An interactive case presentation during the monthly meeting of Early-career psychiatrists in Jeddah, SA. Basically, a case managed and supervised clinically by Dr Shokry Alemam, MD

1. By
Shokry Alemam, MD
Ahmed Elaghoury, MD
ECP Jeddah, Dec 2015
CASE PRESENTATION

2. Ms S is a 32 year old female patient, single,
unemployed, educated till 3rd year of secondary
school.
Presented for the first time to my clinic 2 years ago
by:
Hearing voices threatening her, thinking that her
maid will hurt her and watches her (as voices tell
her), disturbed sleep in the form of difficulty to fall
asleep, and frequent wakening up.

3. Her sister reported that Ms S had many bouts
of agitation, social withdrawal, with
inappropriate behaviors, neglected self
hygiene, and bouts of disorientation to time,
and place.

4. All these symptoms started 17 years ago by
insidious onset, and progressive course, with no
specific precipitating or relieving factors.
She sought medical advice 17 years ago and was
diagnosed as schizoaffective, and in another
hospital as schizophrenia and her last medications
before presenting to our clinic were, Prozac 20 mg,
Risperdal consta 50 mg IM every 2 weeks, Topamax
100 mg daily, lamictal 100 mg BID.

5. • No past medical history.
• Positive family history as her cousin (maternal)
has similar presentation.
• Premorbid personality, she was introverted,
socially retarded, and poor school performance.

6. By examination, Ms S was obese, with psychomotor
slowing, staring look, poor concentration, coherent
speech of decreased volume and pressure, euthymic
mood and blunt affect, concrete thinking with
poverty of thoughts, delusion of reference and
persecution, poor insight and judgment, no suicidal
thoughts, plans or intent.

7. What is your provisional diagnosis?
A)Schizophrenia.
B)Bipolar disorder.
C)Schizophreniform.
D)Psychotic disorder, unspecified.
E)Non of the above.

8. She was diagnosed as schizophrenia
The plan was to continue on
Risperidone LAI 50 mg/ 2 weeks
Fluoxetine 20 mg
Topiramate 100 mg
Start risperidone 3 mg PO nocturnal
But
The next visit after 2 months, the patient reported that she
developed galactorrhea with no improvement of her
symptoms, so the plan was to D/C risperidone tablets and
start quetiapine 200 mg and abilify 10 mg

9. “The difference between a good
neuropsychiatrist and a mediocre
one is a good history”
(David, 2009)

10. PSYCHOSIS: key concepts
• Psychosis / Psychotic ds
• Organic (Symptomatic) Vs Functional
(Nonorganic)
• Primary (Idiopathic) Vs Secondary
• Independent vs Comorbid
• Meaningful connections
Sachdev PS & Keshavan MS (2010). Secondary Schizophrenia, 1St Ed. New York, NY: Cambridge University Press.
Oyebode F (2015). Sims' symptoms in the mind: Textbook of descriptive psychopathology, 5th ed. Saunders Elsevier
ICD 10 (1992)
DSM 5 (2013)

11. Hierarchy vs Comorbidity
Katona C at al (2016). Psychiatry at a glance, 6th ed. John Wiley & Sons Ltd

12. Liddle et al 1987
Cowen P et al (2012). Shorter Oxford Textbook of Psychiatry, 6th ed. Oxford, Oxford University Press.

13. After 4 months the patient still the same regarding
delusions and hallucinations with severe irritability,
and started to complain of dry mouth, abdominal
pain, and poor appetite.
So, what is your next plan of management?
A)Continue the same medications.
B)Discontinue some medications.
C)Adjustment of doses.
D)Add on new medications.

14. The plan was to D/C topiramate and fluoxetine
and start haloperidol 5 mg BID and
benztropine 2 mg BID
RFT, HbA1c were done and were normal

15. After 4 months no improvement, and the patient
still complaining of dry mouth, abdominal pain, and
developed hirsutism and skin pigmentation in her
back, legs, and arms, smelling bad odor and stopped
haloperidol by herself,
so we started olanzapine 15 mg nocte, and
trifluperazine 5 mg BID

16. •All the endocrine profile was investigated with RFT,
LFT, CBC, glucose profile, and electrolyte profile,
and all the results were normal.
•The final medications she was on were Aripiprazole
30 mg, Risperidone LAI 50 mg/ 2 weeks,
Olanzapine 15 mg, Metformin 500 BID,
Benztropine 1 mg BID, and Trifluperazine 5 mg BID
And the patient showed no improvement

17. Mind-Body dualism ?!
Sharpe M & Walker J: Ch 5.1 Mind-body dualism, psychiatry, and medicine. In: Gelder MG et al (2009). New Oxford Textbook of Psychiatry,
2nd ed. Oxford, Oxford University Press

18. Geddes J et al (2012). Psychiatry, 4th ed. Oxford, Oxford University Press

19. Biopsychosocial formulation, 3Ps
Sharpe M & Walker J: Ch 5.1 Mind-body dualism, psychiatry, and medicine. In: Gelder MG et al (2009). New Oxford Textbook of Psychiatry,
2nd ed. Oxford, Oxford University Press

20. Beck BJ et al: Ch 21 Mental Disorders Due to Another Medical Condition. In:Stern T et al (2016). Massachusetts General Hospital
Comprehensive Clinical Psychiatry, 2nd. Elsevier

21. Beck BJ et al: Ch 21 Mental Disorders Due to Another Medical Condition. In:Stern T et al (2016). Massachusetts General Hospital
Comprehensive Clinical Psychiatry, 2nd. Elsevier

22. DD of psychosis
1. Another medical conditions
2. Drugs / substances
3. Other mental ds

23. Depending on the previous data and findings, what
may be the possible diagnosis?
A)Resistant schizophrenia.
B)Substance induced psychosis.
C)Secondary psychosis.
D)Non of the above.

24. The next step was to reevaluate the case
discovering the detailed history of the previous 15
years which revealed:
•The patient developed galactorrhea twice before
once she took risperidone tablets either with or
without risperidone LAI
•She showed some improvement on Valproate 500
BID mg and Quetiapine 900 mg by improvement of
concentration only in 2003.

25. • She did pituitary MRI and was free
• CT brain with contrast which showed venous
malformation at right side of cerebellum ( not
clinically significant) in 3/2011
• In 7/2011 she was referred to do MRI due to
possible complex partial seizures, which showed
decreased volume of right hippocampus, and right
mesial temporal sclerosis
• EEG was done and was unremarkable.

26. •By further history of possible complex partial
seizures, the mother reported that it is
always present and happens many times per
day.
•The next step was to wash out all the
antipsychotics and keep patient only on
clonazepam with close observation and do
MRI, CT, and EEG again.

27. True or False?
•Recent reviews show that chronic interictal
psychosis is schizophrenia-like with frequent
negative symptoms

28. Psychiatric aspects of epilepsy
• Epilepsy is the “bridge” between psychiatry
and neurology
• Related to seizure (ictus): peri ictal / inter
ictal
• Related to psychosocial factors
• Related to shared pathology

29. Laura M: Ch 7 Epilepsy. In: Lyketsos CG et al (2008). Psychiatric aspects of neurologic diseases : practical approaches to patient care. Oxford,
Oxford University Press

30. Psychosis and epilepsy
• Strong association, but in various forms.
• Ictal / Peri-ictal psychosis: status, rare
• Post-ictal psychosis (PIP): single / recurrent
• Inter-ictal psychosis: brief (BIP) / chronic (CIP)
• Bimodal psychosis in some pts: PIP - FN - BIP
Sachdev PS & Keshavan MS (2010). Secondary Schizophrenia, 1St Ed. New York, NY: Cambridge University Press.
● FN: Forced Normalization
Salzberg M. Ch 13: Mood state, anxiety, and psychosis in epilepsy. In:Erik K St et al (2015). Epilepsy and the Interictal State: Co-Morbidities
and Quality of Life, 1st ed. John Wiley & Sons, Ltd

31. Chronic inter-ictal psychosis, CIP
• Chronic inter-ictal psychosis: schizophrenia-like
psychosis with few differences
• Affect: preserved / swing, Visual hall, less negative sx
• Forced normalization (FN) / Alternating psychosis:
paradoxical, spurious, & may be false in few pts
• AED induced psychosis: VGB, TPM, LEV, ……
• Antipsychotic induced seizures
• Post lobectomy psychosis
Salzberg M. Ch 13: Mood state, anxiety, and psychosis in epilepsy. In:Erik K St et al (2015). Epilepsy and the Interictal State: Co-Morbidities
and Quality of Life, 1st ed. John Wiley & Sons, Ltd

32. •The investigations confirmed the previous
findings through MRI brain only
•On the clinical base the patient is much
improved on clonazepam with better
concentration, activity, sleep, and less
delusions and hallucinations.

33. • After confirmation of diagnosis of mesial
temporal sclerosis and complex partial
seizures, we increased the dose of
clonazepam to 3 mg at bedtime, and started
on carbamazepine 200 mg at bedtime.

34. •After 2 weeks of improvement the patient showed
racing thoughts, hyperactivity, delusion of
grandiosity, disinhibition, aggressive behavior,
olfactory hallucinations, but sleeps well, so we
decided to decrease the dose of Clonazepam
gradually, and up titrating of oxcarbazepine to 600
mg BID, and start Quetiapine gradually till the dose
of 1000 mg daily.

35. WHAT HAPPENED?
WHY THIS PATIENT IS RESISTANT TO
MEDICATIONS?
WHAT ARE THE POSSIBLE TREATMENTS OF
SUCH A PATIENT

36. MESIAL TEMPORAL SCLEROSIS

37. • Mesial temporal sclerosis is the commonest cause of
partial complex seizures.
• The etiology of this condition is controversial, but it is
postulated that both acquired and developmental
processes may be involved. Familial cases have also been
reported.
• Magnetic resonance imaging (MRI) is the imaging
investigation of choice for the diagnosis and has been
shown to be highly sensitive and specific(1)
1. Marchetti RL, Tavares AG, Gronich G, et al. Complete remission of epileptic psychosis after temporal
lobectomy: case report. Arq Neuropsiquiatr 2001 Sep;59:802–805

38. Lee TC et al (2015). Netter’s correlative imaging neuroanatomy. Philadelphia, PA, Elsevier Saunders

39. T2 weighted MRI. This image demonstrates an abnormality in the right mesial temporal lobe. It is shrunken and malformed
with enlargement of the temporal horn of the lateral ventricle. There is also a small area of abnormal high T2 signal within
the right hippocampus. The left hippocampus is relatively normal.

40. The T1 weighted image demonstrates the lesion with somewhat better anatomical detail

41. From patient’s record

42. •Mesial temporal sclerosis is the most common
pathologic entity associated with refractory
temporal lobe epilepsy (TLE); it is seen in as many
as 60% to 80% of cases.(2)
2. Bronen RA, Fulbright RK, Spencer DD, et al. Refractory epilepsy: comparison of MR
imaging, CT, and histopathologic findings in 117 patients. Radiology 1996;201:97–105

43. •medical treatment is successful in 25% of cases,
whilst anterior temporal lobectomy (Tailored
resection strategies including selective amygdala-
hippocampectomy are established ) is effective in
70 - 95% of patients, with up to 80%
postoperative seizure freedom within the first 2
years.(6)
6. von Lehe M, Lutz M, Kral T, Schramm J, Elger CE, Clus- mann H (2006) Correlation of health-related quality of
life after surgery for mesial temporal lobe epilepsy with two sei- zure outcome scales. Epilepsy Behav 9:73–82

44. Take-home messages
• Psychosis is a trans-cutting clinical presentation
through medical and mental conditions.
• Schizophrenia is a diagnosis of exclusion after full
medical and psychiatric assessment.
• Epilepsy is strongly associated with mental disorders.
• Psychosis in epileptic pts is around 4%
• Psychosis has different forms with epilepsy
• Mesial temporal sclerosis is a common pathology in
intractable epilepsy and resistance to psychotropic
medications

45. Thank you