Sunday, September 23, 2018

APPA 2018 Spring Conference Poster Presentation

The following abstracts have been approved for presentation at the 2018 APPA Spring Conference. Posters will be judged at the conference and awards given to the highest ranking posters.

Abstract 18-1-01

Title: A Case of Treatment-Resistant OCD after Clozapine Use

Authors: Laura Lockwood D.O., Clinton Martin M.D., and Adrienne Lahti M.D.

Summary:  This is a case report of a patient who has treatment-resistant psychosis and is treated with Clozapine.  He has developed severe obsessive-compulsive disorder (OCD), which is also treatment-resistant.  OCD is a common side effect from Clozapine treatment (seen in 20-28% of patients), and it can be very distressing.  While not much literature exists, first line treatment appears to be CBT and a high-dose SSRI.  If possible, the dose of Clozapine may be lowered.  Other treatments, such as adjunctive Aripiprazole, have promise, but more research is needed.

References:
Englisch S, Esslinger C, Inta D, Weinbrenner A, Peus V, Gutschalk A, Schirmbeck A, Zink M.  “Clozapine-induced Obsessive-compulsive Syndromes Improve In Combination With Aripiprazole.”  Clinical Neuropharmacology.  2009 July-August; 32(4):  227-229.

Fonseka TM, Richter MA, Muller DJ.  “Second Generation Antipsychotic-Induced Obsessive-compulsive Symptoms In Schizophrenia:  A Review of the Experimental Literature.”  Current Psychiatry Reports.  2014 November; 16(11):  510.

Schonfelder S, Schirmbeck F, Waltereit R, Englisch S, Zink M.  “Aripirazole Improves Olanzapine-associated Obsessive Compulsive Symptoms In Schiozphrenia.”  Clinical Neuropharmacology.  2011 November-December; 34(6):  256-257.

Tonna M, Ottoni R, Paglia F, Monici A, Ossola P, DE Panfilis C, Marchesi C.  “Obsessive-compulsive Symptoms in Schizophrenia and in Obsessive-compulsive Disorder:  Differences and Similarities.”  Journal of Psychiatric Practice.  2016 March; 22(2):  111-116.

Tundo A, Necci R.  “Cognitive-behavioral Therapy For Obsessive-compulsive Disorder Co-occurring With Psychosis:  Systematic Review of Evidence.”  World Journal of Psychiatry.  2016 December; 6(4):  449-455.

 

Abstract 18-1-02

Title: Successful Resolution of Prominent Somatic Delusions following Bilateral Electroconvulsive Therapy in a patient with Treatment- Resistant Schizoaffective Disorder

Authors: Joshua L. Cohen, PhD; My-Hanh Thi Vu, MD, MPH; Mirza Adam Beg, BS; Soumya Sivaraman, MD; Badari Birur, MD

Summary: Somatic delusions, in which the individual believes something is wrong with part or all of their body, may occur in variety of mental illnesses, including psychotic disorders such as schizophrenia and schizophreniform disorder, and mood disorders such as major depression and bipolar disorder. Notably, when somatization is a component of a mental illness, it is associated with lower quality of life and overall health, and greater risk for suicide. Although somatic preoccupations influence clinical outcomes, treatment can be difficult and there are no clear practice guidelines. Treatment of somatic delusions is extremely challenging and are usually resistant to treatment.

Here we report an interesting case of severe somatic delusions in a 48-year-old African-American female with a long-standing history of schizoaffective disorder that successfully resolved following six bilateral electroconvulsive treatments. Her symptoms include multiple somatic complaints such as constipation, pregnancy, jaw pain, body aches, vaginal itch, malodorous urine, and neck pain, despite normal clinical examination and negative medical work up. Additionally, she endorsed persistent auditory and visual hallucinations. Due to her concomitant catatonia, antipsychotics were not used, and her symptoms remained resistant to several trials of psychotropic medications. Chart review of past hospitalizations revealed significant improvement with bilateral and unilateral ECT, so the team decided to perform a course of six bilateral ECT treatments administered over two weeks. Stimulation was applied at a current of 800mA for 4.5s, with a pulse width of 1ms and frequency of 60 Hz. This case illustrates the benefits of use of bilateral electroconvulsive therapy (ECT) in treating prominent somatic delusions in a patient with treatment resistant schizoaffective disorder, who had poor response to several second generation antipsychotics and mood stabilizers.

References:

  1. Kamara, T. S., Whyte, E. M., Mulsant, B. H., Peasley-Miklus, C., Rothschild, A. J., Flint, A. J., … Meyers, B. S. (2009). Does major depressive disorder with somatic delusions constitute a distinct subtype of major depressive disorder with psychotic features? Journal of Affective Disorders, 112(1-3), 250–255. http://doi.org/10.1016/j.jad.2008.04.008
  2. Paolini, E., Moretti, P., & Compton, M. T. (2016). Delusions in First-Episode Psychosis: Principal Component Analysis of Twelve Types of Delusions and Demographic and Clinical Correlates of Resulting Domains. Psychiatry Research, 243, 5–13. http://doi.org/10.1016/j.psychres.2016.06.002
  3. McGilchrist, I., & Cutting, J. (1995) Somatic delusions in schizophrenia and the affective psychoses. British Journal of Psychiatry, 167(3):350-361
  4. Schneider, S.D., Jelinek, L., Lincoln, T.M., Moritz, S. (2011) What happened to the voices? A fine-grained analysis of how hallucinations and delusions change under psychiatric treatment. Psychiatry Research, 188:13-17
  5. Sheehan, B., Lall, R., Bass, C. (2005) Does somatization influence quality of life among older primary care patients? International Journal of Geriatric Psychiatry, 20(10):967-972
  6. Slattery, H., & Nance, M. (2015). Treatment resistant somatic delusions in bipolar disorder. BMJ Case Reports, 2015, bcr2014208375. http://doi.org/10.1136/bcr-2014-208375

 

Abstract 18-1-03

Title: Preference of Electronic Versus Paper Reading Resources Among Trainees in Psychiatry

Authors: Abhishek Reddy, M.D., Hillary Duenas, B.A., Austin Luker, M.D., Mounica Thootkur, M.B.B.S., Jung Won Kim, M.D.

Summary: 

Objective: The aim of this article is to understand the impact of technological advances on preference for reading format among psychiatry trainees in attempt to improve the quality of didactic education in residency and fellowship training.

Methods: Authors conducted anonymous survey questionnaires among psychiatry trainees.  Answers to 14 concise questions inquiring about specific aspects of reading behavior or reading style preference were statistically analysed.

Results: When reading for fun, there was clear preference for paper (75%) primarily due to the sensory experience (62.5%). For academic purposes and for gaining in-depth knowledge, most study participants preferred paper (79.2%). Further, most preferred taking notes on paper (79.2%). For academic purposes, a majority of respondents reported remembering more when they read on paper (91.7%) and that taking notes while reading also helped them remember content (91.7%). With regards to reading about medication, for both checking medication dosing and obtaining detailed medication information, most respondents preferred on-screen reading formats (83.3%, 54.2%).

Conclusions: Despite technological advances, a majority of our study participants showed preference to reading on paper. It seems reasonable to suggest that teaching faculty should take into account individual trainees’ preferences when disseminating reading materials for didactic courses. Further studies are warranted to understand actual efficiency of trainees’ preferred reading mode in acquiring new information and the impact of the transition from paper to onscreen on educational programs.

 

Abstract 18-1-04

Title: Access to Care

Authors: Abhishek Reddy, M.D., Melanie McDonald, Lee Ascherman, M.D., Janaki Nimmagadda, M.D., Clinton Martin, M.D.

Summary:

Introduction: In the United States, mental illness impacts 20 percent of the youth and half of all lifetime cases of mental illness begin by age 14, with three-quarters by age 24. In children and adolescents, unidentified and untreated early-stage mental illness is associated with school failure, teenage childbearing, unstable employment, substance use, violence, and increased risk of developing co-occurring mental disorders (NIMH, 2005). Despite having effective treatments, there are delays in average of about 8 to 10 years for access to mental health care, which are crucial developmental years in the life of a child. This longer lag time between symptom onset and treatment has created a mental health crisis on our public health system. Numerous reports and studies over the past decade have highlighted the severe shortage of children’s mental health professionals that affects access to early intervention and mental health services. The Children’s Hospitals report (2012), the IOM (2009), the Annapolis Coalition on the Behavioral Health Workforce (2003), A Surgeon General Report (1999), have all reported on the urgency to address the critical workforce shortages. About 20 percent of children and adolescents with mental illnesses, receive some kind of mental health services, and only a small fraction of them receive an evaluation and treatment by a child and adolescent psychiatrist. The Children’s Hospital Association survey (2012), reported that appointments for child and adolescent psychiatric care far exceeds the recommended two-week wait time in children’s hospitals, with the average wait time being 7.5 weeks. Child and adolescent psychiatric services in the U.S. are severely maldistributed, with children in rural areas and areas of low socioeconomic status having the least access to mental health care. The ratio of child and adolescent psychiatrists per 100,000 youth ranges from 3.1 in Alaska to 21.3 in Massachusetts, with a national average of 8.7.

Objectives: We designed a teaching clinic module that is structured around rapid intake, short-term treatment for stabilization of illness including, but not limited to, ADHD, Mood, and Psychotic disorders, and referral to the next level of care after stabilization. This model allows for a constant flow of intakes and overcomes the barriers that pediatricians and families face, in accessing mental health care. Two faculty members teach and supervise four-second year child and adolescent psychiatry residents each in a four-hour clinic constructed to provide sufficient time for new patients and follow up care. Patients are booked into 90- minute evaluation intake appointments within one month of contact. Each resident gets an evaluation of at least one new patient a week.

Methods: The diagnostic assessments include ongoing clinical assessments and testing. It incorporates short-term treatment interventions with monitoring response to medications and therapies. The patients are receiving treatment on average for a period of three to six months prior to transitioning of. One of the goals of the diagnostic clinic is to keep the waiting time below 4 weeks at any given time in the community we serve. Once stabilized and when mutually agreed upon, patients are subsequently referred to resources in the department or in the community for ongoing care.

Results: Our data collected early this year shows that with the start of our diagnostic clinics in July 2015, wait times where drastically reduced from an average of 167 days to an average of 55 days (Fig 2). No-show rates, was also shown to be reduced from approximately 35% in our standard clinics to less than 5% in the diagnostic short-term clinic. We would like to expand our data to assess for the viability of similar clinical model in the long term, and compare it with traditional intake clinics on variables like, type of diagnosis, wait times, no show rates and quality of care measures.

 

Abstract 18-1-05

Title: Contraceptive and Pregnancy Trends in Women attending a Medication Assisted Treatment (MAT) Facility in Mobile, AL

Authors: Tina Jackson, MD; Lindsey Stewart, MD; Adam Ali, MD; Peyman Tashkandi, DO; Marianne Saitz, DO.

Summary:

Introduction: After noting several women reporting to the MAT facility with unplanned pregnancies, clinicians desired further information about consumers’ use of contraception and the need for improved contraception information and access. A survey was administered to female consumers participating in treatment at the Altapointe MAT facility on Government Blvd, Mobile, AL.

Objective: To determine whether consumers at the MAT clinic have understanding, access and desire for birth control while in treatment. Furthermore, to gauge interest in having contraception access available at the clinic.

Main outcomes and measures: Basic demographics including age and education level; pregnancy information including age of first pregnancy, number of pregnancies and live births; childbearing plans and current contraceptive use; interest in contraception being offered at the clinic. Where applicable, measures were compared to published national statistics.

Results: 34% of total pregnancies were planned; 46% of participants did not plan any of their pregnancies; while 95% were not attempting pregnancy, 45% were using no birth control; 26% of participants were interested in having services offered at the clinic.

Discussion and Conclusion: The most common reported barrier to contraceptive use was convenience. National statistics correlated with findings in Mobile that women in MAT are more likely to have unintended pregnancy than the general population. Participants indicated interest in having contraceptive options available in the same location as their addiction treatment. Many articles have advocated for an integrated approach to contraceptive health and addiction treatment. Further study is planned to explore the possibility of a pilot program to offer contraception at the Mobile location.

References:

  1. Terplan M, Hand DJ, Hutchinson M, Salisbury-Afshar E, Heil SH. Contraceptive use and method choice among women with opioid and other substance use disorders: A systematic review. Preventive Medicine 80 (2015) 23-31.
  2. Black KI, Day CA. Improving access to long-acting contraceptive methods and reducing unplanned pregnancy among women with substance use disorders. Substance abuse: Research and Treatment 2016: 10(S1), 27-33.
  3. Reddy UM, Davis JM, Ren Z, Greene MF. Opioid use in pregnancy, neonatal abstinence syndrome, and childhood outcomes. Opioid epidemic executive summary. Obstetrics & Gynecology (v.130, no. 1) July 2017.
  4. Nasiri B. Windows of opportunity: Adapting services to the needs of people who inject drugs. Int J Drug Policy. 2013; 23:107.
  5. Edelman NL, Patel H, Glasper A, Bogen-Johnston L. Sexual health risks and health-seeking behaviors among substance-misusing women. J Adv Nurs. 2014; 70 (12): 2861-70.

 

Abstract 18-1-06

Title: Morgellons or madness: unraveling the fact and fiction of parasitosis

Authors: Anna C. Williams, BS; Tina Jackson, MD; J. Luke Engeriser, MD

Summary:  Morgellons disease is a psychodermatologic illness that has gained considerable media attention within the last decade. Characterized by sensations of crawling beneath the skin, chronic skin lesions, and the belief that fibers or filaments are extruded from these lesions, it is considered by many medical professionals to be a type of delusional parasitosis. However, many individuals with Morgellons refute this, believing that their condition has an infectious or autoimmune etiology. These individuals have largely turned to the internet to describe and explore their symptoms, with many diagnosing themselves solely based on information available through Morgellons-related forums and the website of the now-defunct Morgellons Research Foundation. Though an extensive study published by the CDC in 2012 found no identifiable infectious or autoimmune cause for Morgellons symptoms, it shed light on the various disabling somatic and neuropsychiatric complaints of these individuals. No official guidelines exist for the evaluation and treatment of Morgellons disease, but various case reports have described alleviation or remission of symptoms with the use of antipsychotic medications. The discussion of Morgellons is important because it illustrates many pertinent topics in psychiatry:  the challenges associated with the growing trend of self-diagnosis, the expanding influence of the internet and social media on patient perception and understanding of illness, and the reality that psychiatric illness is capable of causing profound physical suffering in patients.

References:

  1. Harvey WT, Bransfield RC, Mercer DE, Wright AJ, Ricchi RM, Leitao MM. Morgellons disease, illuminating an undefined illness: a case series. Journal of Medical Case Reports.
  2. Morgellons Research Founation (MRF) website. Accessed March 18, 2018 at www.mrf.com
  3. Murase JE, Wu JJ, Koo J. Morgellons disease: a rapport-enhancing term for delusions of parasitosis. J Am Acad Dermatol. 2006;55(5):913-914.
  4. Ohn J, Park SY, Moon J, Choe YS, Kim KH. Morgellons Disease. Annals of Dermatology. 2017;29(2):223-225.
  5. Pearson et al. Clinical, epidemiologic, histopathologic, and molecular features of an unexplained dermopathy. PLoS ONE. 2012;7(1):1-12.
  6. Ranka N, Godse K, Nadkarni N, Patil S, Agarwal S. Morgellons disease: A myth or reality?. Indian Dermatol Online J 2016;7:430-2.
  7. Savely VR, Stricker RB. Morgellons disease: analysis of a population with clinically confirmed microscopic subcutaneous fibers of unknown etiology. Clinical, cosmetic and investigational dermatology. 2010;3:67-78.

 

Abstract 18-1-07

Title: Development of persistent hiccups following discontinuation of Aripiprazole

Authors: Michael Marshall BS, Adam Ali MD, William Billet MD

Summary:  Hiccups are rhythmic, involuntary contractions of the diaphragm occurring at a typical rate of four to sixty contractions per minute.  Hiccups are classified as acute when lasting less than forty-eight hours, persistent when lasting over forty-eight hours, and intractable when lasting over one month. Involvement of the neurotransmitters dopamine, serotonin, and GABA in the pathogenesis of hiccups has been established through animal modeling and observed medication side effects. Specifically, use of the antipsychotic aripiprazole and subsequent development of hiccups has been extensively documented. Chlorpromazine remains the lone FDA approved treatment for intractable hiccups, further emphasizing the role of serotonergic and dopaminergic system interplay in the pathogenesis and treatment of hiccups.

While the precipitation of hiccups during aripiprazole therapy has been well documented, we report the case of a 56 year old male with schizoaffective disorder, bipolar type who developed hiccups following discontinuation of aripiprazole. Initial symptomatic improvement was achieved with chlorpromazine therapy. Discontinuation of chlorpromazine and titration of quetiapine due to cardiac risk factors was followed by a reemergence of symptoms; however, a second chlorpromazine trial proved ineffective at abolishing the hiccups. Resolution was achieved following initiation of pregabalin therapy and was maintained after discontinuation of the second chlorpromazine trial. Our case highlights an important alternative treatment option for intractable hiccups when standard therapy fails.

References:

  1. Caloro M, Pucci D, Calabrò G, de Pisa E, Mancinelli I, Rosini E, Montebovi F, De Filippis S, Telesforo CL, Cuomo I, Kotzalidis GD, Girardi P. Development of Hiccup in Male Patients Hospitalized in a Psychiatric Ward: Is it Specifically Related to the Aripiprazole-Benzodiazepine Combination. Clinical Neuropharmacology 2016, Vol. 39(2):67-72. DOI:1097/WNF.0000000000000129.
  2. Naro A, Bramanti P, Salvatore Calabro R. Successful Use of Tetrabenazine in a Patient with
    Intractable Hiccups After Stroke. Pharmacotherapy 2014, Vol. 34(12):e345–e348) doi: 10.1002/phar.1523
  3. Nausheen F, Mohsin H, Lakhan S. Neurotransmitters in hiccups. SpringerPlus 2016,Vol. 5:1357. DOI: 10.1186/s40064-016-3034-3
  4. Ray P, Zia Ul Haq M, Nizamie SH. Aripiprazole-induced hiccups: a case report. General Hospital Psychiatry 2009, Vol. 31(4) 382-384. doi: 10.1016/j.genhosppsych.2008.09.014
  5. Silverman MA, Leung JG, Schak KM. Aripiprazole-Associated Hiccups: A Case and Closer Look at the Association Between Hiccups and Antipsychotics. Journal of Pharmacy Practice 2014, Vol. 27(6) 587-590. DOI: 10.1177/0897190014544797

 

Abstract 18-1-08

Title: Hyponatremia Secondary to Psychogenic Polydipsia in the Inpatient Psychiatric Setting

Authors: Amy Yu, BS; James LePage, DO; William Billett, MD

Summary:  Hyponatremia is defined as a serum sodium concentration below 136 mmol/L. The differential diagnosis of hyponatremia is broad and involves first making a determination about whether the hyponatremia is taking place in the setting of normal, increased, or decreased serum osmolality. Further differentiating causes of hypotonic hyponatremia involves the assessment of volume status and urine osmolality. In cases of euvolemic hypotonic hyponatremia with appropriately low urine osmolality and low urine sodium, the differential is further limited to primary polydipsia and low solute states, e.g., so-called beer potomania syndrome.1 Psychogenic polydipsia, a clinical disorder characterized by polydipsia and polyuria, is a common manifestation in patients with psychiatric disorders.2,3 One theory suggests that in unaffected individuals, the cue for thirst and threshold for ADH suppression are close together, whereas in patients with psychogenic polydipsia, there is a greater difference in set points.3 This greater difference allows the patient to remain thirsty as they make themselves more hypotonic. Another theory suggests that dopamine receptor supersensitivity is responsible for psychogenic polydipsia, as elevated dopamine levels have been shown to stimulate thirst centers.3 This may explain why psychogenic polydipsia often occurs late in the course of schizophrenia. In epidemiological studies, 10 to 20% of patients with schizophrenia were found to have polydipsia, but only one-fifth to one-third of these patients experienced symptoms of water intoxication.4 Symptoms of water intoxication associated with hyponatremia secondary to psychogenic polydipsia include delirium, seizures, coma, lethargy, and ataxia.

We describe the case of a 47-year-old man with a diagnosis of schizoaffective disorder, bipolar type and intellectual disability who was admitted to the involuntary unit of a standalone psychiatric inpatient facility with irritability, poor impulse control, and aggressive outbursts at his group home prior to admission. During the course of his stay, staff noted that the patient was consuming large amounts of water from the water station. CMP was obtained which revealed serum sodium of 127 mmol/L, which subsequently trended lower to 122 mmol/L. The hyponatremia was found to be hypotonic, with serum osmolality trending from 259 mOsm/kg down to 248 mOsm/kg. After four days of 1.5 L/day fluid restriction, sodium normalized at 141 mmol/L, with serum osmolality of 290 mmol/kg. While hyponatremic, some increase in agitation was noted, but no other symptoms of water intoxication were identified. Of important note, hyponatremia must be corrected slowly to avoid neurologic sequelae of central pontine myelinolysis and/or extrapontine myelinolysis.5 Urine studies important in the workup of hyponatremia, which include urine sodium and urine osmolality, were ordered but were not collected until after the patient’s sodium had normalized. Early identification of psychogenic polydipsia and prompt institution of therapeutic fluid restriction can prevent the symptoms of water intoxication or limit their severity.

References:

  1. Spasovski, G., et al., 2014. Clinical practice guideline on diagnosis and treatment of hyponatremia. Nephrology Dialysis Transplatation, 29 (2), p. ii1-ii39.
  2. Adrogué, H. and Madias, N., 2002. Hyponatremia. The New England Journal of Medicine, 342 (21), p. 1581-1589.
  3. Dundas, B., et al., 2007. Psychogenic polydipsia review: etiology, differential, and treatment. Current Psychiatric Reports, 9 (3), p. 236-241.
  4. Goldman, M., 2009. The mechanism of life-threatening water imbalance in schizophrenia and its relationship to the underlying psychiatric illness. Brain Research Reviews, 61, p. 210-220.
  5. Penders, T., et al., 2016. Psychogenic polydipsia, hyponatremia and osmotic myelinolysis. BMJ Case Report, p. 1-3.

 

Abstract 18-1-09

Title: Value of CRP Monitoring in Detecting Clozapine-Induced Myocarditis

Authors: Mariah Sankey, M3; Tina Jackson, MD, PGY2; Candace Perry, MD

Summary:  A patient who was started on clozapine therapy began to complain of chest pain and the decision was made to discontinue therapy after his CRP was found to be elevated. The case study discusses research indicating that CRP may be an early indicator of clozapine-induced myocarditis. A 42 yo AAM with history of schizophrenia and substance use disorder was seen in the inpatient unit because of erratic behavior and medication noncompliance. After failed trials of olanzapine and haloperidol the decision was made to start clozapine. After complaints of chest pain, labs were drawn revealing elevated CRP levels. The decision was made to discontinue clozapine and start an alternative antipsychotic. He improved and was discharged to an intermediate care facility for further stabilization. There is developing research indicating that CRP levels may be valuable for predicting impending myocarditis in patients being treated with clozapine. In the face of difficulty accessing medical collaboration in some inpatient psychiatric facilities, this information could assist clinicians in making difficult decisions about medication management. Further research is needed to assess reliability of these values.

References:

  1. Löffler, Stefan. Clozapine therapy raises serum concentrations of high sensitive C-reactive protein in schizophrenic patients. International Clinical Psychopharmacology 2010, Vol 25 No 2.
  2. Ronaldson, Kathlyn J. A new monitoring protocol for clozapine-induced myocarditis based in an analysis of 75 cases and 94 controls. Australian and New Zealand Journal of Psychiatry 2011; 45:458-465.
  3. DR Goldsmith et al. An Unmet Need: A Clozapine-Induced Myocarditis Screening Protocol. Prim Care Companion CNS Disord 19 (4). 2017 Aug 03.

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