent with the absence of end-organ damage symptoms in our case despite
mild eosinophilia.
Duloxetine can induce eosinophilia which can cause end-organ damage. Duloxetine, should be considered as one of the possible
etiologies when eosinophilia was identified. When suspected duloxetine should be tapered and discontinued. As a result, Duloxetineinduced eosinophilia taken into account seriously in order to avoid end organ damage and related adverse effects.
Keywords: duloxetine, eosinophilia, adverse effects
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[Abstract:0533] Pharmacotherapies
Use of risperidone in the treatment of a methylphenidate-induced mania case
Semiha Arslan, Ali Ibis, Esra Ozhan Ibis, Onur Burak Dursun
Department of Child and Adolescent Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
e-mail address: [email protected]
Methylphenidate is one of the first line treatment options of Attention deficit hyperactivity disorder (ADHD). Although methylphenidate
is usually reported as a drug with a wide confidence interval, use of in toxic doses may cause manic and psychotic symptoms. Occurrence
of mania and psychosis-like symptoms is very rare (1/400) in therapeutic doses.
In this poster; we present a case, that manic symptoms occurred on the 4th day following the use of extended-release methylphenidate;
however, these symptoms continued even after discontinuing medication and completely regressed with the use of low-dose risperidone.
A12-year-old boy admitted to our clinic with the complaints of increased mobility, distractibility, more talkative than usual, inflated selfesteem and decreased need for sleep, unexpectedly increased tending of establishing relationship with school teachers and friends and
psychomotor agitation. According to his history; he had been diagnosed with ADHD in a state hospital and he was prescribed 0.6-1.2 mg/
kg/day of long-acting methylphenidate. On the 4th day of treatment, the complaints of reduction in the need for sleep, increased selfconfidence, increase in the amount of speaking and non-obeying the rules of the school have started; and these complaints have become
more severed after 10 days of the treatment; therefore, the medication was discontinued thereafter. Despite the discontinuation of the
drug, these complaints, which were existed for 15 days, were decreased partially, but continued, and severely impaired functionality of
the patient. There was no family history of any psychiatric disorder. The current clinical examinations led us to consider psychostimulantinduced mania. The treatment of Risperidone with a dose of 0.5 mg/day was started and the dose of drug was gradually increased to 2
mg/day. In the 2nd week, the complaints of irritability and mobility were back into the pre-treatment period and his Young Mania Rating
Scale\Parent Form score was dropped from 27 to 7. In the 3rd week, the patient completely recovered and discontinued the medication.
The treatment was continued with therapeutic conversations. In the following period, the patient didn’t have any complaints similar to
manic symptoms.
Although no predisposing factors related to mania-like symptoms were reported due to the use of methylphenidate, it has been
suggested to be cautious in the use of methylphenidate on patients with a family history of mood disorders. In the case presented, there
is no family history of psychiatric disorders. Manic symptoms, which are rarely seen with methylphenidate treatment, occur in the 2nd
day of treatment and disappear within 7 days if either drug dose is reduced or treatment is discontinued. However, in our case, despite
the discontinuation of drug, although there were decreases in complaints of the patients, but they continued partially, so the patient
was started on risperidone. In this regard, it is intended to draw attention to the cases, in which methylphenidate may lead to mania-like
symptoms in the treatment dose and the use of antipsychotic drugs may be required along with reduced dose or discontinuation of
methylphenidate.
Keywords: methylphenidate, mania, antipsychotic
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S403
[Abstract:0557] Pharmacotherapies
Pharmacogenetics in the treatment of obsessive-compulsive disorder
Oguz Tan
Department of Psychiatry, Uskudar University, Istanbul-Turkey
e-mail address: [email protected]
About half of patients with obsessive-compulsive disorder (OCD) do not satisfactorily respond to pharmacological treatment. Clinical
characteristics can modestly predict treatment response. Genetic factors have usually been found useful in predicting treatment
response in depression. We aimed to review the literature about the pharmacogenetic of OCD.Candidate genes that have the potential
to influence OCD treatment may be related to serotonin system, brain-derived neurotrophic factor (BDNF), glutamate transporter gene
and cytochrome (CYP) system. All antidepressants are metabolized through CYP450 enzymes in the liver. Anti-obsessive agents are
principally metabolized through CYP2D6, except citalopram metabolized through CYP2C19. Activities of these enzymes greatly differ
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among individuals due to genetic variability. More than 130 single nucleotide polymorphisms (SNPs) and copy number variations have
been defined on CYP2D6. Decreasing enzyme activity increases plasma levels of drugs, enhancing the risk of toxicity; whereas increasing
enzyme activity decreases plasma levels, producing unresponsiveness to treatment. Serotonin re-uptake is mediated through serotonin
transporter (5-hydroxytriptamine transporter=5-HTT). 5-HTT is encoded by SLC6A4 (solute carrier family 6, member 4). SLC6A4 is located
on the 17th chromosome. An alteration in 5-HTT activity can influence serotonin availability in the synaptic cleft and hence, post-synaptic
serotonin receptor activity. Therefore, SLC6A4 is also only a candidate gene involved in OCD in addition to influencing treatment response
since OCD medication inhibits serotonin re-uptake. Gene polymorphisms involving serotonin receptors have also been investigated.
The gene HTR1B that encodes 5-HT1Dβ might be a candidate gene in the neurobiology of and treatment response to OCD. The effect
of 5-HT2A receptors has been studied in depression treatment, but a polymorphism of 5-HT2C receptor gene was searched in OCD
treatment. Tryptophan hydroxylase is the rate-limiting enzyme of serotonin synthesis. Tph1 and Tph2 are two genes playing roles
in encoding tryptophan hydroxylase. How their polymorphisms affect treatment response has been investigated only in depression
although they have been found abnormal in children and adolescent with OCD. BDNF is a small dimeric protein from neurotrophin family.
The gene for BDNF is located on the 11th chromosome. Val-66Met polymorphism has been found to influence symptom severity as well
as treatment response in OCD.The chromosome region 9p24 has been reported to have a linkage with OCD. This region contains the
gene SLC1A1 (solute carrier family 1, member 1=SLC1A1) that encodes neural glutamate transporter EAAC1/EAAT3 (excitatory amino-acid
carrier/transporter). Glutamate transporters terminate the excitatory signal of glutamate and its uptake into the neuron. SLC1A1 is the
gene that has the most established relationship with OCD. The haplotypes as well as SNPs have been reported to alter treatment response
in OCD.So far, research has failed to show a consistent relationship between these candidate genes and with treatment response OCD.
Few studies have investigated the pharmacogenetics of OCD and therefore, findings are too limited to draw precise conclusions. The
most robust data are about SLC1A1 and BDNF. The fact that different drugs were used in different studies might also be responsible for
inconsistent results due to specific pharmacodynamics differences.
Keywords: pharmacogenetics, psychopharmacology, obsessive-compulsive disorder
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S403-S4
[Abstract:0560] Pharmacotherapies
Zuclopenthixol acetate induced epilepsy, tachycardia and dystonia: a case report
Murat Kuru, Ayse Nur Oguz, Elvan Ciftci
Department of Psychiatry, Erenkoy Training and Research Hospital, Istanbul-Turkey
e-mail address: [email protected]
Here, we aimed to discuss a patient with zuclopenthixol acetate induced epilepsy, tachycardia and dystonia.
A 21-year-old, male patient was admitted to psychiatry with acute onset psychotic symptoms and one day after zuclopenthixol acetate
50 mg im form administration, he was admitted to psychiatry emergency service with complaints of swelling of prolapsing of the tongue,
dysarthria, contractions common in all body, urinary incontinence, confusion and tachycardia. He had been followed with short term
psychotic disorder for 6 months, zuclopenthixol acetate 50 mg IM was administered for one time and zuklopenthixol acetate 20 mg/day
oral form was given for 3 months. Due to his psychotic signs and symptoms regressed in the last three months, his pharmacotherapy was
stopped in the control of his psychiatrist. In the last month, the same treatment was restarted due to the same symptoms.
He had a history of absence type epilepsy starting in the age of 3 and continuing until the age of 11. He had been followed without
medication and any epileptic seizure was not observed. Any additional medical history was not described.
In his examination in the psychiatry emergency service, his blood pressure and temperature were in normal range, the pulse was 120/
min. He was conscious and but his cooperation was decreased. His tongue was swelled and prolapsed, difficulty in the swallowing
was observed. Affect was blunted. He had difficulty in speaking and dysarthria. He had not any psychotic symptoms except paranoid
delusions. After the medical history taken and examination results, it was evaluated as acute dystonia caused by zuclopenthixol acetate
and biperiden 2 mg im form was applied. His dystonic signs and symptoms declined in the ongoing hours. In his clinical follow-up in
the emergency survive, about one and half minute contraction common in all body and unconsciousness were observed. This clinical
picture was evaluated as epileptic seizure caused by seizure threshold decreasing effect of zuclopenthixol administration. During seizure,
diazepam 10 mg iv in the fast infusion form was administered and he was admitted to neurology service. In his cranial CT and MRI
scans, any pathologic abnormality was not detected. His electroencephalogram was reported as hyperexcitability in the disorganized
background in the bilateral frontal areas. Due to ongoing tachycardia in his follow-up, he was consulted to internal medicine. Tachycardia
was also thought to induced by zuclopenthixol acetate administration. Propranolol 40 mg/day for tachycardia and valproic acid 1000
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mg/day for epileptic seizures were started. Then, valproic acid was increased up to 1500 mg/day due to low plasma concentration. His
tachycardia declined and propranolol was stopped by recommendation of internal medicine. Olanzapine 15 mg/day was started for
stabilization of psychotic symptoms. The patient whose psychotic symptoms were declined, acute dystonia was recovered and any
epileptic seizure was not observed was discharged.
Typical antipsychotics may cause side effect related with extrapyramidal, cardiovascular (e.g. tachycardia) and neurologic (e.g. confusion,
decreasing seizure threshold) systems. They should be used in caution in the young, male and with accompanying neurologic comorbidity
patient.
Keywords: zuclopenthixol acetate, epilepsy, tachycardia
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S404-S5
[Abstract:0561] Pharmacotherapies
Parkinsonism associated with long-acting paliperidone
Serdar Atik, Murat Semiz, Murat Erdem, Ozcan Uzun
Department of Psychiatry, Gulhane Military Medical Academy, Ankara-Turkey
e-mail address: [email protected]
Antipsychotics cause Parkinson like motion disorder called Drug-induced parkinsonism (DIP) by blocking D2 receptor of dopamine in
nigrostriatal pathway. In DIP; as a muscle rigour, proneposture, foot dragging mask face, weight loss and having difficulties to start the
motion symptoms are usually seen. Paliperidone is one of the active metabolites of risperidone. Extrapyramidal symptoms (EPS) and
sedation side effect of the long acting Paliperidone reported that having less side effects comparing with risperidone.
In this case report, psychotic disorder diagnosed a 72-year-old male patient presented with using different types of antipsychotics
(Sulpiride 400 mg/day, risperidone 6 mg/day, long acting risperidone 50 mg, amisulprid 800 mg/day, olanzapine 20 mg/day). This
patient had used paliperidone 100 mg once monthly for 3 months. The dosage of paliperidone had been elevated to 150mg/monthly in
fourth month. Approximately after one month DIP developed and then Paliperidone had been stopped. Biperiden and benzodiazepine
have been given. Pramipexole 1.5 mg has been added to therapy due to not to any decrease of the parkinsonism symptoms than
electroconvulsive therapy (ECT) was used for the treatment.
In this case report, although not to get parkinsonism with using several antipsychotics, patient had parkinsonism with long acting
paliperidone. In this report, DIP could occur with using paliperidone and ECT has been shown as one of the most important option of
treatment DIP.
Keywords: long-acting, paliperidone, Parkinsonism
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S405
[Abstract:0583] Pharmacotherapies
Treatment of psychosis in a patient who is under buprenorphine/naloxone treatment
Ayse Erdogan, Ahmet Bulent Yazici, Atila Erol, Esra Yazici
Department of Psychiatry, Sakarya University, Training and Research Hospital, Sakarya-Turkey
e-mail address: [email protected]
Buprenorphinein/naloxone formulation (BUP/NLX) is used in treatment of heroin addiction. Treatment of psychosis is well established for
many years and there are different protocols for comorbid conditions. It is known that substance use may aggravate psychosis and it may
be hard to manage comorbid situations. There is a growing literature about psychosis and substance use disorders however the data is
insufficient about the treatment modality of psychotic disorder in a patient under BUP/NLX treatment. This study presents the successful
treatment of psychosis in the patient who is under BUP/NLX treatment.
A 34-year-old man admitted to the treatment center of alcohol and substance use disorders (AMATEM) for treatment of heroin
dependence. He has been using heroin for 13 years and he reported that he increased the dosage at the last 2-3 months. Initially he
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started to take a pinch of heroin, but for the last 2-3 months he has been taking by intravenous injection of 2-3 mg/day. Also the slight
psychotic symptoms started simultaneously with the increased dosage of heroin but he has not used any medical treatment. He was
accepted to the AMATEM detox unit for treatment. Olanzapine 10 mg, BUP/NLX with the dosages of 4/1 to 12/3 mg, analgesics and
mirtazapine 15 mg were started. Withdrawal symptoms and pain were subsided in few days. Quetiapine 50 mg and risperidone 2 mg were
added to medical treatment after the increase of the severity of insomnia, irritability and delusions. He was transferred to the psychiatry
clinic from AMATEM with hostility, irritability, disorganized speech and behaviors, delusions of persecution and reference, insomnia and
depressive thoughts at sixth day. Positive and Negative Symptom Scale (PANSS) scores were P=31, N= 22, G: 63, total= 116 carried out in
psychiatry clinic.
The patient was diagnosed with substance-induced psychosis and the dosage of risperidone was increased to 4 and 8 mg gradually
and BUP/NLX treatment went on in the same dosage. There were no other withdrawal symptoms except intermittent bone pain. BUP/
NLX dose was reduced from 12 to 8 mg in 2 weeks after the decrease of pain. At the end of the second week the PANSS assessment was
repeated and the scores were P= 7, N= 11, G= 26, total= 44. The patient was discharged with the total PANSS score under 35 and with the
medication of BUP/NLX 8/2 mg, quetiapine 50 mg, risperidone 8mg, olanzapine 10mg.
At the admission to hospital, there was a mild impairment of liver function tests (AST: 42, ALT: 45, GGT: 26) which were observed in the
normal range at the discharge.
This case presents a successful psychosis treatment with antipsychotics in a patient who is under BUP/NLX treatment. The treatment
process was 23 days and both psychotic symptoms and heroin addiction were improved. This study presents an example of safe
antipsychotic combination of risperidone and olanzapine usage for treatment of similar cases. Further follow-up is necessary to achieve
long-term results.
Keywords: buprenorphine/naloxone, heroin, psychosis
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S405-S6
[Abstract:0587] Pharmacotherapies
Venlafaxine and sexual disinhibition
Esra Aydin Sunbul, Emel Basoglu, Esra Koca, Huseyin Gulec
Department of Psychiatry, Erenkoy Training and Research Hospital, Istanbul-Turkey
e-mail address: [email protected]
Sexual dysfunction is a common side effect of antidepressants, particularly of selective serotonin reuptake inhibitor (SSRIs) and serotonin
norepinephrine reuptake inhibitor (SNRİs) medications. The sexual problems reported range from decreased sexual desire, decreased
sexual excitement, diminished or delayed orgasm, to erection or delayed ejaculation problems. Here we mention a rare case with sexual
disinhibition after venlafaxine treatment.
A 52-year-old female, married had a 4 month history of depressive disorder. Her usual sexual activity had been satisfying to her, but this
was moderately decreased during the depressive episode. The depression was treated with various antidepressive agents but these
had no effect on the disease. Treatment was started with venlafaxine, initially 75 mg, titrated up to 150 mg daily. 3 weeks after the dose
increase, she experienced a libido increase which she describes as disturbing. She reported that her sex drive was greater than it had
ever been. But there was no improvement of depressive symptoms. Venlafaxine was tapered off within 7 days. Her sex drive progressively
decreased to her pre-morbid levels.
Libido decrease may be associated with depression. It could be debated that the sexual disinhibition during use of venlafaxine could be
a result of the improvement of the depression. But in this case, the libido increase was considered to be disturbing, suggested that the
libido was much higher than before the depression. The latency in case is 3 weeks which is too short to see improvement of the depressive
symptoms. Venlafaxine enhances norepinephrine transmission and therefore could lead to libido increase in patients treated with this
drug. More studies of the effects of antidepressant drugs on sexual function are needed.
Keywords: depression, venlafaxine, sexual disinhibition
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[Abstract:0590] Pharmacotherapies
Methylphenidate-induced gynecomastia in a preadolescent boy
Ulker Samhalova, Ozge Metin, Dilek Altun Varmis, Aysegul Yolga Tahiroglu, Ayse Avci, Gonca Gul Celik
Department of Child and Adolescent Psychiatry, Cukurova University, Faculty of Medicine, Adana-Turkey
e-mail address: [email protected]
Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder characterized by inattentiveness, hyperactivity,
and/or impulsivity. Stimulants (e.g., methylphenidates and amphetamines) are the first-line medications and have been used to treat
ADHD for several decades, with consistent data demonstrating the efficacy and safety of these drugs. MPH associated gynecomastia has
rarely been reported in subjects with ADHD. We report a case of 13 years boy who developed bilateral gynecomastia during OROS-MPH
treatment.
A 13-year-old boy with normal developmental history was diagnosed with ADHD combine type. 36 mg/day of OROS MPH treatment was
started. He generally tolerated the medications well. Two months later, his ADHD symptoms showed mild to moderate improvement
in parents’ and teacher’s reports. The only medication he took was methylphenidate. The patient noticed the stiffening and growth in
nipples after 2 months after taking 36 mg/day of OROS MPH. On physical examination, bilateral breast was enlarged without galactorrhea,
nipple discharge, nipple retraction, lymphadenopathy, pain or skin changes. There was no known case of gynecomastia in his family.
USG findings were compatible with bilateral gynecomastia. The ADHD treatment was stopped immediately and Pediatric Endocrinology
consultation were ordered. His laboratory testing including liver, thyroid, and renal function tests; electrolytes; blood cell count; prolactin;
testosterone; estrogen; luteinizing hormone; follicle-stimulating hormone; and cortisol levels were all within normal limits (except
FT4). Test revealed lowered free T4 0.48 ng/dL (normal 0.61 – 1.12) and lowered estradiol 8 pg/ml (normal 20 – 47 pg/ml). The Pediatric
Endocrinology Department prescribed 0.1mg/d levothyroxine. Control ultrasonography showed that there was a minimal regression
in glandular tissue. The estradiol and T3, T4, all anti-thyroid antibodies were normal. During the further follow-up the gynecomastia
regressed and showed no recurrence.
This is the first report of MPH-induced bilateral gynecomastia with normal serum prolactin level in a male adolescent boy who had new
diagnosed with hypothyroidism. Currently, exact pathophysiological mechanisms through which MPH can cause gynecomastia are
unknown. In fact, we don’t know thyroid dysfunction of our case was new or old because of detecting former TFT results. Interpreting
relationship of gynecomastia and MPH is difficult because of his hypothyroidism. The cause of gynecomastia could be affected by the
decreased FT4 level, methylphenidate treatment or both. Effects of MPH treatment on dopamine neurotransmission, prolactin and
dopamine relationship and role of pituitary function in thyroid functions are possible related mechanism in regard of gynecomastia.
Further systematic studies are needed to analyze endocrine dysfunctions associated with methylphenidate treatment in young patients
with ADHD.
Keywords: gynecomastia, hypothyroidism, methylphenidate
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S407
[Abstract:0594] Pharmacotherapies
Low-dose clozapine-induced epilepsy: case report
Abdullah Bolu1, Suleyman Akarsu2, Erdal Pan3
1Aircrew’s Health Research and Training Center, Eskisehir-Turkey
2Aksaz Naval Hospital, Mugla-Turkey
3Eskisehir Military Hospital, Eskisehir-Turkey
e-mail address: [email protected]
Clozapine is a serotonin-dopamine receptor antagonist and it is an atypical antipsychotics prototype that used successfully in the
treatment of schizophrenia. Besides being an effective antipsychotic, it has life threatening side-effect profile. Agranulocytosis,
myocarditis, aspiration pneumonia, ileus and weight gain are the major side effects of clozapine. In addition, it is known that clozapine
has effect of lowering the seizure threshold. This risk increase in high-dose and rapid dose titration. In this case report, a patient with
tonic-clonic seizures occurred after using low dose clozapine who had not had these risks except history of substance abuse is presented.
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A 29-year-old male patient had been followed-up with a diagnosis of schizophrenia for about 5 years. Disorder had initiated with
the symptoms especially introversion, impaired social functioning, unwillingness. In the process, auditory hallucinations and suicidal
thoughts occurred and he had been hospitalized twice. He had a history of substance abuse. He had been admitted to our department
with positive symptoms two years ago. He had been hospitalized and clozapine treatment had been started. Low dose titration had been
performed. Remission had been achieved with 150 mg/day clozapine dose. After a while, compliance to treatment had been impaired
and treatment had been interrupted for about 8 months. About three months ago, he applied for treatment and clozapine was initiated
again. The dose of clozapine was made 200 mg/day within one month. He had a tonic-clonic seizure that his mother witnessed at the third
month of the treatment. Pathological findings were obtained in electroencephalography (EEG). Brain magnetic resonance imaging (MRI)
and computerized tomography (CT) results were normal. Valproic acid 1000 mg/day was started. Clozapine dose was reduced to 100 mg/
day. He has been in remission with this dose.
Lowering the seizure threshold side effect of clozapine is considered to be risky over 600 mg/daily dose. The risk of seizure is estimated
that less than 1% under 300 mg/day clozapine dose. Seizures had been observed in our case with low dose clozapine as 200 mg/day so
it made our case remarkable. There have been reported a few case reports about this issue in the literature. Observing the seizures at
low doses of clozapine suggests that there may be other risk factors for seizures apart from dose and titration rate. In this respect, having
history of substance abuse in our case might have an effect.
Keywords: epilepsy, clozapine, low dose
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S407-S8
[Abstract:0598] Pharmacotherapies
Aripiprazole treatment of risperidone-induced hyperprolactinemia in an adolescent with psychotic
disorder: a case report
Hatice Altun, Ebru Findikli, Hayati Sinir, Feyza Hatice Sevgen
Department of Child and Adolescent Psychiatry, Sutcu Imam University, Faculty of Medicine, Kahramanmaras-Turkey
e-mail address: [email protected]
Second-generation antipsychotics are associated with weight gain, metabolic abnormalities, sedation, sleep disturbance, and prolactin
abnormalities. Hyperprolactinemia is a well-established adverse effect associated with the use of typical antipsychotics and the
atypical antipsychotic risperidone. Several authors have reported elevations in serum prolactin levels in children receiving risperidone.
Hyperprolactinemia caused by neuroleptic drugs is related to the degree of blockade of D2 dopaminergic neurons in the adenohypophysis.
It is associated with both acute and chronic clinical consequences, including menstrual irregularities in women galactorrhea and sexual,
a potential increased risk of osteoporosis or reduced bone mineral density, so hyperprolactinemia is important and must be treatment. In
this case report, is presented an adolescent with risperidone induced hyperprolactinemia who successfully treatment with aripiprazole.
A 17-year-old female with childhood onset psychotic disorder according to DSM-IV was started risperidone 1 mg/day and risperidone
dosage was gradually increased to 4 mg/day. After treatment with risperidone, his psychotic symptoms decreased. Three months after
risperidone treatment was initiated he complained about a moderate weight gain of 5 kg, spontaneous galactorrhea and amenorrhea.
The measured serum prolactin level was at 125 ng/mL (normal range; female: 4.79-23.3 ng/mL) three months after the introduction of
risperidone. After risperidone discontinuation in 1 week and a switch to aripiprazole 5 mg/day, the prolactin level dropped within the
normal range (7ng/mL) 2 weeks later. After the replacement of risperidone by aripiprazole, galactorrhea ended and she started to lose
weight. After risperidone discontinuation psychotic symptoms of patients did not ignite and her treatment continued with aripiprazole
dosage 10 mg/day.
Physicians can decrease the dose of the antipsychotic or switch to a prolactin-sparing drug (aripiprazole, olanzapine, quetiapine) and
addiction on dopamine agonists to treat antipsychotic-induced hyperprolactinemia. Aripiprazole functions as a dopamine D2 partial
agonist and appropriates intrinsic activity at dopamine D2 receptors, stabilizing dopamine D2 receptor-mediated neurotransmission
without excessive blocking. These pharmacodynamic properties allow aripiprazole to act as dopamine agonist in the presence of the
risperidone-induced dopaminergic hypoactivity, therefore decreasing lactotroph activity and thus prolactin levels. Aripiprazole may be
the drug of choice in adolescent patients suffering from both psychosis and antipsychotic-induced hyperprolactinemia.
Keywords: aripiprazole, hyperprolactinemia, risperidone
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S408
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[Abstract:0600] Pharmacotherapies
Possible atomoxetine-induced hyperpigmentation: a case report
Hatice Altun, Perihan Ozturk, Hayati Sinir, Umut Karaaslan
Department of Child and Adolescent Psychiatry, Sutcu Imam University, Faculty of Medicine, Kahramanmaras-Turkey
e-mail address: [email protected]
Atomoxetine is a selective noradrenergic reuptake inhibitor that one of the commonly used drugs for the treatment of attention deficit
hyperactivity disorder (ADHD). Atomoxetine was generally well tolerated in children and adolescents with ADHD. Common adverse
events included headache, abdominal pain, decreased appetite, vomiting, somnolence, and nausea. The majority of adverse events were
mild or moderate; there was a very low incidence of serious adverse events. To date, dermatological side effects like atopic dermatitis,
vitiligo, hair loss associated with atomoxetine have been rarely reported. However, hyperpigmentation due to the use of atomoxetine has
not been reported. In this report, we present a 7-year-old child with ADHD and mental retardation who displayed hyperpigmentation in
face following the initiation of atomoxetine.
A 7-year-old female diagnosed with ADHD and mental retardation according to DSM-IV-R criteria and clinical assessment. She had
normal physical examination and no history of significant medical illness. The patient was prescribed atomoxetine 10 mg/day for ADHD
as medical treatment. After 10 days of medication, atomoxetine dosage was increased to 18mg/day. Approximately 3 weeks after starting
atomoxetine her mother noticed that brown hyperpigmented eruption in face. There was brown hyperpigmented macules that with
punctate and linear feature, 1-2 cm in diameter, unfadeable pressing over the right cheek and nose in her dermatological examination.
These lesions were spread to the left cheek 3-4 days after. She did not begin any new medications prior to the onset of the eruption.
The patient had no history of similar complains or any allergic reaction in the past. Atomoxetine therapy was discontinued because
the atomoxetine related event was suspected and resolved within 1 week. Atomoxetine was restarted and subsequently this lesion
reappeared at the same. She was consulted to the dermatology clinic and her lesion described as drug related hyperpigmentation. Druginduced pigmentation of the skin is a rare adverse effect reported in a limited number of psychotropic medications such as imipramine
desipramine, chlorpromazine. To date, however, there are no published studies that have examined the relationship between atomoxetine
treatment and hyperpigmentation. Hyperpigmentation induced by atomoxetine is a possible but rare phenomenon. The exact cause for
the dermatological side effects associated with atomoxetine is not known. Clinicians should be aware of rare dermatological adverse
reactions of atomoxetine treatment.
Keywords: atomoxetine, hyperpigmentation, dermatological side effect
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S409
[Abstract:0614] Pharmacotherapies
Elevation of hepatic enzymes caused by lithium use: a case report
Arif Onder1, Sima Ceren Pak2, Fatih Canan2, Nesrin Koseoglu3
1Department of Child and Adolescent Psychiatry, Akdeniz University, Faculty of Medicine, Antalya-Turkey
2Department of Psychiatry, Akdeniz University, Faculty of Medicine, Antalya-Turkey
3Department of Child and Adolescent Psychiatry,Ege University, Faculty of Medicine, Izmir-Turkey
e-mail address: [email protected]
Widely used in the treatment of mood disorders, lithium is excreted through kidneys and considered safe in terms of hepatotoxicity.
Elevation of hepatic enzymes due to lithium has rarely been described. Here, we describe a patient whose hepatic enzymes were elevated
after lithium was administered and normalized following discontinuation of the drug.
A 51-year-old female, married with 2 children, admitted to Department of Psychiatry, Akdeniz University Faculty of Medicine due to
her complaints about having no joy in life, an increased need of sleep and feeling down. Her first psychiatric admission was in 2005 for
insomnia, self harm, and feeling depressed. At that time she was diagnosed with major depressive disorder and prescribed venlafaxine.
She had several major depressive episodes so far. She also experienced a number of hypomanic episodes characterized by decreased
sleep need, hyperactivity, increased speech and joy that lasted 2-3 weeks. Four months before her present admission, Mrs. S had a
hypomanic episode and was started on 600 mg/day lithium. Her serum lithium level was recorded at 2.0 mEq/L in the second week of the
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treatment with her hepatic enzymes elevated 10 times more than normal. Lithium was then stopped and she was started on fluoxetine,
which continued until admitted to our clinic.
After the patient’s evaluation upon admittance, she was diagnosed with bipolar disorder, type 2. Her routine blood panel revealed no
abnormalities apart from a mild increase in cholesterol levels. Hepatic markers were between the normal ranges, anti-HIV and VDRL
were negative. The patient was started on lithium, which increased to 900 mg/day. In the 3rd week of the treatment routine blood panel
showed increase in hepatic markers, ALT: 100 IU/L, AST: 72 IU/L. Serum lithium level was 0.78 mEq/L and renal markers were also in the
normal range (BUN: 15 mg/L, creatinine: 0.67 mg/dL). Lithium was stopped and after 6 days without lithium hepatic markers decreased.
After discontinuation of lithium, the patient was started on amisulpride 100 mg/day and sertraline 100 mg/day and discharged afterwards.
Only a few case reports have been reported about the effect of lithium on hepatic enzymes. In one of those reports, elevation in hepatic
enzymes caused by lithium use was evident. In another case report development of ascites due to lithium therapy had been noted. Also
elevation of hepatic enzymes after lithium use was reported in an alcoholic patient.
Even though lithium’s effect on elevated hepatic enzymes was not definite in our case; the recurrence of hepatic enzyme elevation while
on lithium therapy and normalization of hepatic enzymes after discontinuation lead us to believe that lithium may have some degree of
hepatotoxicity in our patient.
The clinicians should keep in mind that, although very rare, lithium may cause idiosyncratic drug-induced hepatotoxicity. In a patient with
elevated hepatic enzymes, lithium use should also be inquired.
Keywords: hepatic enzymes, hepatotoxicity, lithium
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S409-S410
[Abstract:0619] Pharmacotherapies
A case report of corticosteroid-induced mania treated with olanzapine
Hatice Celik Yildirim, Fatih Canan
Department of Psychiatry, Akdeniz University, Faculty of Medicine, Antalya-Turkey
e-mail address: [email protected]
Corticosteroids are widely used but they can result in lots of troubling psychiatric side effects. Significant side effects are depression,
mania, psychosis, mood swings and memory deficits. Mania and hypomania are more common than depression. The most commonly
reported symptoms are aggressiveness, uninhibited behavior, increased energy, decreased sleeping.
The association of adverse effects with the use of steroids is well documented. To our knowledge, in most cases symptoms occur in the
first two weeks and above 40 mg daily dosage
A 69-year-old male, married with two children, retired from accountant, lives in Antalya
He had no complaints however his family was concerned about his aggressive behavior, increased speech, loss of sleep and irritability.
He was brought to emergency department (ED). Upon examination at the ED, he had religious delusions, disorganized behavior, auditory
hallucinations, tangential thought processes, flight of ideas, decreased need of sleep, affective lability. In the ED, blood work and urıne
toxicology revealed no abnormalities. A head CT showed no acute changes. 2 weeks prior to emergency presentation, the patient had an
sudden hearing loss. Treatment of 60 mg dexamethasone daily was initiated. When he was admitted to ER, the dosage was reduced to
30 mg/day, however, he still had the same symptoms as before. Mr. ME‘s family noted that he had no psychiatric symptoms or treatment.
On longer-term follow ups, the patient subsequently confirmed this story. He has hypertension and has been on hydrochlorothiazide and
valsartan for 5-6 years.
Dexamethasone was stopped. Olanzapine 10 mg daily was initiated. On his follow-up examinations, he was still manic, grandiose but his
paranoid delusions partially improved.
He had come his follow-ups once a week. His medications were reduced regularly.
Five weeks after the ED presentation and 7 weeks after his last dexamethasone dose, he had no hallucination, persecution regarding his
family, manic or psychotic symptoms. Even so he had used his olanzapine 5 mg/day for one more month. His medication is ceased totally
after 12-week treatment.
Even the exact mechanism of the side effects remains unclear, some studies suggest that the corticosteroids increase dopamine
concentration. The therapeutic efficacy of treatment with a dopamine antagonist in patients with corticosteroid-induced mania proves
that dopamine metabolism plays an important role in occurrence of these side effects.
Studies show that steroid-induced psychiatric symptoms occur more commonly in female and older people. Side effects are dosedependent. Higher doses and systemic use tend to reveal more side effects, and these side effects can occur during any stage of
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treatment, including withdrawal. Sometimes, mood-stabilizing drugs such as lithium or antipsychotic medications such as risperidone
can be used as treatment or prophylaxis. Since corticosteroids have various kinds of side effects, among them psychosis and mania must
be kept in mind. Psychiatric symptoms must be questioned before treatment and on longer term follow-ups.
Keywords: corticosteroids, mania, side effect
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S410-S1
[Abstract:0629] Pharmacotherapies
Switching to aripiprazole for risperidone-induced hyperprolactinemia: a case report
Evrim Aktepe, Funda Ozyay Eroglu, Orhan Kocaman, Adem Isik
Department of Child and Adolescent Psychiatry, Suleyman Demirel University, Faculty of Medicine, Isparta-Turkey
e-mail address: [email protected]
Prolactin is a hormone secreted by lactotroph cells in the anterior pituitary. Dopamine is the base of inhibitory regulation and binds
dopamine receptors D2 on the membrane of lactotroph cells. D2 receptors are blocked by antipsychotic-drugs because of this inhibitory
effect of dopamine on prolactin secretion disappears. All antipsychotic-drugs block D2 receptors so all can induce hyperprolactinemia.
Women, adolescents and children tend to be more sensitive to prolactin elevation than are men. Hyperprolactinemia may cause clinical
symptoms such as galactorrhea, oligomenorrhea, amenorrhea, irregular periods, higher incidences of osteoporosis in women, impotency,
oligospermia and infertility in men. Some symptoms of hyperprolactinemia consist of by hypogonadism that occurs due to disruptive
effects of hyperprolactinemia on the hypothalamic-pituitary-gonadal axis, others are due to direct effects on target tissues.
This case report demonstrates risperidone was associated with a high prolactin level with resultant adverse effects in a 16-year-old girl,
and that changing treatment to aripiprazole normalized this prolactin level and reversed the observed side effects. 16-year old girl was on
risperidone since the 2 years as a case of schizophrenia. Since the last 3 months she had been partial stabilized 6 mg/day of risperidone.
She reported amenorrhea, galactorrhea and hirsutism for the last 4 months, for which she had consulted a gynecologist who opined
the amenorrhea, galactorrhea and hirsutism as a result of risperidone induced hyperprolactinemia. Her serum prolactin was found to be
elevated (44.32 ng/mL; normal range:3.34-26.72). It was decided to switch her to aripiprazole. She was started on aripiprazole 2 mg/day,
which was gradually increased to 10 mg/day over the next 6 weeks and simultaneously, risperidone was tapered off 0.5 mg less every
other week and stopped. She resumed normal menstruation after 5 weeks and her serum prolactin level returned to normal and mental
state has remained stable on aripiprazole 15 mg/ day.
This case report is coherent with literature that has shown that risperidone can cause hyperprolactinemia and aripiprazole is less likely
to cause this side effect. Algorithm for treatment of patients with antipsychotics induced hyperprolactinemia: reduction of antipsychotic
dose, addition of cabergoline, bromocriptine, amantadine and/or transition other antipsychotic, which has minimal affect on prolactin
levels (switching). We have applied to another antipsychotic gradual transition protocol in this case. The effects of hyperprolactinemia may
be considered unimportant because they depend on self-report, and may be overlooked for common adolescent problems of irregular
menstrual cycles. Clinicians need to ask patients taking antipsychotic medications about possible side effects and check prolactin levels
for those who exhibit symptoms and may be at risk for short and long term side effects of hyperprolactinemia.
Keywords: aripiprazole, hyperprolactinemia, risperidone
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Case Report Abstracts
[Abstract:0638] Pharmacotherapies
Henoch–schonlein purpura during treatment with fluoxetine
Ayse Suleyman1, Funda Suleyman2, Ahmet Zihni Soyata3, Behiye Alyanak2
1Department of Pediatric Allergy and Immunology, Erzurum State Hospital, Erzurum-Turkey
2Department Of Child And Adolescent Psychiatry, Istanbul University, Cerrahpasa Faculty of Medicine, Istanbul-Turkey
3Department Of Psychiatry, Istanbul University, Cerrahpasa Faculty of Medicine, Istanbul-Turkey
e-mail address: [email protected]
Selective serotonin reuptake inhibitors (SSRIs) have rarely been reported to be related with vasculitis in young or adult subjects. Herein
we present an adolescent boy who developed Henoch-Schonlein Purpura(HSP) upon treatment with fluoxetine.
A boy aged 15 years was referred to emergency clinic with widely spread skin rash on his lower legs and pain in his ankles. He had been
using fluoxetine 20 mg qd for a week for depressive symptoms. D-Dimer level was 3468 microgram/L, fibrinogen level was 332.02, which
were consistent with vasculitis. He was diagnosed as having HSP and fluoxetine treatment was stopped.
He had no previous psychiatric or medical diagnoses. His developmental history and psychometric assessment were within normal limits.
Vasculitis resolved in 2 months.There are some case reports describing adult patients with urticarial and leukocytoclastic vasculitis related
with SSRI treatment. Paroxetine and fluoxetine have been reported to be related with leukocytoclastic vasculitis, which develops within a
few weeks after the initiation of SSRI treatment. However, there is no report of vasculitis related to SSRIs in children or adolescents. In our
case vasculitis emerged after one week of fluoxetine treatment. HSP is also a type of leukocytoclastic vasculitis of childhood that results
in a triad of symptoms, including a purpuric rash occurring on the lower extremities, abdominal pain or renal involvement and arthritis.
Although the etiology and pathophysiology of HSP remains unclear; infectious agents, drugs, and vaccinations have been implicated as
possible triggers for HSP.
In conclusion, clinicians should be aware of HSP as an adverse effect of SSRI. More research is warranted regarding psychopharmacological
mechanisms of SSRI-related vasculitis.
Keywords: fluoxetine, Henoch–Schonlein purpura, vasculitis
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S412
[Abstract:0646] Pharmacotherapies
Toxic epidermal necrolysis developing in bipolar patient receiving lamotrigine, lithium and
duloxetine combination treatment
Emel Uysal1, Filiz Civil Arslan1, Evrim Ozkorumak1, Zeynep Calıskan Ilter1, Deniz Aksu Arica2
1Department of Psychiatry, Karadeniz Technical University, Faculty of Medicine, Trabzon-Turkey
2Department of Dermatology, Karadeniz Technical University, Faculty of Medicine, Trabzon-Turkey
e-mail address: [email protected]
Toxic Epidermal Necrolysis are rare and life-threatening mucocutanosis reactions. They are generally caused by drugs, and rarely by
infections. These drugs include anti-convulsants, antibiotics and nonsteroidal anti-inflammatory drugs. Lamotrigine is an anti-epileptic
drug, which can cause simple maculopapular rash up to severe skin reactions such as toxic epidermal necrolysis. Side effects that caused
by lamotrigine are generally appear in first 2-8 week of the treatment, affect 3-10% of patients and they’re mostly in the shape of
maculopapular rash. Toxic Epidermal Necrolysis is a severe side affect, which can lead high mortality. Mortality rate changes from 20% to
66%. Mortality usually associated with sepsis, which caused by skin or pulmonary infection linked with pseudomonas or staphylococcus.
Also usage of lamotrigine has increased these side effects risks in bipolar patients.
In this paper we reported a patient who has diagnosed as bipolar affective disorder type-II and having 900 mg/day lithium, 60 mg/
day duloxetine and 25 mg/day lamotrigine as treatment; and then had red rash all over her body, edema on her hands and feet,
breathing problems and sting feeling in her eyes after the increase of lamotrigine dose to 75 mg/day. In physical examination, purulent
conjunctivitis, general macular and vesiculobullous rash in the body and wide erosive lesions in the oral mucosa has been deteminated.
Nikolski phenomenon was positive and the patient had genital edema so she diagnosed as Toxic Epidermal Necrolysis and hospitalized
at the burn unit. At the second day of her hospitalization the patient has consulted to us for her psychiatric treatment management; after
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our assessment we thought her clinical condition is a lamotrigine related Toxic Epidermal Necrolysis and then stopped all of her medical
treatment. Patient was having corticosteroid and some support therapies, and in 15 days there has been big regression in her symptoms
and complains. Severe skin reactions related with lamotrigine occurred 0.3% of additional epilepsy therapies, 0.08% of monotherapy
in bipolar disease and 0.13% of additional bipolar disease therapies. Risks of skin side effects in lamotrigine treatment are; increasing
the dose faster than recommended, beginning treatment with higher dose than it recommended, using it with valproic acid and using
it in the pediatric population. The pathogenesis of the disease has not yet been cleared but it’s mostly explained with immunological
mechanisms. There has been lots of Toxic Epidermal Necrolysis declared in the patients who had lamotrigine because of epilepsy, yet it’s
not so much for the bipolar patients who are using the same drug. In conclusion, severe skin reactions which have high morbidity and
mortality can be decreased by paying attention to the recommended starting dose, dose increasing rate and additional therapies that
metabolizing in the liver.
Keywords: bipolar affective disorder, lithium, toxic epidermal necrolysis
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S412-S3
[Abstract:0654] Pharmacotherapies
Spontaneous ejaculation caused by duloxetine
Mehmet Akif Camkurt1, Mehmet Fatih Yilmaz2, Mahmut Sami Metin3
1Afsin State Hospital, Kahramanmaras-Turkey
2Ardahan State Hospital, Ardahan-Turkey
3Department of Dermatology, Afsin State Hospital, Kahramanmaras-Turkey
e-mail address: [email protected]
Duloxetine is a potent dual reuptake inhibitor of serotonin and norepinephrine and widely used in major depressive disorder, general
anxiety disorder and peripheric neuropathic pain in diabetes as an antidepressant. Spontaneous ejaculation is a rare adverse event of
antidepressants and may cause a bothersome effect on patient. In this case we aim to discuss a patient with spontaneous ejaculation with
duloxetine throughout a year unnoticed.
A 46 year old man was referred to psychiatry clinic with anhedonia, sleep disturbance, lack of appetite, suicidal thoughts, ruminations,
pain in all over the body, diarrhea and constipation, anxiety, palpitation. He was diagnosed with “Major Depressive Disorder” and 30 mg of
duloxetine was initiated and after a month, dose was increased to 60 mg. After the therapy, spontaneous ejaculation has begun in nearly
every day, mostly after micturition, occasionally after defecation. Loss of sexual arousal was also begun. The patients’ complaints were
reduced and he continued duloxetine approximately 1 year. When the patient referred to our clinic we thought the ejaculation may be
related to duloxetine so, the medicine lowered and stopped. 1 week after the stoppage, ejaculations are also ended.
Ejaculation is a natural activation, led by complex neuronal network activity and multiple neurotransmitter interactions and important
for mankind solidity. Spinal cord injuries, sympatectomi, diabetic autonomic neuropathy, drugs (sympatholytic antihypertensions,
antipsychotics, SSRIs) may cause retrograde ejaculation or prolonged or absent ejaculation. Spontaneous ejaculations are reported with
citalopram, reboxetine, nefazadone, venlafaxine in literature but spontaneous ejaculation caused by duloxetine is nor reported before.
While in psychiatric interview, sexual side effects and its treatment, which are hard to talk especially in our society, must be questioned
carefully.
Keywords: duloxetine, spontaneous, ejaculation
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[Abstract:0683] Pharmacotherapies
A case report of angioedema side effect with atomoxetine
Yasemin Yulaf1, Canan Yusufoglu2, Elif Akin2
1Tekirdag Child And Adolescence Mental Health Clinic, Tekirdag-Turkey
2Erenkoy Training and Research Hospital, Istanbul-Turkey
e-mail address: [email protected]
Atomoxetine is a selective inhibitor of the norepinephrine transporter, exerts its therapeutic effect for attention-deficit hyperactivity
disorder (ADHD) by increasing the concentration of synaptic norepinephrine. The effectiveness of atomoxetine in the treatment of ADHD
has been demonstrated among children and adolescents. In this case, angioedema occurred within a few hours after atomoxetine use
and disappeared after discontinuation of the drug. A 13.5-year-old female who was brought in for attention problems. She was given a
diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) predominantly inattentive type. Because of family history of death from heart
attack) was consulted to cardiology department and the department did not approve the use of methylphenidate (MPH). She was started
on Atomoxetine 10 mg/day. A few hours after using atomoxetine redness and swelling occurred around the eyes, neck and forehead. She
didn’t report alcohol or any other drug like ACE inhibitor use with atomoxetine. One month later she took one more atomoxetine 10 mg
capsule and the same symptoms appeared again. Angioedema presents as pale or pink swellings, mainly on the face, affecting the eyelids
and lips; however, other areas of the body, such as the ears, neck, hands, feet, and genitalia, may also be affected. Mucosal swellings occur
inside the oral cavity on the buccal mucosa, tongue, pharynx, and larynx. The lesions may be preceded by an itching or tingling sensation
but are not always pruritic. Each capsule of atomoxetine contains; atomoxetine hydrochloride and inactive ingredients are pregelatinized
starch, dimethicone, gelatin, sodium lauryl sulfate, FD&C Blue No. 2, synthetic yellow iron oxide, titanium dioxide, red iron oxide, and
edible black ink. An allergic reaction to any of these substances can be seen. The clinician should be aware of this side effect and counsel
the children/adolescents and their families about its occurrence in order to improve the adaptation of atomoxetine treatment. Further
investigation is required to understand the psychopathological mechanism of this side effect in some of the children and adolescents.
Keywords: angioedema, atomoxetine, attention deficit hyperactivity disorder
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S414
[Abstract:0684] Pharmacotherapies
Electroconvulsive therapy experience in adolescence: case series
Ipek Suzer Gamli, Gonca Gul Celik, Oguz Sevince, Aysegul Yolga Tahiroglu, Ozge Metin, Ayse Avci, Zeynep Tunc
Department of Child and Adolescent Psychiatry, Cukurova University, Faculty of Medicine, Adana-Turkey
e-mail address: [email protected]
Electroconvulsive Therapy (ECT), is a well known, highly effective psychiatric treatment which is preferred in several neuropsychiatric
conditions including major depressive disorder, bipolar disorder, active suicidality, schizoaffective disorder, psychosis and catatonia.
However, the usage of ECT between child and adolescents is less frequent than adults. In this paper, our aim is to present three adolescent
cases that are treated with ECT with different psychiatric illnesses.
Typically developed 16 year-old teenage boy was suffering from insomnia, uncontrollable agitation, visual and auditory hallucinations,
suspiciousness, injurious behaviors to himself and others since 2 weeks. According to DSM-IV criteria he was diagnosed with “Bipolar
Disorder – Manic Episode with Psychotic Features”, consulted to our psychiatry inpatient clinic and was started antipsychotic medication.
Although, combination therapies are given, it failed to work. Seven ECT sessions were applied and he had improved profoundly and
his Young Mani score dropped hastily. He never had a serious episode since then, he’s being followed by our outpatient clinic with
maintenance medication treatment. Typically developed 16 year-old teenage girl was consulted to our clinic from court with a formal
request regarding her physical and mental health after she was abused sexually by her father. She had re-experiences, insomnia,
nightmares, avoidance from male, fear of darkness, flashbacks, unhappiness, worthlessness and was diagnosed with “Posttraumatic
Stress Disorder (PTSD)” and “Depression” and started medication. After three years of treatment, she started self-harming, and stopped
using her medication. She had serious suicidality and willing to die. After detailed assessment, seven ECT sessions was applied and her
suicidality disappeared. However, PTSD symptoms are in partial remission and her treatment is being followed by out outpatient clinic. 15
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Case Report Abstracts
year-old girl with delayed developmental stages, was referred to our outpatient clinic. She was totally mutistic, could not cooperate with
other people, walk independently and she had refusal to eat and drink since last 20 days, and had a weight loss about 20 kg. She started
bed-wetting, laughing by herself, had distortion, waxy-like movements and psychomotor retardation. She wasn’t able to make any eye
contact, or answer any question. According to her mother, since 1 year she was withdrawn and using risperidone 1 mg/day, but never had
an illness like this. She was referred to our pediatric clinic with diagnosis of “Catatonic Psychosis” with possible diagnosis of “Neuroleptic
Malign Syndrome”. Diazepam 15 mg was started, but she didn’t improved well so ECT was planned. Seven sessions were applied, and
afterwards she started to look when she was called, eat by herself and walk independently gradually.
In all our cases, there were life-threatening symptoms such as uncontrollable agitation, suicidality and refusal to eat and the medication
offered failed to improve. Some psychiatrists have little knowledge and experience or consider ECT as an unethical treatment, but as in
our cases, ECT is helpful in many conditions. It would be useful to keep in mind that ECT as an alternative treatment for adolescents with
serious psychiatric conditions.
Keywords: adolescence, electroconvulsive, therapy
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S414-S5
[Abstract:0712] Pharmacotherapies
Natalizumab induced mania: a case report
Hilal Seven, Ali Metehan Caliskan, Seda Yildirim, Ikbal Inanli, Ibrahim Eren
Department of Psychiatry, Konya Training and Research Hospital, Konya-Turkey
e-mail address: [email protected]
Multiple sclerosis (MS) is a chronic demyelinating disorder characterized by multiple neuropsychiatric symptoms related to multifocal
lesions in the white matter of the central nervous system. MS disrupt the conductance of action potential by effecting myelin coats of the
neurons. Thus, many neurological symptoms and consequently disability may occur. Psychiatric disorders and symptoms accompanies in
the course of MS as primary or secondary reasons.
We present here, a case of a 33-year-old, female patient with a new-onset manic episode following natalizumab treatment. The patient
was followed by the diagnosis of multiple sclerosis for 11 years. The patient was initially treated with interferon-beta 4 years ago.
Interferon-beta switched to glatiramer acetate treatment due to significant clinical relapses. 4 months ago, glatiramer acetate was
changed to natalizumab treatment because of new relapses. Natalizumab, a monoclonal antibody against alpha 4 integrin, represents a
second-line therapy for relapsing-remitting MS, significantly reducing clinical relapses and disease progression. Serious adverse effects of
natalizumab recorded in a few patients, fatal progressive multifocal leucoencephalopathy, suicide, led to restriction of natalizumab’s use
to cases which are resistant to treatment with both IFN-Beta and glatiramer. On the seventh day of the natalizumab treatment, the patient
developed manic symptoms. Increased motor activity, energy and grandiosity, decreased sleep, talkativeness, irritability was noted. The
psychiatric history and clinical course of this patient suggest that the mania is likely to be related to natalizumab use. The treatment of MS
includes corticosteroids and the immunosuppressive agents, which have various psychiatric side effects. Clinicians should always keep in
their mind that there may be psychiatric side effects of monoclonal antibodies.
Keywords: multiple sclerosis, mania, natalizumab
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S415
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Case Report Abstracts
[Abstract:0713] Pharmacotherapies
Pramipexole augmentation in treatment-resistant bipolar depression: a case report
Hilal Seven, Ali Metehan Caliskan, Yusuf Emre Yilmaz, Ikbal Inanli, Ibrahim Eren
Department of Psychiatry, Konya Training and Research Hospital, Konya-Turkey
e-mail address: [email protected]
Patients with bipolar disorder experience depressive episodes three times more often than they do manic and hypomanic episodes Despite
a wide range of various drugs, a significant proportion of depressed bipolar patients fail to respond to the treatment strategies. Currently
available international treatment guidelines for bipolar depression indicate compounds targeting the dopaminergic system as useful
augmentative strategies, in case of poor response. In particular, dopamine agonists (i.e., pramipexole) have received increasing interest for
their potential antidepressant effects in bipolar depression. Mrs. S, a 58-year-old woman with bipolar I disorder. The patient was hospitalized
because of depressive episode. For the last one-year, the patient was receiving lithium (900 mg/day) and risperidone (3mg/day). The patient
was severely depressed and developed parkinsonism one months ago from the last hospitalization. Risperidone was stopped, biperidene
was added to treatment. Electroconvulsive therapy was applied for suicidal ideation. Depressive and parkinsonian symptoms did not improve
with this therapy. Biperidene was stopped, pramipexole and rasagiline was added to treatment. After addition of pramipexole stabilized both
the patient’s depressive and parkinsonian symptoms. We present a case of bipolar depression in which the patient responded significantly to
addition with pramipexole, without any side effects, after failure of adjunctive repetitive electroconvulsive therapy.
This case report suggests that pramipexole may be an effective and safe medication for treating treatment-resistant bipolar depression.
Keywords: bipolar disorder, treatment resistant, pramipexole
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S416
[Abstract:0733] Pharmacotherapies
Acute dystonia induced by aripiprazole in a child: a case report
Hatice Altun, Hayati Sinir, Umut Karaaslan
Department of Child and Adolescent Psychiatry, Sutcu Imam University, Faculty of Medicine, Kahramanmaras-Turkey
e-mail address: [email protected]
Aripiprazole, the third generation atypical antipsychotic that is a partial agonist at D2 and 5HT1A and blocks 5HT2A receptors, is known
for its low propensity to cause extrapyramidal symptoms according to other atypical antipsychotic drugs. Extrapyramidal signs include
increased motor tone, changes in the amount and velocity of movement, and involuntary motor activity.. There has been one report of
severe extrapyramidal symptoms in a 3-year-old child and another report of an adolescent with a previous history of such symptoms. We
report a case of the severe acute dystonia in a 7 year old boy after accidental of a single dose 20 mg of aripiprazole.
A 7 year-old female diagnosed with ADHD and conduct disorder according to DSM-IV-R criteria and clinical assessment. There was
an extensive past history of pharmacological attempts including methylphenidate, risperidone, aripiprazole, valproic acid. He is using
atomoxetine 40 mg/day now. Patient’s mother had used accidental of a single dose 20 mg of aripiprazole. He developed acute dystonic
symptoms after 2 to 3 hours of medication intake, which included facial grimace, dysarthria, slurred speech, macroglossia, dysphasia, spasms
around the mouth, salivation, tongue protruding. There was previously history of acute dystonia with risperidone. All of these symptoms
resolved after a single 2.5 mg the anticholinergic agent biperidene. Patient was observed for 24 hours without reoccurrence of the symptoms.
The extrapyramidal adverse effects of antipsychotic drugs, such as dystonia and parkinsonian-like symptoms, have been attributed to
blockade of striatal D2 receptors and are commonly treated with anticholinergic agents such as biperidene. Dystonic reactions occur most
commonly in the first few days of antipsychotic initiation, and at higher potency or dose of antipsychotic formulation as well as with rapid
titration of the antipsychotic medication. The risk factor for developing acute dystonia in this case is history of acute dystonia, male and
high dose. This case report reveals that aripiprazole may cause rare acute dystonia in vulnerable individuals, despite having a favorable
receptor profile. However, this side effect is amenable to conventional anticholinergic treatment.
Keywords: aripiprazole, acute dystonia, child
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S416
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[Abstract:0745] Pharmacotherapies
Antidepressants induced tardive dystonia: a case report
Ayse Kurtulmus, Ismet Kirpinar, Erdem Deveci, Emel Kocer, Aynur Gormez
Department of Psychiatry, Bezmialem University, Faculty od Medicine, Istanbul-Turkey
e-mail address: [email protected]
Dystonia is a movement disorder characterized by involuntary, sustained muscle contractions. Drug induced dystonia may occur within
minutes, hours or even days after initiation of drug. Even if dystonia is often associated with antipsychotic drugs, it may be caused by
antidepressants, calcium channel blockers or antiemetic drugs. In this case a delayed onset dystonia syndrome in a patient who used
antidepressants was presented.
Mr. C is 34 year-old. He was admitted on an outpatient basis with complaints of involuntary contractions on his neck, which occurred
after antidepressants protocol was initiated. In his psychiatricexamination, anxiety, restlessness, feeling keyed up, depressed mood, lost
of interest and anhedonia were detected. In his neurological examination he had cervical dystonia and essential tremors. In his medical
story, he had started to use sertraline 50 mg with general anxiety disorder diagnosis in 2000, and it was titrated up to 100 mg. He has taken
sertraline 100 mg for 9 years and had no side effects during this period. In 2009, sertraline 100 mg had been stopped and paroxetine 20
mg was administered. Three months after treatment innovation, his anxiety symptoms had increased and for that reason paroxetine had
been changed to sertraline 100 mg again. Two months after sertraline was restarted, dystonic contractions in patients neck was noticed.
In 2011, the patient had stopped sertraline treatment and than dystonic contractions had completely dissipated. However, his anxiety
symptoms continued. Therefore a new treatment had been added wıth escitalopram 20 mg and buspirone 15 mg. He has continued these
drugs for three years and there were no extrapyramidal side effects during this period. In 2014, his anxiety and depressive symptoms had
increased and escitalopram and buspirone were discontinued. Duloxetine 30 mg was initiated. Two months after duloxetine innovation,
dystonic contractions had started again and it has not regressed despite the discontinuation of this drug.
Although in the literature there are many tardive dystonia cases that are associated with antidepressants, the pathophysiologic
mechanism, which is underlying this effect, still remains unclear. Diminished dopamine turnover as a result of increased serotonergic
activity in the inhibitory projections to nigral cells, decreased dopamine and increased acetylcholine in basal ganglia are the most
suggested mechanisms. Furthermore, in a study which was conducted in 2011, after citalopram and fluoxetine were used, increased
microglial activation in substantia nigra, decreased thyrosine hydroxylase cell count were investigated in rats. These kind of cellular
changes need more time to complete and it may explain the delayed onset of extrapyramidal side effects. Also, MaCGIllivray et all. have
observed an increase in immunological markers in the substantia nigra after the use of SSRIs. Thıs finding brings the idea to mind that,
long-term antidepressant use, as in our case, may cause cumulative deterioration on dopaminergic transmission.
Although antidepressant drugs have a lower risk of causing tardive syndrome, if it occurs, it can impair the quality of life of the patient.
Hence, clinicians pay attention to early signs of movement abnormality during antidepressant treatment.
Keywords: antidepressant, tardive dystonia, extrapyramidal side effects
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S417
[Abstract:0760] Pharmacotherapies
Single dose olanzapine induced recurrent priapism: a case report
Atakan Yucel1, Halil Ozcan1, Mehmet Fatih Ustundag1, Nermin Yucel2, Tevfik Ziypak3
1Department of Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
2Department of Child and Adolescent Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
3Department of Urology, Ataturk University, Faculty of Medicine, Erzurum-Turkey
e-mail address: [email protected]
Priapism is a permanent and usually painful penile erection, lasting approximately 4 hours, frequently having no relation to sexual stimuli.
Drug-induced priapism is usually idiosyncratic, and it is also thought that alpha blockage is a crucial etiological factor in priapism. Various
groups of medications are included, such as antidepressants, antihypertensive, anticoagulants, alpha-blockers, and some psychoactive
substances. In this report, we present a case with olanzapine-induced priapism in order to draw the attention of clinicians to this rare
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side effect.
A 24 year-old male with schizoaffective disorder checked into our outpatient clinic with his parents. He had been using quetiapine 600
mg/day for over two years. He declared that he had stopped using quetiapine for the last three months because it slowed down his
movements, and thought that his present clinical condition was good. However his parents complained that his usage of quetiapine
was irregular and that he suffered from insomnia and nervousness, talked to himself and thought that people talked about him.
Moreover, he experienced increasing on amount of speech, laughing and movements. During his psychiatric examination, the patient
was conscious and his orientation relating to people, place, and time was completely normal. His memory and mental capacity were
also normal. Affect and mood were irritable, while increased self-esteem was observed. The content of his thoughts involved reference
and persecutory delusions. The need for sleep decreased in the last month, and hallucination was not reported by him or his parents.
Laboratory examinations were normal. The patient also insisted on not using quetiapine, and then olanzapine 10 mg/day was initiated.
Priapism occurred in the 6th hour of first dosage. He consulted with the urology department, and the corpus cavernous was then drained
in accordance with the consultation. Olanzapine 2.5 mg was initiated the following day, and also the dose was set to increase slowly.
However the priapism occurred again. The drainage of the corpus cavernosum was repeated and then the erection was ended; shunt
was not required. Finally, olanzapine was stopped and risperidone 2 mg/day was initiated – this is the 5th week of patient follow-up with
risperidone. The priapism has not occurred again, and affective and psychotic symptoms have decreased.
Priapism is an urgent situation that requires intervention via drainage of the corpus cavernosum and using alpha adrenergic agonist.
Additionally, some patients who do not respond to drainage of the corpus cavernosum may require shunt surgery. Olanzapine-induced
priapism was reported previously. Contrary to others, priapism was observed with single-dose olanzapine in our case; furthermore,
priapism occurred with repeated low doses of olanzapine. Another interesting aspect of our case is that the priapism did not occur due to
quetiapine during the two-year period, although the 600 mg/day dose of quetiapine is considerably higher than the equivalent dose of
olanzapine 2.5 mg/day. Both of drugs also affect similar receptors but their pharmacokinetic and pharmacodynamics profiles and binding
potentials on alpha-1 adrenergic receptors might be different. These differences might explain why in our case priapism occurred with
olanzapine and without quetiapine.
Keywords: olanzapine, priapism, schizoaffective
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S417-S8
[Abstract:0762] Pharmacotherapies
Tardive parkinsonism with aripiprazole
Erdem Onder Sonmez, Tulay Sati Kirkan
Department of Psychiatry, Erzurum Regional Training and Research Hospital, Erzurum-Turkey
e-mail address: [email protected]
Parkinsonism due to antipsychotic medications frequently occurs in the weeks after initiation of treatment. The typical signs are clogwheel rigidity, mask face, trembling at rest, bradykinesia and anterograde posture. Late disorders of movement should be associated with
at least one antipsychotic drug for at least 3 months, and should continue for at least 1 month after stopping this treatment. Although late
cases of Parkinsonism were reported before, data is limited and the presence of late Parkinsonism due to drugs is still unclear. Gupta and
Masand have shown that rates of extrapyramidal side effects with aripiprazole are similar to those of placebo administration. We present
here a case with late onset Parkinsonism secondary to aripiprazole use.
O.C. Male patient aged 54 years; primary school graduate. Complaints of introversion, persecution delusions and aggression had started
10 years before, and he had not received any treatments in 7 years. He had a cerebrovascular accident (CVA) 3 years before, with a mild
loss of strength at his right side and inability to speak as sequel. He was referred for a psychiatric consultation during his hospitalization for
CVA, and aripiprazole 10 mg was initiated. His relatives reported an increase in his communications and a decrease in aggression after this
treatment, and he had continued this treatment for the last 3 years regularly. The patient was admitted at the department of neurology
due to a slowing in his movements and tremor in his hands. Parkinsonism due to medications was considered as a working diagnosis,
and the patient was referred to our institution. Tremor was observed in both of his hands, rigidity was detected at both extremities, a
mask-face and clog-wheel signs were also found. His relatives reported the presence of this condition for 2 years, which had occurred one
year after initiation to psychiatric drugs. A late-onset Parkinsonism due to medications was considered, and the dose of aripiprazole was
decreased, until stopping it. At the end of 2 months, during which the patient was kept under close observation, signs of Parkinsonism
had totally improved.
Blockage of dopaminergic receptors at nigrostriatal pathways are considered to play a role in the mechanism of probable late-onset
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Parkinsonism. Symptoms of Parkinsonism were reported to persist for up to 3 months after termination of antipsychotics in elderly
patients. Our case is important in that late parkinsonism as a rare type of extrapyramidal syndrome was caused by a second generation
antipsychotic such as aripiprazole, which also rarely causes extrapyramidal syndrome. Abnormal involuntary movements should regularly
be checked with evaluation scales in patients who take second generation antipsychotic medications.
Keywords: tardive parkinsonism, aripiprazole, schizophrenia
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S418-S9
[Abstract:0763] Pharmacotherapies
Black hairy tongue associated with lithium: a case report
Atakan Yucel1, Nermin Yucel2, Unsal Aydinoglu1, Elif Oral1
1Department of Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
2Department of Child and Adolescent Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
e-mail address: [email protected]
Black Hairy Tongue (BHT) is a benign condition, characterized by hypertrophy and elongation of filiform papillae with black or brown
discoloration on the surface of tongue. Dry mouth is a commonly predisposed factor for the development of BHT. Side effects such as
dryness of mouth during lithium therapy is well documented that may have played a role in the development of BHT. We present here
the case of a male patient with bipolar disorder, who developed black hairy tongue on lithium treatment.
A 45 year-old male was referred from psychiatric department for the complaint of black discoloration on dorsum of tongue for 4 days
duration. Patient was a known case of bipolar affective disorder for which he had been receiving lithium for 10 years. There was no use
of cigarette and alcohol in his history. On examination of the oral cavity, elongated and hypertrophied filiform papillae was seen in the
posterior-dorsal of tongue, with black to brown discoloration. All laboratory tests including hemogram, liver function tests, kidney function
tests and electrolytes were normal. However he reported suffering diarrhea during a week before hairy tongue and at the same time
he neglected oral hygiene. He was in remission for 3 years with the treatment of lithium so medication was continued after the tongue
discoloration with recommendations such as cleaning his tongue with normal saline twice daily, drinking plenty of water and paying more
attention to oral hygiene in conditions with loss of fluid such as diarrhea. After two weeks, the discoloration of tongue totally disappeared.
During a follow-up of 2 years with lithium medication, our patient has not experienced further development of BHT as described above.
BHT is a rare and reversible condition. Etiological factors of BHT are various that include malignancies, smoking, heavy black tea or
coffee consumption, alcohol, radiation to the head and neck region, allogeneic stem-cell transplantation, and poor oral hygiene. Use of
systemic and local medications such as xerostomia agents, erlotinib, antibiotics and antipsychotics (olanzapine and chlorpromazine) may
predispose development of BHT. BHT has been reported associated with dry mouth as an adverse effect on treatment of combination
olanzapine and lithium before. However, in the present case, dry mouth, which is an adverse reaction of lithium, may have caused BHT.
Clinicians should recommend improving oral hygiene of patients that use drugs with a possible side effect of dry mouth.
Keywords: hairy, lithium, tongue
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S419
[Abstract:0768] Pharmacotherapies
Rabbit syndrome caused by paliperidone palmitate: presentation of a case
Erdem Onder Sonmez, Tulay Sati Kirkan, Hacer Akgul Ceyhun
Department of Psychiatry, Erzurum Regional Training and Research Hospital, Erzurum-Turkey
e-mail address: [email protected]
Rabbit Syndrome is an extrapyramidal clinical picture very similar to tardive dyskinesia. There is a perioral tremor in the chewing muscles,
resembling the chewing motions of a rabbit. Movements of the tongue nearly never accompany this clinical picture. It is known that
antipsychotic use rarely causes extrapyramidal syndromes. We present here a case of Rabbit syndrome caused by paliperidone palmitate.
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Case Report Abstracts
F.U. 36 year-old, single, college graduate. Schizophrenia was diagnosed approximately 5 years ago, with complaints of persecution and
reference delusions, introversion, auditory hallucinations. Treatment was initiated with antipsychotics such as olanzapine, aripiprazole,
and haloperidol. The patient did not take the medications regularly, and complaints persisted, after which treatment with paliperidone
palmitate 150 mg/month was started. The complaints showed a partial improvement with this treatment. Approximately 6 months
after starting this treatment, rhythmic movements had occurred around the mouth and the patient was admitted at our outpatient
clinics due to this complaint. The patient was conscious, with an intact orientation, normal thought content, slowed thought flow, and
decreased talking at his/her psychiatric evaluation. Perioral tremor was observed at physical examination, with absent involuntary tongue
movements. Other signs of extrapyramidal system such as rigidity and clogged wheel were not detected. Results of biochemistry and
hematology tests were normal at laboratory investigations. The patient was not expected to use oral medications, and risperidone consta
50 mg/15 days were started. Perioral tremor was observed to decrease considerably after 3 months.
Rabbit syndrome may be seen after a long-term or short-term use of antipsychotics. The patient we present here had taken 100 mg/
month paliperidone palmitate for 6 months, before development of rabbit syndrome. Use of paliperidone palmitate was considered to
cause this rabbit syndrome.
Keywords: paliperidone palmitate, rabbit syndrome, schizophrenia
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[Abstract:0775] Pharmacotherapies
Drospirenone/ethinyl estradiol induced mania
Atakan Yucel1, Nermin Yucel2, Mehmet Akif Camkurt3
1Department of Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
2Department of Child and Adolescent Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
3Department of Psychiatry, Afsin State Hospital, Kahramanmaras-Turkey
e-mail address: [email protected]
Combined oral contraceptives (COC) such as drospirenone/ ethinyl estradiol is widely used for effective birth control methods in many
countries. On the other hand, oral contraceptives are commonly prescribed in order to ameliorate irregular menstrual bleeding and
menstrual-related side effects. In our case, we present a case of hypomania after using drospirenone/ ethinyl estradiol for regulation of
menstrual cycles.
A 27 year-old female patient with bipolar disorder was admitted to outpatient clinic with gradually increased complaints of hypomanic
symptoms such as cheerfulness, distractibility, talkativeness, insomnia, hypersexuality and self-esteem which was lasting 6 days. She
mentioned that she had used drospirenone/ ethinyl estradiol in order to manage her irregular menstrual cycles and bleeding for 8 days.
In her medical history, she was followed with diagnosis of bipolar disorder and treatment with valproic acid (VPA) 1000 mg/day for 5
years. She experienced 2 manic episode and 1 depressive episode during the last 5 years. There was no psychiatric family history. In her
psychiatric examination, she was conscious and oriented. Her affect and mood were elevated. Her speech was understandable and rapid.
There were no hallucinations or delusions. Her physical, neurological and laboratory examinations were unremarkable. Blood level of VPA
was 53 (N: 50-100). The diagnosis was compatible with hypomania related with drug according to DSM-5. VPA dose increased to 1500
mg/day and quetiapine 100 mg/day was started and discontinuation of drospirenone/ ethinyl estradiol was advised. The hypomanic
symptoms recovered completely in 2 weeks and quetiapine was stopped after regulation of sleep cycles one more week. At the end of
3rd month, the medication was tolerated well, and there was no any hypomanic and other psychiatric symptom observed.
VPA is used for epilepsy and bipolar disorders, widely eliminated by hepatic glucuronidation which is activated by COC. Therefore, the
serum concentration and pharmacologic effect of VPA may be reduced by COC. As far as we know, our case who induced hypomania by
drospirenone/ ethinyl estradiol, is the first in the literature. In the case of intervention that adding or withdrawing of drug, in patient with
bipolar disorder or epilepsy, the physician should take into account of drug interaction. Also it might be useful if the patient is consulted
to related department for closely monitoring the dosage of VPA and symptom profile. We would like to emphasize the importance of drug
interaction in clinical practice.
Keywords: drospirenone, ethinyl estradiol, mania
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[Abstract:0791] Pharmacotherapies
Olanzapine induced tardive oculogyric crisis: a case report
Gamze Akcay, Duygu Kubra Gocmen Yigit, Salime Gursoy, Medine Yazici Gulec
Erenkoy Training and Research Hospital, Istanbul-Turkey
e-mail address: [email protected]
Atypical antipsychotics have high binding affinity to 5-HT (2A,2C,6,7), alpha adrenergic, muscarinic and histaminergic receptors and low
binding affinity to dopaminergic (2A) that is associated extrapyramidal side effects receptors.
Atypical antipsychotics is considered to cause metabolic and hormonal side effects such as hyperlipidemia, hyperprolactinemia,
predisposition to diabetes mellitus, sedation etc. more than extrapyramidal symptoms and tardive syndromes that are commonly
associated with the use of typical antipsychotic drugs. However, atypical antipsychotics are increasingly being associated with
neurological side effects.
Tardive oculogyric crisis is a manifestation of tardive dystonia characterized by sustained upward deviation of eyeballs and restlessness.
Olanzapine that is an atypical antipsychotics with an intermediate level of D2-binding affinity is not expected to cause oculogyric crisis.
But in higher doses, olanzapine has been shown to have high D2 affinity, increasing the chance of oculogyric crisis. We aimed to present
a young male with bipolar and obsessive compulsive disorder who had developed tardive oculogyric crisis with low dose olanzapine.
A 23 year-old single male diagnosed of bipolar affective disorder and obsessive compulsive disorder for 2 years had been hospitalized
five times. He was receiving oral olanzapine (7,5 mg/day) for 2 years intermittently. He complained of recent onset repeated episodes of
sustained upward deviations of eyeballs, along with anxiety; restlessness; backward flexions of neck and intrusive, unwanted thoughts
of mess someone over, abuse/rape/kill someone like his mother or sister. The stereotyped cluster of symptoms occurred 2-3 times per
day for a month and spontaneously remitted after 1-2 hours. He could not voluntarily bring down the eyes to normal position. He was
distressed by these symptoms and expressed feeling culpability. These episodes mostly occured in the evenings and improved with sleep
and its frequency was increased with stress. “Tardive dystonia” was a term introduced by Burke in 1982. The syndrome of tardive dystonia
has been reported with most of the typical antipsychotics. Compared with typical antipsychotics, olanzapine has a greater affinity for
serotonin 5-HT2A than dopamine D2 receptors and affects the mesolimbic dopamine pathway more than the nigrostriatal dopamine
pathway thus olanzapine is accepted to have low extrapyramidal adverse effects than typical antipsychotic drugs. CATIE study has
seriously doubted the prevalent belief of atypical antipsychotics including olanzapine having lesser neurological side effects. Our case
report supports this doubt. Although possibility of such a side effect is low, we still need a cautious approach regarding this agent. Also, it
is reported that comorbid obsessive-compulsive syndrome was related to tardive movement syndromes. However, more data is required
to know the typical characteristics and risk factors associated with olanzapine-induced TD.
In our case, the direction of eyeball, the associated symptoms and both remitting of oculogyric crisis and associated symptoms were
similar to those previously reported. It is remarkable that our case was a young man diagnosed with bipolar affective and obsessive
compulsive disorder experienced oculogyric crisis with low doses of olanzapine.
Keywords: obsessive compulsive disorder, oculogyric crisis, olanzapine
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S421 [Abstract:0803] Pharmacotherapies
Depression and electroencephalography anomaly as a result of colchicine use in an adolescent with
familial Mediterranean fever
Birim Sungu Talu1, Celal Salcini1, Husnu Erkmen1, Selime Celik2
1Uskudar University, Istanbul-Turkey
2Sisli Hamidiye Etfal Research and Training Hospital, Istanbul-Turkey
e-mail address: [email protected]
Familial Mediterranean Fever is an autosomal recessive autoinflammatory disease characterized by paroxysmal attacks of serosal
inflammation. Colchicine is highly effective in preventing these attacks. In this poster presentation we report an adolescent case with
familial Mediterranean fever using colchicine presented with depression and electroencephalography (EEG) anomaly
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The 15 year old female patient had no psychiatric or neurological symptoms or disorders prior to colchicine use. She presented to our
clinic with headache, fatigue, inability to concentrate, anhedonia. Her mental motor development history was normal. She claimed that
she had presenting symptoms for 1 year. She had a prediagnosis of Familial Mediterranean Fever 3 years ago and she was using colchicine
1 mg/day for 1 year. Her psychiatric examination revealed retardation of psychomotor activity, depressedmood, anxiousaffect. She had no
ideation of suicide or homicide, no psychotic symptoms.
Bilateral temporocentral high amplitude slow wave activity was detected on EEG. Head M.RI was normal.She scored 93 on WISC-R
Intelligence Test, performance and verbal IQ were 94,93 correspondingly. Her blood cell count, thyroid function tests, levels of B12,
vitamin D3, iron, liver and kidney function tests were all within normal limits. Beck Anxiety Inventory and Beck Depression Inventory
scores were 4 and 9 respectively. In light of literature after consultation with pediatrics colchicine was stopped due to fact that it could
be responsible for the presenting symptoms. After 4 week EEG was repeated and was normal. During her 1 year follow up she had no
symptoms, Beck Anxiety Inventory scores, Beck Depression Inventory scores were 1 and 0 respectively
Colchicine is an alkaloid with an antimitotic activity, interfering microtubule formation thus causing central nervous system side effects.
Colchicine is used to make epileptic foci in rats experimentally. Especially intracranial use of colchicine can cause convulsions and death.
Frequently diarrhea and rise of transaminases can be seen. To the best of our knowledge this is the first case of depression associated with
EEG anomaly in an adolescent with a prediagnosis of Familial Mediteranian Fever using colchicine.
Keywords: depression, colchicine, adolescent
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S421-S2
[Abstract:0808] Pharmacotherapies
Neuroleptic malignant syndrome following initial parenteral treatment in a patient who uses oral
haloperidol: a case report
Selma Huner, Merih Altıntas, Neslisah Atguden, Gamze Akcay
Erenkoy Training and Research Hospital, Istanbul-Turkey
e-mail address: [email protected]
Neuroleptic Malignant Syndrome (NMS) is a life threatening idiosyncratic reaction, associated with the use of neuroleptic drugs. NMS
manifests itself with fever, muscle rigidity, altered mental status and autonomic imbalance tetrad in 50% of patients. In most cases,
symptoms occur within the first two weeks of treatment, even with low dose drug administration. Intramuscular administration is a risk
factor. Approximately half of the cases have increased creatine kinase levels and leukocytosis in early stages.
49 year-old male, high school graduate, married with two children, lives with his family. He has been unable to work for 20 years. Patient
has been hospitalized three times over the course of 24 years of schizophrenia, the most recent one was 15 years ago. The patient has
been in remission for 15 years with haloperidol 5mg/day. Patient has not attended to clinical controls, yet he has had proper sociability
and partially protected functionality. When haloperidol was not available in the market, a month age after patient admitted to the clinic,
risperidone 2mg/day and quetiapine 50mg/day has been started as replacement. It was learned that four days ago, soliloquy, crying,
extreme suspiciousness, receiving private messages from TV, hostile behaviors towards relatives and insomnia started. Patient was
admitted to service with the diagnosis of schizophrenia.
Once patient was admitted to the service, haloperidol 20 mg/day, biperidene 4 mg/day, chlorpromazine 100 mg/day and lorazepam
1 mg/day has been started. He was kept in close observation, due to his homicidal behaviors towards other patients and healthcare
personnel. Blood tests results were AST:507, ALT: 87, urate: 15.5, LDH: 2491, CPK: 4000. Leukocytosis was present at that time and fever
had begun. CPK value was elevated to 42.670 shortly afterwards. 3000 cc/day fluid infusion was started. The patient was diagnosed with
NMS in intensive care unit. Although forced diuresis was applied, CPK value did not return to normal range. ECT was administrated and
clozapine was started.
Herein, we report a case which psychotic relapse occurred after 15 years remission with haloperidol 5mg/day when treatment was
changed. As in this case, in which no hospitalization has been required, sociability and functionality has been preserved for 15 years prior
to medication change, clinicians should be careful in changing beneficial treatment, unless there is an important justification for this
change.
Neuroleptic malign syndrome can be seen anytime during neuroleptic treatment, though more frequently it has a tendency to occur
24-72 hours later after beginning of treatment or high increase in dose in particular, or after parenteral use. Symptoms can last 44 days,
although in average they continue 1-10 days. In this reported case, after 15 years of oral drug administration, our patient experienced
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Case Report Abstracts
NMS following first parenteral dose.
In this case report, we want to emphasize that extensive caution and consideration should be given by clinicians before changing
beneficial treatment, as even the already used antipsychotic drugs can trigger NMS when administered parenterally.
Keywords: neuroleptic malignant syndrome, antipsychotic, parenteral
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S422-S3
[Abstract:0817] Pharmacotherapies
Kleptomania after pramipexole use in a case of restless leg syndrome
Birim Sungu Talu1, Celal Salcini1, Husnu Erkmen1, Selime Celik Erden2
1Uskudar University, Istanbul-Turkey
2Sisli Hamidiye Etfal Research and Training Hospital, Istanbul-Turkey
e-mail address: [email protected]
Kleptomania is the recurrent failure to resist urges to steal items which aren’t needed or have little value. Impulse control failure results
with emotional and behavioral problems. Herein, we report a case with kleptomania after pramipexole use for treatment of restless leg
syndrome and cessation of kleptomania after pramipexole was stopped.
The 60 year old female patient had no psychiatric or neurological symptoms prior to pramipexole use. She reported that she had been
stealing items having little value from markets such as chewing gum or chocolate for 6 years. She declared failure to resist urges to steal
and informed her family for getting help from them to resist. She stated she was using pramipexole 0.5 mg/day for 6 years which was
prescribed for her restless leg syndrome. Her psychiatric examination revealed depressed mood. She had ideas of guilt and regret because
of her stealing experiences. Her blood cell count, routine biochemistry workup was within normal limits. Her head magnetic resonance
imaging was normal. Her electroencephalography was normal with predominant slow teta waves. Her neuropsychological assessment
was done. Her personal and current information fields were sufficient. Her orientation was intact, her ability to concentrate was mildly
detoriated,verbal fluency was mildly decreased, her Stroop test was normal, parietal fields responsible for visual and spatial functions
were intact, understanding and naming objects were intact, primary and secondary memory processes were preserved. Visual memory
and instant memory were mildly detoriated. After consultation with neurology pramipexole was stopped. During 1 year follow up she
reported no urge to steal and had no experience of stealing
Many class of drugs are used for the treatment of restless leg syndrome. Among them dopaminergic agents and alpha 2 ligand are mostly
used ones. Pramipexole has high affinity for cerebral D3 receptors. D3 receptor expression is high in limbic system which has important
roles in modulation of physiological and emotional experiences such as novelty, reward, risk assessment. Pathological gambling,
hypersexuality and compulsive shopping associated with dopamine receptor agonist drugs were reported. Thus restless leg syndrome
patients should be cautioned about potential dopamine dysregulation syndromes. To the best of our knowledge, this is the first case of
kleptomania described after pramipexole use due to treatment of restless leg syndrome.
Keywords: restless leg syndrome, pramipexole, kleptomania
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S423
[Abstract:0824] Pharmacotherapies
Increased liver enzymes induced by long acting risperidone
Saliha Ozsoy, Koksal Dinc, Figen Unal, Mustafa Erdogan
Department of Psychiatry, Erciyes University, Faculty of Medicine, Kayseri-Turkey
e-mail address: [email protected]
Few studies reported risperidone-induced hepatic abnormalities. Long acting risperidone is known generally associated with lower
side effects and discontinuations due to adverse events. The aim of our case report is to point out long acting risperidone associated
hepatotoxicity. A 29 year-old male patient was suffering from schizoaffective disorder for three years. He had poor medication compliance
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Case Report Abstracts
and was hospitalized three times for mania with psychotic features. Biochemical tests were within normal range before treatment. He was
treated with long acting injectable (LAI) risperidone 50 mg, valproic acid 2000 mg/day and oral risperidone 3 mg/day at the beginning of
treatment. While he was taking LAI-risperidone and valproic acid, laboratory investigation revealed elevated liver enzyme levels (62 U/l
for aspartate aminotransferase (AST), 98 U/l for alanine aminotransferase). Possible cause of elevated liver enzymes levels was considered
to be valproic acid, so it was discontinued and switched to lithium treatment. Liver enzyme levels did not change, even after one month
of valproic acid treatment termination AST/ALT levels increased to 68/128. The probable other causes of hepatitis were excluded through
consultation with gastroenterology. However, we realized that elevation of the liver enzymes was induced by risperidone injection
concomitantly.
In conclusion, monitoring of liver function test was recommended during antipsychotic treatment.
Keywords: risperidone, liver, enzymes
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S423-S4
[Abstract:0831] Pharmacotherapies
Acute dystonia in two first episode psychosispatients due to aripiprazole treatment: case reports
Ibrahim Oner1, Alparslan Asil Budakli1, Onat Yilmaz2, Mehmet Alpay Ates1
1Department of Psychiatry, GATA Haydarpasa Training Hospital, Istanbul-Turkey
2Department of Psychiatry, Kasımpasa Military Hospital, Istanbul-Turkey
e-mail address: [email protected]
Dopamine hypothesis keeps its place in the etiology of schizophrenia and the mechanisms of antipsychotic drugs acts on dopaminergic
system. Dopamine receptor antagonism might cause unfavorable movement disorders in the patients. Aripiprazole, acting as a partial
agonist of dopamine, rarely causes adverse effects. We report two cases of acute dystonia after aripiprazole treatment in first episode
psychosis.
A 20 year-old male patient was referred to our inpatient clinic with a two month history of paranoid delusions. He had no history of
psychiatric treatment before. He fulfilled the criteria of DSM-TR diagnosis of psychotic disorder. Laboratory and imaging tests and EEG
revealed no organic causes. He was started on the treatment of aripiprazole 10 mg per day and on the fifth day of treatment oculogyric
crisis and bilateral dystonia in elbow joints was detected. Three days after adding biperidene 4 mg per day to treatment, all adverse affects
were diminished.
B 22 year-old male patient was referred to our psychiatry department with a three month history of disorganized speech and behaviors,
verbal hallucinations and lack of awareness. He had a history of cannabis abuse with some features of Cluster B personality traits but
had no history of treatment. Laboratory and imaging tests and EEG revealed no organic causes. He was started on the treatment of
aripiprazole 15 mg per day and on the 10th day of the treatment the dosage raised to 30 mg per day due to insufficient treatment
response. In the very next day, akathisia, torticollis and rigidity in bilateral elbow and ankle joints were detected. Biperidene 2 mg per day
added to the treatment and three days after addition he was symptom free of any adverse affect.
Aripiprazole mechanism has been attributed to their serotonin 5HT2A,C receptor antagonism and/or 5HT1A partial agonism in addition
to its dopamine D2 receptor antagonism. Having lesser than 60% D2 receptor blockage causes insufficient affect and more than 80%
blockage of D2 receptors results in adverse effects. Blockade of dopamine receptors in the mesolimbic pathway is thought to mediate
antipsychotic efficacy, in particular the ability to decrease positive symptoms. However, D2 receptor blockade in the mesocortical,
nigrostriatal, and tuberoinfundibular pathways is correlated with a dysfunctional reward system and increased liability for extrapyramidal
symptoms. According to this, we hypothesize that, rapid dose increase in the second case might cause these adverse effects.
Keywords: acute dystonia, first episode psychosis, aripiprazole
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[Abstract:0835] Pharmacotherapies
Mirtazapine induced hypertension: case report
Birmay Cam
Manisa Mental Health and Diseases Hospital, Manisa-Turkey
e-mail address: [email protected]
Mirtazapine has a double effect antidepressant and increase both noradrenergic and serotonergic transmission. Mirtazapine block
5-HT2A and 5HT3 receptors and stimulates 5HT1A receptor. We presented an elderly patient who has hypertensive attacks as a result of
mirtazapine treatment.
72 year-old woman. The patient was admitted to the psychiatry outpatient clinic with unhappiness, anxiety, insomnia, loss of appetite.
There was no previous psychiatric admissions. Five years were diagnosed with hypertension and diabetes mellitus. The patient was
taking perindopril 10 mg/day and metformin 1000 mg/day the last year. Blood pressure and blood sugar was followed regularly. Liver,
kidney function tests, electrolytes, thyroid function tests were normal. 15 mg/day mirtazapine was started to patient diagnosed with
mixed anxiety and depressive disorder. After 5 days, the patient was again admitted to the clinic because of high blood pressure. Tension
was 160/90. The patient was consulted by internal medicine physicians and tests were normal. We were thought to be related to high
blood pressure and mirtazapine and mirtazapine was stopped. Patient came for a week later and had blood pressure remained normal.
Escitalopram 10 mg/day and quetiapine 25 mg/day treatment was started to patient. Depressive and anxiety symptoms had partially
improved after a month and blood pressure remained normal. Escitalopram dose of 20 mg/day was increased. Depressive and anxiety
symptoms of patients were in complete remission and blood pressure was normal along for a year.
In our case, hypertension begins after mirtazapine treatment and the blood pressure remained normal after discontinuation of treatment.
Liver, kidney function tests, electrolytes, thyroid function tests were normal. Hypertension depending on mirtazapine is limited to case
reports in the literature. Daniel and his friends reported 36 year-old female patient used venlafaxine and mirtazapine, develops the
hypertensive episode, this effect would depend on noradrenergic activity-dependent increase combinations mentioned, argued that
the improve of hypertensive episode with the discontinuation of venlafaxine. 75 year-old man connected to the patient mirtazapine
serotonin syndrome has been observed to develop hypertension, researchers has been proposed low doses below 15 mg in elderly
patients. Another case report, clonidine and mirtazapine combination was seen hypertension. Mirtazapine used in high doses (45 mg/
day), which separates from the ground and are said to bind the clonidine reduced the antihypertensive effect.
Especially be careful in the choice of the side effects of antidepressants in elderly patients, it is important to consider the drugs.
Keywords: antidepressant, hypertension, mirtazapine
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POST-TRAUMATIC STRESS DISORDER
[Abstract:0362] Post-traumatic stress disorder
Does posttraumatic stress disorder occur with the learning of the traumatic experiences? case report
Taner Oznur1, Abdullah Bolu2, Suleyman Akarsu3, Emre Aydemir1
1Department of Psychiatry, Gulhane Military Medical Academy, Ankara-Turkey
2Aircrew’ s Health Research and Training Center, Eskisehir-Turkey
3Aksaz Naval Hospital, Mugla-Turkey
e-mail address: [email protected]
Posttraumatic Stress Disorder (PTSD) diagnostic criteria have changed with DSM-5. The most important changes are adding the criteria of
learning the traumatic experience of a family member or close friend (A3) and exposure to traumatic events intensely due to professional
obligations (A4) in to the criteria of exposed to traumatic events exactly or to witness to traumatic events (A1-A2). Herein, we present the
case of PTSD developed after the learning the violence that his grandson and bride exposed.
A 61 year-old male patient. He was admitted to the psychiatric outpatient clinic with complaints of irritability, inability to sleep at night,
nightmares, to live traumatic events again, not to do his daily activities, to avoid from the crowds and events reminiscent of street protests.
His complaints were initiated after the learning of violence that his grandson and bride exposed from the street activists about 3 months
ago by phone. The first complaints were in the form of insomnia and nightmares. An increase in his complaints was occurred after moving
into house of bride and grandchildren because of the security concerns. Patient did not receive a psychiatric treatment before. He had
witnessed a terrorist attack in 1992 in a city but had not have any complaint at that time. Mostly he concurrently began to re-experience
the violence that his grandson and bride exposed and the terrorist attack that he witnessed in the past. In relation to this, an increase in
the nightmares had occurred. He was afraid of the idea of exposing to demonstrations, boycotts and actions so he could not leave the
house. Similarly, he did not allow his wife, bride and grandson to go out except compulsory conditions. He was staying away from the
television and newspaper. The patient was diagnosed as Post Traumatic Stress Disorder by psychiatric evaluation and CAPS. Traumatic
experiences of the patient in the past did not cause PTSD, however it had functioned as a facilitating factor for the development of
psychopathology. PTSD was considered to develop after learning the traumatic events lived by family members.
Classification of PTSD has been the subject of debate with the publication of DSM-5. The question that is PTSD a stress-related disorder or
an anxiety disorder have been discussed at different platforms. Another change brought by DSM-5 is the definition of trauma. Definitions
relevant to the subjective components of traumatic events in DSM-IV are extracted and instead of it, definitions about the details of the
traumatic event have been added. This change is in line with the principle of objectivity and clarifying the boundaries. With the expansion
of the definition, probably not previously considered PTSD cases gained the possibility to meet these diagnostic criteria. Therefore, there
will have economic and other important outcomes of this change.
Keywords: DSM-5, learning, trauma
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[Abstract:0603] Post-traumatic stress disorder
Neurobiological developments in posttraumatic stress disorder: neuroimaging updates
Abdullah Bolu
Aircrew’s Health Research and Training Center, Eskisehir-Turkey
e-mail address: [email protected]
Resting-state neuroimaging studies have attracted attention in recent years. Seven neural network related to the different regions of the
brain were mentioned in this Method: Default mode network (DMN), Salience network (SN), Executive control network, dorsal attention
network, Auditory network, Visual network and sensorimotor network. Increased or decreased connectivity were observed between
some DMN regions. Findings about the relationship between the strength of this connectivity and the severity of PTSD symptoms
were conflicting. Some evidence has been obtained which is believed to be a prognostic indicator for PTSD symptoms. Resting-State
neuroimaging findings were obtained between the posterior cingulated cortex and amygdala. Increased connectivity between SN and
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DMN has been identified. PTSD has been associated with altered brain responses between limbic and paralimbic regions as a response
to emotional stimuli related with the trauma. A positive correlation has been demonstrated between altered low-frequency fluctuation
of cortical thickness and medial prefrontal cortex (PFC) and PTSD symptoms. Some authors have taken the idea that structural integrity
of medial PFC may affect other brain functional network connections and this may contribute to the progress of the PTSD process.
Connection status of brain regions associated with cognitive-behavioral outcomes was investigated and remarkable results were
obtained. In addition that, hippocampus that is associated with episodic memory was scrutinized. Relationship between all these
obtained findings and symptoms of PTSD were examined. Brain in the form of resting-state was examined in the recently published study
about magnetoencephalography (MEG). PTSD symptoms scores are associated with left amygdala and posterolateral OFC and negatively
with MEG activity in vmPFC and precuneous.
Keywords: neurobiological, neuroimaging, posttraumatic stress disorder
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[Abstract:0613] Post-traumatic stress disorder
Posttraumatic stress disorder after an internet game: a case report
Gulen Guler, Veli Yildirim, Fevziye Toros
Department of Child and Adolescent Psychiatry, Mersin University, Faculty of Medicine, Mersin-Turkey
e-mail address: [email protected]
There are some studies about that violent television images may have an effect on development of posttraumatic stress disorder (PTSD).
The relationship between development of PTSD and viewing scary internet games, movies, and pictures is not known yet. Until now, there
has been any publication about internet games whether can cause PTSD. In the present report, we will share a case developing PTSD after
seeing an internet game.
A 13-year-old-boy. He saw an internet game about zombies, scary creatures, war and death, on his friend’s notebook, two months ago.
He was referred to our clinic with complaints of insomnia, nightmares, irritability, anxiety, fear, avoidance of loneliness, flashbacks of the
scary creatures and bloody scenes. He couldn’t keep away flashbacks from his mind all day. He has remembered zombies whenever he saw
soil and something in green. He has woken up at the midnight with sweat. Additionally he developed insomnia and reduced appetite. He
couldn’t take attention to his lessons anymore. He was concerned that zombies might come into his class and maybe, they might harm to
himself. He was aware that his fear was very extreme. He was very depressed and about to cry. He began to pray to get rid of these fears.
He wanted to be able to erase the memory but if not possible, he wanted to die. Before this, he had no psychiatric history. There was no
family history of any psychiatric illness and developmental milestones were reportedly normal. It was considered the most appropriate
diagnosis for this patient as PTSD.
PTSD diagnostic criteria were revised by DSM-5 and traumatic events concept were expanded. According to DSM-5, person may have
experienced traumatic event himself or witnessed. Indirectly, he may have learned that a close friend was exposed to trauma. He may
have confronted repeatedly or indirectly to unpleasant details of the event but this does not include exposure through electronic media,
television, movies, or pictures, unless this exposure is not related to professional career. A study about 1995 Oklahoma city bombing
showed watching television about trauma may make contribution to PTSD. Another study also highlight watching violent television
images can cause PTSD. In the literature, a 22 year old woman who presented with intrusive thoughts flashbacks of a horror film was
reported, but there is no case or study that scary internet games, zombies, or vampires can cause PTSD. In this case, the patient developed
PTSD after he had exposed scary internet game as distinct from DSM-IV and DSM-5. It must be kept in mind that internet games may have
a traumatic effect and cause PTSD on children and adolescents. Further researches are needed on this regard.
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[Abstract:0667] Post-traumatic stress disorder
Eye movement desensitization and reprocessing (EMDR) therapy for complex post traumatic stress
disorder
Onder Kavakci
Department of Psychiatry, Cumhuriyet University, Faculty of Medicine, Sivas-Turkey
e-mail address: [email protected]
Complex Post Traumatic Stress disorder (C-PTSD) is quite different formally diagnosed PTSD. Complex psychological trauma involving
traumatic stressor that are repetitive or prolonged, involve direct harm and/ or neglect and abandonment by caregivers or ostensibly
responsible adults, occur at development vulnerable times in the victim’s life, such as early childhood and have a great potential to
compromise severely a child’s development.
Due to nature from repeated interpersonal or chronic or early traumatic experiences, C-PTSD cause severe impairment for mental health.
These patients have problems many different areas, which include emotion dysregulation, dissociation, somatic distress, identity and
relational disturbance and spiritual alienation. There are no formal diagnosis in DSM-5, but this disorder is defined ICD-11. Patients
with C-PTSD do not respond to the conventional therapy. Eye movement desensitization and reprocessing (EMDR) is different therapy
approach that accelerates information processing and facilitates the integration of fragmented traumatic memories. This process is stated
to allow better integration of the information that a person has to handle in the future. Recently developed therapeutic EMDR related
tools possibility providing treatment for CPTSD. In these course will be discussed new developments for C-PTSD and it’s EMDR related
therapeutic options.
Keywords: complex post traumatic stress disorder, eye movement desensitization and reprocessing, therapy
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[Abstract:0766] Post-traumatic stress disorder
Treatment of a sexual abuser who occured Posttraumatic Stress Disorder symptoms with Eye
Movements and Desensitization and Reprocessing
Ali Karayagmurlu1, Elif Karayagmurlu2, Gokay Alpak3
1Department of Child and Adolescent Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
2Department of Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
3Department of Psychiatry, Gaziantep University, Faculty of Medicine, Gaziantep-Turkey
e-mail address: [email protected]
Eye Movements and Desensitization and Reprocessing (EMDR) is an effective treatment method that used in Posttraumatic Stress
Disorder (PTSD) combines well-known elements of the different approaches such as psychodynamic, cognitive, behavioral and clientcentered approach. PTSD, psychiatric symptoms including cognitive, emotional, behavioral and social disorders as a result of experienced
or witnessed life-threatening trauma to a person’s life and physical integrity. In recent years, there has been an increasing amount of
literature on efficacy of EMDR in PTSD. Besides PTSD, there have been some publications on the efficacy of EMDR in patients with chronic
pain, phantom pain, specific phobia and stress related disorders. In this paper, EMDR treatment of a 26-year-old male, who have been
found in the harassment by touching two children ten years ago and six years later his symptoms like relive the event itself, nightmares,
sudden awakening from sleep and desperation, was presented.
A 20 year-old single male patient (Z.U.) living with his family was referred to our outpatients clinic with the complaints of restlessnes, quick
temper, sudden awakening from sleep, relive the event itself. According to the information received from the patient, he have been found
in the harassment by touching two children ten years ago and six years later his complaints were started and were increased in the last
year. He was diagnosed with PTSD according to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Drug therapy
with venlafaxine 150 mg/day was initiated and EMDR treatment was suggested. Two EMDR sessions were applied and PTSD symptoms
regressed after the treatment.
EMDR focuses to the perceptual components of the memory (emotional, cognitive and physical) to speed up the processing of the
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disturbing event and to improve the learning process. EMDR which is used in the treatment of PTSD were found to be effective in many
studies. A meta-analysis made by Bisson et al Trauma Focused CBT and EMDR has been reported to be superior to other therapies in the
treatment of PTSD. This case is important because there are relatively few case reports regarding EMDR treatment of sexual abusers who
occured PTSD symptoms in the literature. As a result, clinicians should note that EMDR is a treatment option for patients with PTSD.
Keywords: EMDR, PTSD, sexual abuser
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[Abstract:0773] Post-traumatic stress disorder
Differential diagnosis and treatment in an adolescent case with complex posttraumatic stress
disorder
Ezgi Eynalli, Aysegul Yolga Tahiroglu, Ozge Metin, Ayse Avci, Gonca Gul Celik
Child and Adolescent Psychiatry Department, Cukurova University, Faculty of Medicine, Adana-Turkey
e-mail address: [email protected]
There are some common symptoms of posttraumatic stress disorder (PTSD) and bipolar disorder (BPD) like affective dysregulation, sleep
disturbances, aggressive behaviors. Younger age of onset and repeated interpersonal trauma are associated with a more complicated
symptom profile, sometimes referred to as complex PTSD. Here, we report an adolescent case of complex PTSD was misdiagnosed
psychotic attack and bipolar disorder.
A 14 year-old girl who was referred to child and adolescent outpatient clinic with the complaint of auditory hallucinations that gave
orders, said to self-harming, tactile hallucinations (like someone was touching her), suspiciousness, feel that watched in 2007. Clinician
made a preliminary diagnosis of acute psychotic attack. So, she received aripiprazole 5 mg/day and gradually dose was increased to
15 mg/day. One month later, she told that suffered from increasing psychotic symptoms, somatic complaints, dissociative amnesia
and syncope. After than aripiprazole dose was increased to 20 mg/day. After two months, she exhibited elevated mood, reduction
on requirement of sleep, talkativeness, distractibility, poor attention and moderate increase in psychomotor activation. Because the
diagnosis of hypomanic episode, valproic acid 500 mg/day began and it was titrated to 750 mg/day gradually. Her psychotic and
dissociative symptoms decreased with this treatment. In the course of treatment aripiprazole was decreased to 10 mg for extrapyramidal
side effect. Her mood state was euthymic for five months. After then she told that suffered from depressive mood, depressive thoughts,
suicidal ideas and attempted suicide. In the light of this clinic, we thought a depressive episode of bipolar affective disorder. Increase in
frequency of dissociative syncope was also recognized. So sertraline 50 mg/d was added to treatment. Hypomanic symptoms were begun
after a week which sertraline was added to treatment. Aripiprazole was increased to 15 mg/day and sertraline treatment has ended. In
the course of one-year period we had seen a significant reduction in psychotic and mood symptoms. She told us that was victim of sexual
abuse by familiar person in six year-old at the end of the first year of clinical follow-up. She had been suffered from sexual abuse almost
every night for a year. In the light of this information, following psychiatric assessments were focused on this abuse and the effects of the
patient’s life. All the symptoms except dissociative symptoms decreased dramatically after this disclosure although same treatment. Soon,
patient’s symptoms stopped abruptly and spontaneously. After then all drugs were gradually discontinued within six months. We were
not observed affective or psychotic symptoms during three years of follow-up.
Affective destabilizations, behavioral dysregulation, sleep disturbances on patient caused to misdiagnose BPD instead of PTSD. Then,
symptoms of PTSD were realized like prominent dissociation, dissociative syncope attacks, somatic symptoms, rapidly switch of the
patient’s symptoms after the sertraline was started. Sexual abuse history was the last evidence of PTSD diagnosis. The described case
indicates that sexual abuse of children and adolescents frequently remains unrecognized. It is important to emphasize the significance of
examining history of abuse during the diagnostic of certain mental disorders.
Keywords: bipolar disorder, posttraumatic stress disorder, sexual abuse
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[Abstract:0811] Post-traumatic stress disorder
Current treatment modalities for children and adolescents with post traumatic stress disorder
Gonca Celik
Department of Child and Adolescent Psychiatry, Cukurova University, Faculty of Medicine, Adana-Turkey
e-mail address: [email protected]
Childhood sexual abuse like other childhood adversities (neglect, emotional abuse, physical abuse) results with impairment of
development.
The bio-psychosocial model of Post Traumatic Stress Disorder (PTSD) suggests that effects of an environmental event are not limited
to the initial exposure, but also can persist through the lifespan. It is reported as cumulative trauma predicts of symptom complexity
in children. In accordance with this, a new diagnostic category, Developmental Trauma or Complex Traumatic Disorder, has been
emphasized in DSM-5 classification.
Reactions to trauma exposure are defined according to their timeframe: Immediate or peri-traumatic (lasting minutes to hours), Acute
Stress Disorder (lasting between two days and one month), and PTSD (when symptoms persist for more than one month). A vast majority
of abused child and adolescents would not have attended to clinics because of fear of stigma.
Treatments with evidence of effectiveness for child and adolescent PTSD are Cognitive Behavioral Therapies. Some studies of youth
suggest that cortisol levels can be altered by therapy interventions. Cognitive Behavioral Therapy, Trauma Systems Therapy, Psycho
Education are the most emphasized issues about trauma therapy. It is important to support a therapeutic alliance with caregivers because
children and adolescents need their parents to take clinical care.
Considering the developmental pattern of traumatic events, treatment modalities may vary by depending on individual variables (age,
gender, co-morbid psychiatric disorders, family history, academic achievement, life-threaten conditions). For example while a PTSD
patient who has ADHD co-morbid bipolar diagnosis may response to methylphenidate, however its dopaminergic and noradrenergic
activity may worsen the flashbacks or traumatic memories in other subjects. Some treatment guidelines recommend avoiding the use
of benzodiazepines in the early posttraumatic period. Consequently, there is no standardized medication regimen for the treatment of
PTSD in child and adolescent population.
The neuroendocrine systems including adrenergic, serotonergic, dopaminergic, Gamma-Amino Butyric Acid (GABA), opioid, N-methyl-Daspartate (NMDA) have been implicated in the pathophysiology of PTSD. Current data support that biomarkers and gene variants play
significant role in the stress response. Some of these include Cortisol, Pituitary Adenylate Cyclase-Activating Polypeptide (PACAP), The
Serotonin Transporter (SLC6A4), FK506-binding protein 5 (FKBP5) and Stathmin.
Additionally, epigenetic mechanisms may contribute to the inflammatory and immune dysregulation observed in subjects with PTSD.
Coding and recalling traumatic memories via NMDA receptors will be focus of interest in future studies for treatment. In this presentation,
current treatment modalities will be discussed in child and adolescent PTSD treatment.
Keywords: post traumatic stress disorder, children, adolescents
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[Abstract:0820] Post-traumatic stress disorder
Evaluation of current neurochemical findings in post-traumatic stress disorder
Suleyman Akarsu
Aksaz Naval Hospital, Mugla-Turkey
e-mail address: [email protected]
Neurochemical findings in Post-traumatic Stress Disorder (PTSD) have focused on especially noradrenergic, serotonergic, glutamatergic,
endogenous cannabinoid, and opioid systems as well as the hypothalamic-pituitary adrenal (HPA) axis. However it must take into account
that neurochemical findings in PTSD may vary according to some specific characteristics of the disorder. For example, neurochemical
findings of a PTSD patient with acute phase of trauma exposure may not be the same as the values obtained after a certain period of time
after the trauma. In addition, findings may differ from each other in patients exposed to different kinds of trauma (eg: combat-related
trauma, sexual assault), patients exposed to trauma and not exposed to trauma, adverse environmental stimulation, and stress responses/
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reactions.
HPA plays a central role in PTSD. Defects in HPA have been found in many studies. Data about hypoactivity of HPA in PTSD patients have
been increased in recent years. Serum and cerebrospinal fluid levels of corticotropin-releasing factor (CRF) and cortisol still see interest
in the studies. Adrenoreceptors (α1, α2 and β with associated subtypes) in noradrenergic system influence amygdala functioning and
fear signaling. New researches about drugs targeting 5-HT1A and 5-HT1B have given hope for the treatment of PTSD. Endogenous
cannabinoid receptors (CB1, CB2) and opioid receptors especially dynorphin/κ opioid receptor play an important role in the development
of stress responses and stress-induced behaviors. Neuropeptide Y has an effect on decreasing the release of noradrenaline and it may
well be protective against the development of PTSD. Inappropriate glutamate signaling could contribute to the processing distortion
experienced by many PTSD patients because it plays a critical role in emotional processing in stressful conditions or following stress
exposure.
Currently, PTSD is diagnosed according to clinical symptoms, as are many other psychiatric disorders. With data obtained from further
biological researches, biomarkers that could be used for the diagnosis and follow-up of PTSD may be discovered. Also, if knowledge about
neurochemistry of PTSD increase, treatment alternatives of PTSD will diversify and patients quality of life will improve.
Keywords: post-traumatic stress disorder, neurochemical findings, biomarkers
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PSYCHOTHERAPIES IN PSYCHIATRY
[Abstract:0354] Psychotherapies in psychiatry
How to use cbt-five part model in outpatient setting
Ugur Cakir
Department of Psychiatry, Abant Izzet Baysal University, Faculty of Medicine, Bolu-Turkey.
e-mail address: [email protected]
Five part model as introduced by Padesky is a very basic and useful method to provide clients a written model to help them understand
their difficulty and the treatment plan (Padesky). It also help therapist to be able to draw an individualized model to describe and
understand the problem along with a very specific treatment plan. Participants are expected to gain and/or improve following skills at
the end of the course.
Establishing a collaborative relationship with clients formulating clients problems in terms of five part model teaching client five part
model and establishing his/her engagement practicing frequently used behavioral modification techniques.
Keywords: CBT, outpatient, five-part
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[Abstract:0396] Psychiatric classification
DSM-5 vs. RDoC vs ICD towards the “ideal” diagnostic tool in psychiatry
Serdar Dursun
University of Alberta, Edmonton-Canada
e-mail address: [email protected]
Despite accelerated scientific advances in phenomenology, and discoveries of potential biomarkers, precise and objective clinical
diagnosis in psychiatry remains a major challenge. The intense scientific debate continues on the validity and applicability of available
diagnostic schemas for clinical and research purposes. Most recently, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is
introduced which also simultaneously include ICD-10 codes along with DSM-5 codes. However, it is widely accepted that DSM-5 remains
as the “gold standard” diagnostic guide and tool for clinicians for clinical therapeutic and research purposes.
National Institute of Mental Health (NIMH) has its own, predominantly research-oriented, diagnostic scheme which is known as “the
Research Domain Criteria” (RDoC) project. Currently the RDoC project remains a research framework, it has not been formally used as
a clinical diagnostic tool in general psychiatric/medical practice. However, certainly it forms the basis of a futuristic diagnostic scheme
in psychiatry. RDoC is based on the evidence that origins of mental illnesses are related to dysfunction of brain circuits which can be
identified using neuroscientific methodology.
Therefore, in this presentation these diagnostic schemes will be presented and discussed.
Keywords: DSM-5, RDoC, ICD
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PSYCHOSOMATIC DISORDERS
[Abstract:0247] Psychosomatic disorders
Is it easy to say conversion disorder?
Elif Ozcan, Mehmet Fatih Ustundag, Halil Ozcan, Gokhan Ozpolat
Department of Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
e-mail address: [email protected]
Conversion disorder, accompanied psychological conflict, which goes with a physical disorder loss of physical functioning suggestive
manner, with one or more neurological symptom is defined as a specific disorder. The most important problem in the diagnosis of
conversion disorder is to rule out other medical disorders. It’s shown that 25-50% percent of patient diagnosing conversion disorder
may come across with medical illness out of neurological or psychiatric illness. That’s why full medical and neurologic assessment has
significance patient of conversion disorder. In our case a patient is presented that might has conversion disorder, although there is
different symptoms apart from classic appendicitis, a patient who has the diagnosis of appendicitis after detailed examination.
A 25-year-old woman applied to emergency service because of sudden spam and pain in right arm after an argument with his boyfriend.
She expressed that she didn’t want to move her arm, she had pain when she pulled her arm to her abdominal. There was no known
illness. Psychiatric consultation was requested because of not finding any pathology in the neurological examination and brain CT and
advanced neurological examination. In her story, she was in a special dinner with her boyfriend and while discussing sudden she felt bad.
Her conscious was open and cooperating. During the examination she was crying and talking about the debate. In the foreground it was
thought that patient had conversion disorder. At examination patient freed her arm and she took away from her body with suggestion,
but when she removed she felt extreme pain and screamed again. After that she pushed down arm to body and lower part of abdominal.
She said that by pushing down she felt less pain. Spams and the pain changing especially because of the position of patient’s arm it was
thought that pain would be relationship with abdominal pain. General surgery consultation was requested for the patient who hadn’t any
precision result of abdominal examination that was done despite of the abdominal pain. Leukocytosis (14000 per mm3) was determined
at routine laboratory examination. Findings compatible with acute appendicitis were detected in the patient’s abdominal CT and patient
was taken to surgery. Patient who hadn’t any complaint was discharged after surgery.
Studies in recent year have observed that patient having organic disorder and it’s first diagnosis is conversion disorder will have lower
incidence. Among the reasons for this can be considered to be developed and spread of advanced diagnostic techniques. In one of the
recent studies on this topic although the false positive rates have decreased compared to years it’s still high. In the present case we want
to emphasize that if there is not evidence that cannot explain with any known medical disorder, rapid diagnosis of conversion disorder is
dangerous and patient that has conversion disorder should be followed.
Keywords: acute appendicitis, conversion disorder, diagnosis
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[Abstract:0310] Psychosomatic disorders
Broken heart syndrome and ECT: treatment of depression in Takotsubo cardiomyopathy
Elvin Guliyev1, Aygul Mahmutova2, Mehmet Yuruyen3, Fagan Zakirov1, Murat Emul1
1Department of Psychiatry, Istanbul University, Cerrahpasa Faculty of Medicine, Istanbul-Turkey
2Department of Neurology, Istanbul University, Cerrahpasa Faculty of Medicine, Istanbul-Turkey
3Department of Internal Medicine/Geriatry, Istanbul University, Cerrahpasa Faculty of Medicine, Istanbul-Turkey
e-mail address: [email protected]
Takotsubo cardiomyopathy is a transient cardiac dysfunction with characteristic morphology, commonly induced by emotional or
physical stress although no trigger may be detected one in five persons. It is firstly described in Japan in 1992 and also typically defined
as “transient apical ballooning”, “stress cardiomyopathy”, or “broken heart syndrome”. The wall motion abnormalities of takotsubo
cardiomyopathy are typically characterized by apical systolic dysfunction and hyperdynamic basal contraction. Here, we present ECT
treatment in a depressive male patient with psychotic features, with a history of chest pain which is abruptly initiated after excessive
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feelings of being ashamed.
A 72-year-old man applied to psychiatry outpatient clinics with complaining of anxiety, being followed up, insomnia and nightmares.
In mental examination: self-care is reduced, the speech rate and contents are decreased. Affect is limited and mood was depressive and
anxious. The production of thought rate was increased and delusions of paranoid, persecutory and reference delusions as being followed
up by journalists, being presented in newspapers aiming to embarrass him were detected. No hallucination was detected. Spontaneous
attention was increased while voluntary attention was decreased. Insight and judgment was impaired. In history, his nephew had
embarrassed him “do not mention my father’s name” in front of his relatives in funeral of his brother which was described as “the most
awful two things I have in my life” by patient. After the 4th day of funeral and that event social withdrawal, chest pain, thought of being
ashamed had been developed. The patient had been checked up for angina or acute myocardial infarction and then was referred to
psychiatry inpatient clinics. In echocardiography, left ventricular hypertrophy and hypokinesia in inferior septum, inferior basal, basal
mid anterior septum was detected. Ejection fraction was 50%. The unresponsive prescription history of sertraline 100mg/day, quetiapine
25 mg/day was detected. After hospitalization, we performed myocardial perfusion scintigraphy and the result was intact. We indicated
ECT because of unresponsiveness and psychotic features of depression and the patient was remitted after fifth ECT session uneventfully.
The link between emotional stress and acute cardiovascular events involve sympathetic activation (supply vs. response). Here, for the first
time in literature, we have shown positive effects of ECT in a patient with broken heart syndrome with a history of unresponsiveness to
psychotic depression treatment.
Keywords: broken heart, ECT, takotsubo cardiomyopathy
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PSYCHOTHERAPIES IN PSYCHIATRY
[Abstract:0375] Psychotherapies in psychiatry
EMDR augmentation in patients with depression: a case series
Murat Semiz, Serdar Atik, Murat Erdem
Department of Psychiatry, Gulhane Military Medical Academy, Ankara-Turkey
e-mail address: [email protected]
Depression is a frequent disorder, which may have a recurring and chronic course and, as a result may conduce seriously morbidity and
mortality. However, approximately half of the patients have an inadequate response to initial antidepressant therapy and as many as 20%
of the patients have chronic depression with no benefit from any other alternative drugs. At the same time, antidepressant medications,
cognitive behavioral therapy (CBT), and interpersonal therapy (IPT) are the treatment alternatives whose efficacies have been proven
in the treatment of depression. In this case series, three patients diagnosed with depression were attempted to be treated with Eye
Movement Desensitization and Reprocessing (EMDR) approach. 28-44 years aged two women and one man diagnosed with depression
were admitted. All patients actually underwent the antipressant treatment. Moreover, we also paid special attention to ensure a stable
dose regimen for at least one months in patients on treatment. Two patients have been receiving 150 mg/day venlafaxine. One patient
has been receiving 300 mg/day bupropion and 30 mg/day mirtazapine. Six-eight sessions of EMDR was applied to the patients. Before and
after the treatment, patients filled in Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), State-Trait Anxiety Inventory (STAI).
After the treatment, there was statistically significant reduction in patient reported BAI, STAI and BDI scores. EMDR therapy augmentation
was effective in the treatment of patients with depression.
Keywords: augmentation, depression, EMDR
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[Abstract:0404] Psychotherapies in psychiatry
Cinematherapy in psychiatry and its use in inpatients
Esra Yazici
Department of Psychiatry, Sakarya University, Faculty of Medicine, Sakarya-Turkey
e-mail address: [email protected]
İnpatient clinics care for patients with schizophrenia, bipolar affective disorder, severe depression, addictions, and other severe and acute
psychiatric disorders. Positive symptoms of psychotic patients, such as excitation, aggression, hostility, hallucinations, and delusions,
usually are easily controlled by medication.
However, some symptoms, such as refusal of treatment, lack of cooperativeness, lack of social responsiveness or interest in others, serious
communicative impairments, failure to develop normal relationships or friendships, and other cognitive disabilities caused by illness,
need therapeutic treatment in addition to medication.
Here, group psychotherapy may support medicines as a complementary approach. However, inpatients in groups have different
diagnoses and symptoms at different levels of severity and thus have diverse needs. Patients with forms of psychosis need to control their
impulsivity, gain insight, and override the tendency to over-excitement and aggression, as well as other symptoms. Depressives and other
neurotics need a supportive therapeutic approach and cognitive reconstruction. These different needs require integrative and enhanced
approaches during group therapy. Thus, a multi-faceted approach may support group therapy and provide an opportunity to help these
people in areas where medicinesmay not be effective.
Films facilitate the use of several therapeutic tools, such as imagination, story, music, sound effects, role playing, visual and auditory
expressions of life, different viewpoints, and so on.
‘Use of Movies for Group Therapy of Psychiatric Inpatients- cinematheraphy’ presents a new multifaceted approach for group therapy for
inpatient clinics. Using films as a therapeutic tool generally seemed to lead to better management of the sessions and improved outcomes
for the patients. Cinema therapy is a creative approach on the part of healers and educators in mental health.
The use of films opens up an entertaining and valuable way to reach the unconscious of patients during group therapy sessions. It allows
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them to establish a therapeutic alliance and a safe context
in which to convey their beliefs, thoughts, and needs. This course aims share the theory and practice of ’Use of Movies for Group Therapy
of Psychiatric İnpatients- cinematheraphy’ and give practical tools for application of participants.
Keywords: cinema, group therapy, psychotherapy
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[Abstract:0685] Psychotherapies in psychiatry
Acceptance and commitment therapy for schizophrenia
Yasir Safak
Department of Psychiatry, Ankara Diskapi Yildirim Beyazit Training and Research Hospital, Ankara-Turkey
e-mail address: [email protected]
Various pharmacological treatments are available for patients suffering with psychotic symptoms, but these symptoms often continue
to occur even when medications are taken. Traditional psychosocial methods such as family therapy and cognitive-behavioral therapy
alleviate symptoms. A variety of newer behavioral and cognitive therapies have emerged in recent that are focused on acceptance,
mindfulness, cognitive defusion and similar methods. Acceptance and commitment therapy (ACT) represents a new generation of
behavior therapies that, after having received empirical support in a variety of disorders characterized by experiential avoidance, also
offers a promising new treatment for psychosis. In contrast to the traditional treatment, in which both antipsychotic medication and
cognitive-behavioral therapy focus on reducing symptoms, ACT proposes active acceptance and at the same time orientation of the
person toward the achievement of worthwhile goals for his or her life in spite of symptoms, such as auditory hallucinations. Briefly, ACT
encourages individuals to accept and experience private events nonjudgmentally while simultaneously working toward the pursuit of
personally defined behavioral goals or values. Therefore, ACT does not concentrate on directly changing private experience nor the
symptoms present but on simultaneous acceptance and orientation of the person toward worthwhile goals in spite of the experience
and other symptoms. Empirical support for ACT for psychosis up to now has come from two controlled studies and several case studies.
The first controlled study was carried out by Bach and Hayes (2002). This study shows that apparently paradoxical result of increased
frequency of symptoms and decreased stress and believability is explained by the authors in terms of their acceptance of the symptoms.
ACT also reduced hospitalization 50% versus treatment-as-usual.Several features and components of ACT suggest its value in working
with persisting hallucinations or delusions. Acceptance: Persisting symptoms are difficult to change – learning ways to get on with life
even though they persist is a realistic focus for a therapy. Mindfulness & defusion are promising alternatives to unsuccessful coping with
symptoms by resistance, suppression, avoidance or engulfment. The values focus - getting in touch with what is important in your life
and translating this into everyday living - is consistent with recovery models. ACT materials and methods that are used when working
with psychosis should be modified because these patients are in many ways different from other patients. For example, patients with
psychosis can be more difficult to engage and retain in therapy, and treatment nonadherence is a frequent clinical problem that requires
attention. ACT interventions can significantly reduce hospitalization and improve patient functioning over medication alone. Acceptance
approaches can readily be combined with other psychosocial components that are known to be helpful with this population. The
relatively large impact of even a very short acceptance intervention suggests that this form of intervention deserves research attention
in psychotic populations.
Keywords: schizophrenia, psychotherapy, behavior therapy
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S436
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[Abstract:0734] Psychotherapies in psychiatry
An introduction to acceptance and commitment therapy
K. Fatih Yavuz1, Sevinc Ulusoy2
1Bakirkoy Prof. Dr. Mazhar Osman Training and Research Hospital, Istanbul-Turkey
2Elazig Mental Health and Disorders Hospital, Elazig-Turkey
e-mail address: [email protected]
Acceptance and Commitment Therapy is a kind of behavioral psychotherapy approach that is based on clinical behavior analysis and
relational frame theory. It aims to increase psychological flexibility- the ability to contact the present moment more fully as a conscious
human being, and to change or persist in behavior when doing so serves valued ends- by using acceptance and mindfulness strategies
rather than reducing the symptoms. Psychological flexibility is established through six core ACT processes. These six processes are;
1. Acceptance: Acceptance that is taught as an alternative to experiential avoidance, involves the active and aware embrace of those
private events occasioned by one’s history without unnecessary attempts to change their frequency or form. For example, anxiety patients
are taught to feel anxiety, as a feeling, fully and without defense; pain patients are given methods that encourage them to let go of a
struggle with pain.
2. Cognitive Fusion: Cognitive defusion techniques attempt to alter the undesirable functions of thoughts and other private events,
rather than trying to alter their form, frequency or situational sensitivity. ACT attempts to change the way one interacts with or relates
to thoughts by creating contexts in which their unhelpful functions are diminished. The result of defusion is usually a decrease in
believability of, or attachment to, private events rather than an immediate change in their frequency.
3. Being Present: It can be defined as awareness of the here and now, experienced with openness, interest, and receptiveness. ACT
promotes ongoing non-judgmental contact with psychological and environmental events as they occur. The goal is to have clients
experience the world more directly so that their behavior is more flexible and thus their actions more consistent with the values that
they hold.
4. Self as Context: As a result of relational frames such as I versus You, Now versus Then, and Here versus There, human language leads to
a sense of self as a locus or perspective, and provides a transcendent, spiritual side to normal verbal humans. Self as context is important
because one can be aware of one’s own flow of experiences without attachment to them or an investment in which particular experiences
occur: thus defusion and acceptance is fostered.
5. Values: Values are chosen qualities of purposive action that can never be obtained as an object but can be instantiated moment by
moment. In ACT, acceptance, defusion, being present, and so on are not ends in themselves; rather they clear the path for a more vital,
values consistent life.
6. Committed Action: Setting goals according to values and carrying them out responsibly.This course is designed to introduce
Acceptance and Commitment Therapy (ACT) and teach practical techniques, tools and strategies for beginning to work with ACT by using
experiential techniques. At the end of the course; participants will gain knowledge and understanding of the ACT model, ACT based case
conceptualization, the six core therapeutic processes of ACT, tools and strategies for each of the therapeutic processes.
Keywords: acceptance, commitment, psychological flexibility
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S437
[Abstract:0796] Psychotherapies in psychiatry
Psychodynamic psychotherapy models and neuroscience
Serhat Citak
Erenkoy Training and Research Hospital, Istanbul-Turkey
e-mail address: [email protected]
Polarization of biological and psychosocial aspects of psychiatry has promoted a form of Cartesian dualism of mind and brain. In
psychodynamic psychiatry, we must differentiate causation from meaning. Psychiatry that loses domain of meaning is mindless.
Unconscious processes, private issues and more generally, psychoanalytic concepts have to be addressed at the experimental level to
achieve a comprehensive theory of the human mind. A collaboration between psychotherapy and neuroscience may be the best way to
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Case Report Abstracts
escape from the sterile and counterproductive hostility between the disciplines and to move forward together in order to benefit science
and medical practices.
Advances in neuroscience research have led to a more sophisticated understanding of how psychotherapy may affect brain functioning.
These developments point the way towards a new era of psychotherapy research and practice in which specific modes of psychotherapy
can be designed to target specific sites of brain functioning. The findings from neurobiology are informing our understanding of
psychotherapy at a remarkable rate in recent years. A brief overview of these findings underscores the fact that psychotherapy has a
major impact on the brain. The hypothesis that dynamic psychotherapy process involves memory and learning processes has opened
the possibility of a dialogue between neuroscience and psychoanalysis and related psychotherapy techniques. Molecular biology studies
have indicated that gene expression is influenced by several environmental factors, including early experiences, traumas, learning, and
memory processes. The learning process that occurs in psychotherapy may produce alterations of gene expression and thereby alter
the strength of synaptic connections. Neuroimaging studies have found that not only cognitive but also dynamic psychotherapy has
measurable effects on the brain. In addition, psychotherapy may modify brain function and metabolism in specific brain areas. Most
of these studies have considered patients with major depressive disorders and compared the effects of psychotherapy with the effect
of standard pharmacotherapy. An integral part of psychodynamic psychotherapy is the acquisition of insight about one’s problems.
Imaging studies demonstrated increased activity in the right hemisphere anterior superior temporal gyrus for insight relative to noninsight solutions. SPECT studies suggested that, dynamic therapy may have normalized the serotonin metabolism. The investigation
of the neurophysiological correlates of psychoanalytical concepts could result in a better understanding of the links between some
psychoanalytical concepts, as neurophysiological results have already resulted in a better understanding of concepts from experimental
psychology. While psychoanalysis allows neuroscientific researchers to embrace the full complexity of human subjective experience
and its determination by unconscious conflicts, results from the neurosciences may eventually provide psychoanalysis with a new
metapsychological framework.
In conclusion, recent results from neuroscience studies have suggested that, dynamic psychotherapy has a significant impact on brain
function and metabolism in specific brain areas.
During this presentation; recent data on neurobiological effects of dynamic psychotherapy in psychiatric disorders, conceptual models of
how psychotherapy may affect the brain will be overviewed and the possible applications and developments of this new area of research
toward the conceptualization of an integrative approach to treatment of psychiatric disorders will be discussed.
Keywords: neuroscience, psychodynamic, psychotherapy
Bulletin of Clinical Psychopharmacology 2015;25(Suppl. 1):S437-S8
[Abstract:0805] Psychotherapies in psychiatry
Fluoxetine associated with neutropenia and treatment with agomelatine
Atakan Yucel1, Nermin Yucel2, Elif Oral1
1Department of Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
2Department of Child and Adolescent Psychiatry, Ataturk University, Faculty of Medicine, Erzurum-Turkey
e-mail address: [email protected]
Neutrophils, most abundant members of immune system, counteract against infections. An absolute neutrophil count less than 2000
cells/pL is termed neutropenia, in additionally an absolute neutrophil count less than 500 cells/pL is termed severe neutropenia that
include high mortality caused by infections. The majority of psychiatric drugs have been reported to cause neutropenia as a rare adverse
effect. Drugs related neutropenia most common occurs with clozapine, phenothiazines and antiepileptics. However, there is only one case
report of fluoxetine induced agranulocytosis. We present the case of neutropenia presented as incidentally realized in a routine control.
A 45 year-old married woman presented to the outpatient clinic with depressive complaints. There was no any family or her history of
psychiatric or medical illness. The depressive symptoms had included pervasive sad mood, anhedonia, insomnia, early morning waking,
anorexia, and fatigue that started 4 months ago. At that time she had already visited a family physician, and had received a therapy
of fluoxetine, 20 mg per day for 2 months, without significant improvement. Physical examination was unremarkable. Mental status
examination revealed a depressed affect, anhedonia, insomnia, hopelessness and pessimism. She diagnosed with major depressive
disorder according to DSM-5 criteria and was recommended trial of fluoxetine 40 mg/day. In the 3rd week of fluoxetine 40 mg/day
treatment, the neutrophil count was realized incidentally as 300/µL. She was hospitalized to hematology. All other tests including her liver
function tests (LFT), EC