Objective. The fact is highlighted that mental disorders including depressive mood may develop as the early or even the only clinical symptoms of proliferated neoplastic disease with metastases to the central nervous system (CNS).
Case report. A 48-year-old woman was referred to a psychiatric hospital with the diagnosis of depressive syndrome including gait disorders, among other symptoms. In the course of the disease she developed left-sided hemiplegia, and a proliferated neoplastic process with metastases to the CNS was found.
Commentary. The patient's symptoms did not differ from these of endogenous depression, which acted as a mask of neoplastic metastases to the CNS. The case suggests that if any organic background is suspected, perhaps neuroimaging diagnostic techniques should be used more often.
Objective. Psychiatric symptoms due to the frontal lobe tumours may be seen long before the onset of neurological symptoms. The correct diagnosis is difficult, especially in case of long-term ailments and complaints in patients whose behaviour can suggest neurotic or personality disorders. An analysis is presented ofpsychopathological symptoms in a case of arteriovenous malformation (AVM) in the right frontal lobe.
Case. An emergency admission of a 47-year-old woman was due to her marked anxiety in the past 2 days. During observation at a psychiatric ward a tentative diagnosis of adaptation or neurotic disorders was considered in this case, but in view of the presence of subtle features of the frontal lobe syndrome, a CT brain scan was preformed. An arteriovenous malformation in the right frontal lobe was found and subsequently removed.
Commentary. Anxiety, depressive symptoms, depersonalization, and derealization with concomitant subtle features of the frontal lobe syndrome may be the only, neurologically silent cues suggesting an organic process in the frontal lobes of the brain.
Objective. The paper presents diagnostic difficulties resulting from concomitance of mental disorders and cerebrospinal fluid flow impairment.
Case. In the course of observation a 16-year-old boy with atypical psychotic symptoms was diagnosed with normal pressure hydrocephalus and arachnoid cyst. Treatment outcome in this case is reported.
Commentary. Diagnostic difficulties associated with concomitance of mental disorders, normal pressure hydrocephalus and arachnoid cyst are largely due to atypical and multiform clinical symptoms. The organic origin of the disease may be masked by predominance of mental disorders in the clinical picture.
Objective. To investigate psychiatric symptoms associated with a colloidal cyst of the third ventricle of the brain. Such a cyst is a benign toumour, but it may be dangerous depending on its localization. It may be symptom-free, but its most common symptoms are headaches, and sometimes mental disorders. Since cysts producing clinical symptoms may be threatening to life, it is recommended that they should be removed.
Case. A patient admitted to a mental hospital after a suicide attempt and probable epileptic fit was diagnosed with depressive syndrome and vegetative symptoms of alcohol withdrawal. Moreover, he manifested paleness of affect, emotional lability, and impulsive character of suicidal thoughts. CT and MRI scans revealed a colloidal cyst of the third ventricle and dilatation of the lateral ventricles of the brain. His depressive symptoms abated after treatment with paroxetine. The cyst was removed, but after the surgery his emotional lability remained and his mood was (periodically) mildly depressed. At a check-up MRI examination the ventrical dilatation was found to be back to normal, but a distinct dilatation ofsubarachnoid spaces in the frontal and temporal areas of the brain was found. These structural changes remaining in the CNS after the surgery ware considered to be the organic background of the patients's chronic mood and affective disorders.
Commentary. The patient's depressive symptoms with subtle "organic" affective features and his abnormal response to alcohol may be the only symptoms of developing hydrocephalus in the course of colloidal cyst of the third ventricle.
Objective. To present diagnostic and therapeutic difficulties in a patient diagnosed with organic anxiety disorder
Case. A 29-year-old male patent with epilepsy and a history of encephalopathy in early childhood was admitted to a Psychiatry Ward on a motion for his compulsory treatment brought by the family and supported by the guardianship court.
Commentary. The importance of hospitalization was highlighted in cases where possibilities of outpatient diagnostics are limited.
Objective. Hypercortisolism is associated not only with typical somatic symptoms, but also with mental state changes: mood disorders, psychomotor drive abnormality, irritability and impetuousness. Also psychotic complications develop sometimes in the form of paranoid syndromes.
Case. A 42-year-old woman admitted to a mental hospital as an emergency case with symptoms of a paranoid-manic syndrome subsequently complained of other symptoms. A detailed endocrinological examination performed due to her complaints revealed hypercortisolism to be their cause. An adrenal adenoma was removed with no relapse of productive symptoms after the surgery. However, depressive mood disorders persisted.
Commentary. In some cases acute psychotic disorders result from a systemic disease. A thorough physical examination and diagnostics of the somatic symptoms present are a prerequisite of causal treatment.
Objective. To analyse hyponatraemia symptoms in psychiatric inpatients, with the focus on factors adversely affecting the course of the condition. Hyponatreamia may develop in the course of mental disorders and somatic diseases. Early symptoms may either suggest the onset of mental disorders or modify the clinical pattern of those already present. An increasing hyponatraemia may lead to an irreversible brain damage and death. Too rapid sodium supplementation may be also life threatening.
Case. In the first case hyponatraemia resulted in an irreversible brain damage and the patient's death. He suffered from chronic schizophrenia and unrecognized polydipsia, and was treated with haloperidol. The second patient with schizoaffective psychosis and unrecognized adrenal tumours developed hyponatraemia in the course of an infection of upper airways, and his death was due to septicaemia. In the third case mental disorders were caused by hyponatraemia in the course of a paraneoplastic syndrome with ecotopic ADH secretion by a latent microcellular carcinoma of the left lung. In this case psychiatric symptoms and metabolic disorders preceded by a few months both the clinical and radiological manifestation of the neoplastic process.
Commentary. Long-term schizophrenia and persistent, chronic psychotic symptoms increase the risk of polydipsia with overhydration and hyponatraemia. In such cases the amount of ingested liquids, urine specific weight and natraemia should be controlled. There is a need for more accessible specialist medical services for patients living in a local community, who suffer from chronic mental disorders and are helpless. The first episode of hyponatraemia in the course of mental disorders always requires a thorough diagnosis of the patient's physical state.
Objective. To present a case highlighting a relationship between the presence of autistic symptoms and schizophrenia.
Case. A 12-year-old girl diagnosed with childhood autism developed schizophrenia-spectrum symptoms in the course of further observation. Since the age of 2 she had demonstrated difficulties with interpersonal contacts, communicating (disorders and retardation of speech), and playing. A few years later she developed delusions of influence, „extraverbal" contact with a bus conductor, visual and auditory hallucinations, as well as inappropriate behaviour and affect.
Commentary. The onset of schizophrenia symptoms in a person with the diagnosis of childhood autism fundamentally changes the course of the condition. Many factors determining childhood autism may contribute to the development of schizophrenia at a somewhat later age.
Objective. Three cases are presented offemale patients with several relapses ofparanoid psychosis and no distinct cognitive impairment found in neuropsychological assessment.
Case. All three patients are young, quite well functioning in interpersonal contacts, and with a history of several hospitalizations due to relapsing paranoid psychoses. The neuropsychological assessment using the Vienna System revealed no clear-cut deficits in their cognitive functions examined.
Commentary. An analysis of the results obtained indicates the importance of cognitive assessment in the diagnostics of schizophrenia and other mental disorders.
Objective. A dual case is reported of a father and daughter, both with psychotic symptoms.
Case. The 31-year-old daughter was diagnosed with undifferentiated schizophrenia. Her personal history suggests that the onset of schizophrenic symptoms preceded her hospitalization by 9 years. She did not receive any regular treatment. Her father has never been treated psychiatrically. The presence of his psychiatric symptoms was found during the family history taking.
Commentary. Both patients shared some of the delusional content, which contributed to the schizophrenic daughter decision to consent to treatment.
Objective. Difficulties in diagnostic differentiation between dementia and late-onset schizophrenia in a 48-year-old female patient are discussed.
Case. The patient developed her first complaints, initially of neurotic character, at the age of 46. These were followed by the onset of psychotic symptoms, increasingly impaired functioning, and more and more marked cognitive deficits. Her medication included antidepressive, antipsychotic andprocognitive treatment. Late-onset schizophrenia was diagnosed. In the differential diagnosis an early-onset dementia, neurological conditions, and atypical depression were taken into consideration.
Commentary. Our doubts concerning the patient's further treatment are emphasized due to the complexity of the clinical picture of her condition and its atypical course. The eventual diagnosis, treatment and prognosis remain an "open question".
Objective. The diversity of clinical patterns of depression requires a thorough differential diagnosis and constant effortfrom psychiatrists who analyse symptomatology and dynamics of a condition with an atypical course.
Case. A case is presented of a wrong diagnosis of schizophrenia - in consequence the patient was treated with neuroleptics and developed aggravated schizophrenia-like disorders. A good antidepressant treatment outcome confirmed the diagnosis of atypical depression.
Commentary. Since atfirst delusional disorders and then schizophrenia were recognized, it can be concluded that in this case depression was definitely atypical. It can be hoped that thorough analysing of the clinical picture of depressive disorders may reduce the number ofpremature false diagnoses.
Objective. The authors describe their diagnostic doubts in a case of a female patient complaining of cognitive and mood disorders.
Case. A 47-year-old woman hospitalized on three separate occasions had been diagnosed with depressive and delusional disorders. During her most recent hospitalization the dissociative spectrum symptoms were observed.
Commentary. A detailed interview revealed a difficult family situation of the patent. After a modification of her pharmacotherapy her mental state has gradually improved.
Objective. To indicate the importance of somatic and behavioural symptoms of a psychological trauma for the diagnostic process and further treatment planning.
Case. A case is reported of a self-injuring woman, suffering from alopecia areata, hospitalized for depressive disorders with associated suicidal tendencies.
Commentary. Alopecia areata may be a somatic manifestation of self-aggression. An analysis of the course of alopecia areata is a source of information valuable in the diagnostic process. Verification of a psychological background to the dermatological condition allows to introduce an appropriate treatment leading to a remission of somatic symptoms.
Objective. A case is presented of the Ganser syndrome, a rather rare and little known dissociative disorder Its precise etiology, classification and clinical pattern are still open to discussion.
Case. A 52-year-old male patient hospitalized for the first time at a psychiatric ward displayed specific cognitive disorders with a considerable deterioration offunctioning. Differential diagnostic methods including a computer-aided examination of cognitive functions, EEG, and psychological assessment, confirmed a dissociative background of his symptoms. Support received during hospitalization and an analysis of trigger factors have resulted in a rapid amelioration of the patient's psychological condition.
Commentary. The authors point out that the Ganser syndrome should be differentiated from a similar psychopathological pattern seen both in organic brain disorders and in psychoses.
Objective. On the grounds of the literature an analysis was performed ofpersonality and family traits that might significantly contribute to the patient's internet addiction.
Case. A 16-year-old patient diagnosed with adjustment disorder, was admitted for his second hospitalization after another suicidal attempt. An analysis of his psychological test performance revealed that he was addicted to internet. The patient's developing personality traits are described, as well as his self-image, mechanisms of coping with stress, type ofpreferred aggressive behaviours, and relationship between his personality factors and internet addiction. Also parental attitudes, the parents' image as perceived by the patient, and relations between family members were analyzed.
Commentary. It was concluded that this mode of communication is ofparticular importance in view of the patient's difficulties in the real world. It served not only as his way of coping with problems, stress, and emotions, but also as a way of his emotional needs gratification. Next conclusion can be drawn that the patient's addiction to internet is related to his familial situation and attitudes of his parents. His "internet activity " is a response to the family situation and a way ofgratifying his emotional and social needs that are for him so difficult to satisfy in the real world.
Objective. A clinical description is presented of a patient with the diagnosis ofparanoid schizophrenia who developed post-treatment leukopenia.
Case. The patient aged 26 participated in a clinical trial of a new atypical neuroleptic. Since the medication turned out to be ineffective, clozapine was administered with good effects. A few months later the patient developed granulocytopenia neglected by the doctor responsible for his outpatient treatment.
Commentary. The necessity of white cell count monitoring in the course of clozapine treatment is sometimes neglected. In this case leukopenia was diagnosed (and subsequently cured) only due to a periodic checkup that the patient was given as a participant of the clinical trial of a new antipsychotic drug.
Objective. A case is presented of successful comprehensive therapy of a female patient with severe recurring depressive disorder.
Case. A 40-year-old woman with recurring depressive episodes received psychiatric treatment over the past few years. She had a difficult family situation and a problem of "co-dependence "from her alcohol dependent husband. His death was followed by the patient 's decompensation leading to a series of suicide attempts and her ineffective hospitalization for over a year. A comprehensive psychotherapy was introduced - group psychotherapy of cognitive orientation (based on the model by A. Beck) within a cognitive-behavioral system of the psychiatric ward functioning. Simultaneously the patient was treated with venlafaxin. A very good treatment outcome was achieved, and amelioration of the patient's psychological state was confirmed at a one-year follow-up.
Commentary. Comprehensive treatment, or a combination of antidepressive psychopharmacotherapy with cognitive-behavioral group psychotherapy yielded a good and stable therapy outcome in this chronic and treatment resistant case.
Objective. The paper illustrates the problem of taking advantage ofpeople with mental disorders by financial institutions and/or other persons.
Case. In the reported case a female patient despite her severe dementia was given several bank loans in various banks. The patient is not aware of her bank loans and has not used them, but all the time pays her debt in installments.
Commentary. In accordance with the legal provisions currently in force transactions made by the patient and similar individuals are legal and binding, unless on each occasion their legal incapacity is proven. Therefore, the only way ofprotecting such persons is to frequently and precisely document their mental status.