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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.

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.

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.

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.

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.

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.

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.

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.

Capgras syndrome, the delusion that identical-appearing impostors have replaced familiar people, is an unusual phenomenon usually seen in schizophrenia or dementia. We recently cared for a 78 year old man who seemed to develop Capgras syndrome as an adverse reaction to diazepam. An iatrogenic cause should be considered in the differential diagnosis of any new delusion, including Capgras syndrome.

Aggressive behavior in children and adolescents is a heterogeneous phenomenon occurring in a wide variety of illnesses. No single etiologic model seems adequate to explain this phenomenon. In many cases, pharmacotherapy may prove to be a useful adjunct to treatment. Potentially useful medications are described in reference to psychiatric diagnosis. Pharmacological treatment can be helpful in the management of the aggressive youth when judiciously applied in the context of a comprehensive treatment plan.