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Background: Quinacrine is an older antimalarial drug that remains in use for a variety of illnesses including treatment-resistant giardiasis. Case Presentation: We report a patient with no prior psychiatric history who developed mild, prodromal psychiatric symptoms when treated with quinacrine for treatment-resistant giardiasis. Symptoms resolved when the drug was stopped, recurred with greater severity (requiring involuntary psychiatric hospitalization) when restarted and promptly resolved again when the drug was finally stopped. Conclusion: Although quinacrine remains in use today, providers may be unaware of its potential for serious neuropsychiatric toxicity.

Purpose Benzodiazepines (BZDs) are a mainstay of treatment of catatonia with response rates of 60 to 80%, but there is virtually no data regarding the relative efficacy of different agents. We report a patient with catatonia who responded incompletely to lorazepam but much more definitively to clonazepam. Procedures Single case report. Findings A 74 year old man with recurrent catatonia had responded only partially to lorazepam and to a number of other interventions. He was ultimately treated with clonazepam monotherapy and exhibited a much more robust response. Conclusions In this patient, clonazepam may have proved more effective than lorazepam due to its higher affinity for the BZD binding site of the GABAA receptor or possibly due to its longer half life or intrinsic serotonergic activity. It may be reasonable to consider clonazepam in a patient whose response to other BZDs has been incomplete, but this remains to be confirmed in controlled studies.

Dementia management is complicated by neuropsychiatric symptoms such that the longitudinal care of a psychiatrist or other mental health provider is often an essential part of patient care and a major source of family support. Given the importance of end-of-life continuity of care, the involvement of psychiatry in palliative and hospice services affords an important opportunity for growth. Common challenges involve sharing prognostic information with patients and families to aid in advance planning, and management of persistent pain and nutritional issues. Future research will yield important new insights and guidelines for care.

Depression is common in patients after liver transplantation and, when severe, can threaten both viability of the graft and the patient's life. Electroconvulsive therapy (ECT) is a safe and highly effective therapy for severe depression, but there have been very few reports of its use in liver transplant recipients. We describe a patient who had undergone a successful orthotopic liver transplant 26 years previously, who developed severe major depression. The patient tolerated an index course of ECT well and responded robustly. There were no complications pertinent to the graft or otherwise. Liver transplantation is not a contraindication to ECT, and clinicians should not hesitate to proceed when necessary.

Chronic microaspiration and diffuse aspiration bronchiolitis may account for some otherwise unexplained frailty in nursing home patients.

Objectives The objective of this study was to report the effectiveness of trazodone for treatment of bruxism in dementia. Methods A single case study of a 66-year-old man with severe vascular dementia and awake bruxism was performed. Results The patient's bruxism responded robustly to titration of trazodone. He tolerated the medication with no untoward sedation or other adverse effects. Conclusions Bruxism is occasionally encountered in patients with advanced dementia and raises concerns about nutritional compromise and about potential need for poorly tolerated dental treatment. Trazodone may potentially be effective for bruxism in some patients.

Disorders of swallowing are poorly characterized but quite common in schizophrenia. They are a source of considerable morbidity and mortality in this population, generally as a result of either acute asphyxia from airway obstruction or more insidious aspiration and pneumonia. The death rate from acute asphyxia may be as high as one hundred times that of the general population. Most swallowing disorders in schizophrenia seem to fall into one of two categories, changes in eating and swallowing due to the illness itself and changes related to psychotropic medications. Behavioral changes related to the illness are poorly understood and often involve eating too quickly or taking inappropriately large boluses of food. Iatrogenic problems are mostly related to drug-induced extrapyramidal side effects, including drug-induced parkinsonism, dystonia, and tardive dyskinesia, but may also include xerostomia, sialorrhea, and changes related to sedation. This paper will provide an overview of common swallowing problems encountered in patients with schizophrenia, their pathophysiology, and management. While there is a scarcity of quality evidence in the literature, a thorough history and examination will generally elucidate the predominant problem or problems, often leading to effective management strategies.

Objectives To examine the effectiveness of low-dose lithium carbonate for managing carbamazepine-induced hyponatremia. Methods Single case study in an 88 year old man with bipolar illness and vascular dementia who had failed to respond to other mood stabilizers. Results The patient had developed hyponatremia on two separate occasions when treated with carbamazepine. Introduction of low-dose lithium resulted in prompt normalization of serum sodium levels, which was maintained for the subsequent 8 weeks. Conclusions Carbamazepine may sometimes be the best or only viable treatment option for patients with bipolar illness or other conditions. When its use is complicated by syndrome of inappropriate ADH, dose reduction and fluid restriction are the simplest options but, if ineffective, addition of lithium may be a feasible, albeit somewhat complicated, alternative.

Delusional disorder is a relatively rare psychotic illness characterized by delusions with contents that are theoretically possible but highly unlikely, and an absence of the disorganized thought and negative symptoms characteristic of schizophrenia. The illness is rarely studied systematically and most guidance with regard to the treatment derives from case reports and small case series. Antipsychotic medications are the mainstay of treatment, but it is not clear whether any particular agent is more effective than others. We report the case of a patient with delusional disorder who had failed to respond to risperidone but improved markedly with aripiprazole. Aripiprazole may show promise as a treatment for delusional disorder, possibly as a result of its effects on both dopaminergic and serotonergic receptors.

Received December 18, 2015; revised January 11, 2016; accepted January 11, 2016. From Department of Psychiatry, University of South Florida College of Medicine, Tampa, FL (WLW, GAS); Departments of Psychiatry and Geriatric Medicine, University of South Florida College of Medicine, Tampa, FL (JTS). Send correspondence and reprint requests to Jonathan T. Stewart, M.D., D.F.A.P.A., A.G.S.F., Mental Health and Behavioral Sciences Service (116A), James A Haley VA Hospital, 13000 Bruce B Downs BLVD, Tampa FL 33612; e-mail: jonathan.stewart1@va.gov Published by Elsevier Inc. on behalf of The Academy of Psychosomatic Medicine. Introduction

Musical hallucinations (MHs) are relatively uncommon phenomena sometimes encountered in older patients, especially older women. They usually involve popular, overlearned music, either entire songs or repetitive snippets. While MHs are most commonly associated with hearing loss, they may occur in a variety of psychiatric, neurologic, and iatrogenic conditions. We report a 91-year-old man whose MHs were causally related to the antidepressant mirtazapine. Although mirtazapine is generally well tolerated, it may rarely cause MHs or other psychotic symptoms.

A 65-year-old man with a lifelong history of paranoid schizophrenia had been treated with 50 mg of risperidone microspheres every 2 weeks for the past 10 years and had tolerated this therapy well. Approximately 1 year ago some drooling and a modest resting tremor developed, but there were no other

With the growing care needs for the older population at the end of their lives, there has been a substantial increase in attention to the management of the patient with dementia in hospice and palliative care services. This article reviews issues in access to care and the optimal management of the patient with dementia, particularly in the context of neuropsychiatric complexities. Special issues such as delirium, cachexia, behavioral symptoms, and pain management are addressed. Future challenges in research such as the development of better prognostic models are noted as well as the importance of attention to access to care.

Hypothyroidism is commonly associated with a variety of psychiatric conditions, most commonly depression and cognitive impairment, but up to 5% to 15% of symptomatically hypothyroid patients may develop a nonaffective psychosis, classically referred to as "myxedema madness." We report the case of a woman who developed Capgras syndrome in the context of hypothyroidism, and whose psychosis rapidly resolved with levothyroxine supplementation. To date, very few cases of Capgras syndrome related to hypothyroidism have been reported. The pathophysiology of this condition remains unclear but it may be related to global cerebral hypometabolism or possibly to increased cerebral dopamine. Given the robust response of "myxedema madness" to thyroid replacement, psychiatrists should remain vigilant for covert hypothyroidism in patients with psychosis and atypical histories or presentations.

Tardive dyskinesia (TD) is a chronic and often irreversible movement disorder that usually evolves after years of neuroleptic use but can sometimes develop over a much shorter time frame. Paradoxically, a higher dose of the neuroleptic agent that causes TD can often temporarily suppress the movement disorder. This is generally an inadvisable approach, though, as its effectiveness is probably limited to only a matter of weeks and as it will worsen the problem in the long run. We describe a patient with widely metastatic squamous cell carcinoma of the lung who developed severe TD when treated with chlorpromazine for severe hiccups. As his prognosis was only days to weeks, we were able to effectively suppress his TD with haloperidol. Hospice care emphasizes relief of suffering at the end of life, often at the expense of attention to long-range adverse effects, and this approach may be a viable management strategy for patients with TD and very limited prognosis.

Behavioral problems are seen in most patients with dementia and are often poorly characterized in the literature. We present a 70-year-old man with advanced Alzheimer disease and problematic disinhibited behaviors, including intrusiveness and Witzelsucht (disinhibited humor). These symptoms responded robustly to carbamazepine. Carbamazepine may be a useful adjunct in managing problematic behaviors in dementia, especially when those problems can be framed as behavioral disinhibition.

Gait ignition failure (GIF) is a syndrome characterized by hesitation or inability to initiate gait from a static position. It may occur in a variety of conditions, including normal pressure hydrocephalus, subcortical vascular disease, parkinsonian syndromes and a variety of focal lesions. Previous information on the treatment of GIF has been primarily anecdotal, but there have been a few reports of response to dopamine agonists. We report a 63-year-old man with anoxic encephalopathy who developed GIF nine years after the initial anoxic insult. The patient's GIF responded robustly, albeit transiently, to ropinirole. MRI was unrevealing, but a positron emission tomography scan showed hypometabolism in the deep frontal ACA/MCA watershed area; this may have disconnected the basal ganglia from the motor cortex and/or interrupted dopaminergic mesocortical transmission. Our understanding of the pathophysiology and the treatment of GIF remains limited, but there may be at least a limited therapeutic role for dopamine agonists.

Both animal and human evidence suggest that estrogen has a modulatory role in seizure threshold, although there have been no reports to date suggesting the relevance of this to ECT practice. We describe the case of a woman who had been receiving maintenance ECT for several years with a stable seizure threshold. She developed breast cancer and ultimately agreed to begin estrogen deprivation therapy with tamoxifen; this treatment regimen resulted in an increased seizure threshold, necessitating an increase in stimulus power settings. ECT practitioners should be aware that estrogen deprivation therapy may have the potential to alter seizure threshold.

Vascular dementia (VaD) is the second most common cause of dementia, accounting for about 20% of all cases. Psychiatric and behavioral problems are at least as common in VaD as in Alzheimer's disease but are very different qualitatively. Patients with VaD, and especially those with small vessel disease, typically manifest symptoms related to damage to the frontal-subcortical system of the brain, including loss of executive function (which is not generally detected with most conventional tests of cognitive function), loss of drive, and disinhibited behaviors. Patients with VaD also commonly develop treatable mood disorders, most commonly depression. Once the symptoms are recognized, the clinician is in an ideal position to manage them and to educate caregivers about their nature.

Persistent or intractable hiccups are not uncommon at the end of life, occurring in approximately 4% to 9% of patients, and can cause considerable suffering, including difficulties in eating, drinking, and speaking, insomnia, pain, fatigue, and depression. In palliative practice, the etiology of hiccups is often either unknown or untreatable, and empirical pharmacologic treatment is the norm. Unfortunately, many of the agents reported as effective for hiccups can cause undesirable sedation. The authors describe a patient with end-stage vascular dementia and a 4-year history of idiopathic intractable hiccups who responded dramatically to amantadine, a nonsedating dopamine agonist. The role of dopamine in hiccups is somewhat ambiguous and likely not central to their cause or treatment. Amantadine may be a reasonable option for patients with distressing hiccups who cannot tolerate a sedating agent.

Neurobehavioral problems are very common sequelae of traumatic brain injury (TBI), occurring in more than 60% of patients in a series, and they are strong predictors of poor social and vocational outcome. The literature on pharmacologic treatment of these problems unfortunately consistsmostly of uncontrolled case reports and series confounded by diagnostic imprecision, short follow-up, and polypharmacy. This is especially the case with lithium, with almost all published articles beingmore than 30 years old. Indeed, in literature of this era, there are some poorly substantiated suggestions that lithium is contraindicated in “organic brain syndrome” a rumor that is still sometimes heard today. Nevertheless, this older literature strongly suggests its potential utility in at least a subpopulation of patients with TBI. We describe the case of a patient, Mr. A, who had a history of severe TBI whose behavioral volatility had persisted for 23 years but improved markedly with lithium monotherapy.

Geriatric depression is commonly encountered in consultation-liaison settings and is associated with greater morbidity and mortality than in younger patients. Depression in older patients is highly treatable, although many patients still do not respond adequately to treatment. It is estimated that only 60% to 70% of patients with depression respond to antidepressant therapy. The STAR*D trial was perhaps even more discouraging, reporting that only about 33% of patients achieve full symptomatic remission. As such, clarification of the pathophysiologic mechanisms of depression and development of novel treatments for refractory patients remain high priorities. Over the past several decades, there has been a great deal of work on the association of abnormalities of the hypothalamic-pituitary-adrenal (HPA) axis with depression. It is well established that depression is frequently associated with a relative hypercortisolemia. Additionally, exogenous corticosteroids have long been known to exert a profound impact on mood regulation, with up to 10% of patients experiencing severe psychiatric adverse effects, including depression, mood cycling and psychosis. More recently, a population-based retrospective study by Fardet et al. demonstrated a 2-fold increase in the incidence of depression, and an almost 7-fold increase in the incidence of suicide or suicide attempts, in patients who were prescribed corticosteroids. These steroid-associated mood changes may occur through both indirect effects on gene transcription and direct effects on neuronal membranes and receptors. There have been several studies documenting antidepressant effects of corticosteroid antagonists, including glucocorticoid synthesis inhibitors and receptor blockers. Conversely, there have also been several small, short-term studies demonstrating an antidepressant effect of corticosteroids themselves. We recently cared for a patient with a highly refractory depression, which paradoxically remitted only when he was treated with corticosteroids for chronic obstructive pulmonary disease (COPD).

Clinicians commonly encounter dysphagia and constipation in a skilled nursing population. Increasing the viscosity of liquids, usually with a starch- or xanthan gum-based thickener, serves as a key intervention for patients with dysphagia. We report a newly identified and potentially dangerous interaction between polyethylene glycol 3350 laxative (PEG) and starch-thickened liquids. A patient requiring nectar-thickened liquids became constipated, and medical staff prescribed PEG for constipation. His nurse observed that the thickened apple juice immediately thinned to near-water consistency when PEG was added. She obtained the same results with thickened water and coffee. We quantified this phenomenon by isothermal rotational rheology. Results confirmed a precipitous loss of thickening when PEG was added to starch-based thickeners but not with xanthan gum-based thickeners. Clinicians and front-line staff should be aware of this potentially critical interaction between PEG- and starch-based thickeners. Although confirmatory studies are needed, our preliminary data suggest that PEG may be compatible with xanthan gum-- based thickeners.

It is an ageless principle in medicine that physicians cannot diagnose and treat an illness they do not recognize. In the past two decades, we have come to recognize the classic clinical picture of diffuse Lewy body disease. Once primary care physicians understand this challenging disorder, they are in an ideal position to identify and manage it. As with many dementing illnesses and other medical conditions, diffuse Lewy body disease is not curable, but much can be done to improve the quality of life of patients and their family.

Background Valproic acid is associated with a variety of hematologic abnormalities, most commonly thrombocytopenia. Pancytopenia is much less common and potentially much more serious. Little is known about the natural course of valproate-induced pancytopenia. Case summary We present a patient who developed pancytopenia while taking valproic acid for bipolar illness. After failing to respond to several other mood stabilizers, valproic acid was cautiously reintroduced with close hematologic monitoring. The pancytopenia has not recurred in the past 6 months. Conclusions Pancytopenia may not represent an absolute contraindication to continuing valproate therapy, although caution is warranted.

Resistiveness to physical care among patients with dementia is a common and burdensome problem. Forty-nine nursing home residents with dementia were administered the Mini-Mental State Exam (MMSE) and the Royall Executive Interview (EXIT), a specific test of frontal-subcortical function. Nurses rated resistiveness on every shift for 3 days. Correlation with resistiveness ratings was stronger for the EXIT (r=0. 73) than for the MMSE (r=-0. 46); logistic modeling found the EXIT to be a strong independent predictor of resistiveness. Executive dysfunction as measured by the EXIT is a major determinant of resistiveness to care in long-term care residents with dementia, possibly as a result of such patients' tendency toward inertia.

Nausea and vomiting are common and often highly distressing symptoms in advanced cancer and in hospice and palliative medicine practice. Nausea and vomiting generally respond well to correction of the underlying etiology (when possible) and appropriate selection of antiemetic medication, but up to 7% of patients will have refractory symptoms. Dronabinol is extensively studied for chemotherapy-related nausea and vomiting, but there are only a few case reports of its use in nausea and vomiting unrelated to chemotherapy. We report a patient with end-stage ovarian cancer with peritoneal carcinomatosis and refractory nausea and vomiting who responded dramatically to addition of dronabinol. Dronabinol is usually well tolerated and may have several novel mechanisms of antiemetic action; further study of its scope of efficacy is warranted.

There is increasing evidence that a greater degree of postictal suppression (the abruptness and magnitude of the EEG voltage drop at the end of the seizure) may be associated with better clinical response to electroconvulsive therapy. Retrospective studies have shown better postictal suppression when propofol is used for induction rather than the more commonly used methohexital. We report two patients in whom poor postictal suppression was rectified by switching from methohexital to propofol. The clinical significance of this improvement in postictal suppression is unclear, and prospective studies will be needed to clarify any clinical benefits.

Catatonia is an episodic syndrome characterized by specific affective, behavioral, and motor symptoms and thought to result from regional abnormalities in neurotransmitter function. Although generally thought to represent a manifestation of schizophrenia or depression, there is strong evidence that it may represent a distinct entity, caused by a number of psychogenic, infectious, iatrogenic, and neurological conditions. The morbidity associated with catatonia is significant, and, in some cases, the condition may be life threatening.

To the Editor: Frontotemporal dementia (FTD) is a pathologically heterogeneous illness characterized by progressive atrophy of the frontal and anterior temporal cortex. Some cases are familial, but the etiology is more often idiopathic.1 There is no known treatment, and the illness progresses inexorably to death, with a mean survival of about 8 years.1 FTD is often misdiagnosed because of its confusing initial presentation.2–4 A variety of psychiatric symptoms may be seen during the course of illness. We describe a patient with FTD who presented initially with mood and psychotic symptoms. Case report. Ms A, a 45-year-old woman, was in good health until May 2008. Her initial symptoms were depressed mood, crying spells, decreased energy, anhedonia, and poor appetite and sleep and were attributed to her father's death. She also reported that the police were keeping her under surveillance and that a neighbor was “messing with my head” and trying to harm her children, leading to homicidal threats. After accosting the neighbor, she was admitted with a diagnosis of bipolar disorder, mixed, with psychotic features (DSM-IV criteria). Results of routine laboratory work, urine drug screen, and computed tomography scan were unremarkable. After 3 weeks of inpatient treatment, she was discharged with improvement of symptoms and resolution of the homicidal ideation. Within 1 month, a change in her behavior was noticed; she became loud and aggressive, started making obscene calls to her mother, and developed pressured speech. She quickly deteriorated, becoming dependent in activities of daily living. She was readmitted in December 2008; this admission lasted for about 3 months. Results from full medical and neurologic evaluation, including magnetic resonance imaging scan, electroencephalogram, and lumbar puncture, were unrevealing. Neuropsychological testing revealed prominent executive dysfunction, and positron emission tomography scan revealed severe frontal and temporal hypometabolism. The DSM-IV criteria for dementia were used and, furthermore, were also correlated with the Consensus Clinical Diagnostic Criteria for frontotemporal dementia.5 On presentation to our Memory Disorder Clinic in November 2009, she was mute, minimally interactive, and markedly apathetic; there was also some evidence of dysphagia. The family reported trials of numerous psychotropic medications, all with minimal effect. She had an unsteady gait, swaying from side to side and magnetic in nature. She was restless, repeatedly rising from her seat, but was easily redirected. Her mood could not be assessed, but her affect was flat. It did not appear that she was responding to internal stimuli. She died in January 2010. Frontotemporal dementia is the second most common dementia in younger individuals.6 A young person presenting with psychotic and mood symptoms may suggest a primary psychiatric diagnosis, but the clinician must consider a neuropsychiatric syndrome such as FTD. Often, the clinical picture will evolve over time. Importantly, the consensus criteria for diagnosis of FTD do not emphasize psychiatric features.3 For our patient, the onset of what appeared to be a typical depressive illness after her father's death proved to be a “red herring.” While she clearly presented with symptoms of a delusional depression, the clinical picture quickly evolved with increasing dependence in activities of daily living and mutism, and death soon followed. A review of the literature reveals cases in which the initial presentation of FTD was suggestive of a primary psychotic illness or a mood disorder.4,7 A greater index of suspicion for FTD in younger patients with new-onset psychiatric symptoms, and a longitudinal view as the disease progresses, will lead to better clinical diagnosis.

With the legalization of physician-assisted suicide (PAS) in several states, it remains controversial whether present guidelines take into account the complexity of identifying treatable sources of suffering, including underlying depression and other psychiatric disorders, in this high risk population. We present a case in which a patient with end-stage prostate cancer requested PAS; this request was in a state where PAS is not a legal option. He was evaluated psychiatrically and was not found to be depressed, but ample opportunities were found to improve his quality of life. With appropriate treatment, he lost interest in PAS as an option. We discuss the need for a comprehensive evaluation to properly assess and manage the untreated physical and emotional suffering that may influence a patient’s decision to hasten death.

Effective treatment of patients with dementia involves supporting and educating the primary caregiver, uncovering and correcting the underlying cause of any decompensation that may occur, and deciding when drug therapy is appropriate. Caregivers must be taught how to cope with the patient's denial and how to modify the patient's environment so that it is safe and easy to understand. Pharmacologic therapy for depression accompanying dementia can improve a patient's quality of life and independence considerably; drugs may also be of help in dealing with patients who resist care. Psychotic symptoms usually do not require pharmacologic treatment, and hypnotics should, if possible, be avoided as a solution to sleep problems.

Post-electroconvulsive therapy (ECT) delirium is commonly encountered in practice, occurring in up to 12% of treatments. Although often easily managed nonpharmacologically, more severe or persistent cases are generally treated with benzodiazepines or propofol. We describe a patient who failed to respond adequately to these medications but responded quite favorably to dexmedetomidine, a centrally acting α2 agonist. There is evidence that dexmedetomidine may have unique, "delirium-sparing" properties; this makes it an attractive option for this indication.

In 1990, as authorized and requested by Congress, President George H. W. Bush proclaimed the 1990s the Decade of the Brain. 1 It was an extraordinary decade: advances in the basic neurosciences and in diagnosis and treatment of neurologic and psychiatric illnesses during that period are unparalleled. Sadly, though, one of the most common, most morbid, and yet most treatable of all brain illnesses still goes undiagnosed with frightening frequency.

Headache after administration of electroconvulsive therapy (ECT) is common, affecting approximately half of patients treated. Post-ECT headache is typically treated with acetaminophen or nonsteroidal anti-inflammatory drugs but occasionally requires agents such as sumatriptan, opioids, or β-blockers. We report on a patient whose severe post-ECT headaches responded completely to methyl salicylate ointment, applied to the area of his temporalis and masseter muscles. Topical methyl salicylate is generally well tolerated and may be a viable option for some patients with post-ECT headache.

Although a highly effective medication, the usage of clozapine is limited mostly by its 2.7% incidence of neutropenia. It is often a treatment of last resort for patients with severe psychiatric illnesses, and therefore often the only medication to which a patient has responded. There has thus been a great deal of interest in ways to continue the medication in spite of emergent blood dyscrasias. There have been several reports documenting the successful continuation of clozapine in spite of neutropenia by adding granulocyte colony-stimulating factors such as filgrastim. This strategy was unsuccessful for a 63-year-old man, resulting in severe, prolonged agranulocytosis. Although a promising strategy for such refractory patients, its inherent dangers should not be underestimated.