Psychotic acute episode - comorbidity or complication of endocrine. disorders to teenager
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1 Psychotic acute episode - comorbidity or complication of endocrine disorders to teenager GEORGIANA ALINA TOCACI 1, CARMEN IOANA TRUŢESCU 1 ABSTRACT: The nervous and endocrine systems are in a strong functional interrelationship. The nervous system releases chemical agents that can act as local mediators or circulating hormones. A number of hormones can act as functional mediators in the central nervous system. There are known a number of level alterations of neurohormonal and neuromodulator concentrations in the systemic circulation or in the cerebrospinal fluid in a series of mental disorders. Although anxiety and depression are the most common psychiatric symptoms associated with endocrinopathies, hormonal imbalances can mimic other psychiatric disorders such as dysthymic disorder, mania or psychotic episodes. Key words: psychosis, thyroiditis, Basedow-Graves, teenager REZUMAT: Sistemul nervos şi endocrin sunt într-o interdependenţă funcţională puternică. Sistemul nervos eliberează agenţi chimici, care pot acţiona ca mediatori locali sau hormoni care circulă. O serie de hormoni pot acţiona ca mediatori funcţionali în sistemul nervos central. Sunt cunoscute o serie de modificari de concentraţii la nivel neurohormonal şi neuromodulator în circulaţia sistemică sau în lichidul cefalorahidian intr-o serie de tulburări mentale. Deşi anxietatea şi depresia sunt cele mai frecvente simptome psihiatrice, dezechilibrele hormonale pot mima si alte tulburări psihiatrice, cum sunt tulburările distimice, episoadele psihotice sau mania. 1 MD, resident in Child and Adolescent Psychiatry, Child and Adolescent Psychiatry Department, Prof. Dr. Al. Obregia Hospital of Psychiatry, Bucharest
2 Cuvinte cheie: psihoza, tiroidita, Basedow-Graves, adolescent The reasons for hospitalization: D.V. is a patient aged 14 years that was brought by her parents for: auditory hallucinations ( there are more voices that are talking to me, they are mischievous, sometimes they talk about me, they say that is over, that I'm done ); olfactory hallucinations ( I feel an odor ); interoceptive hallucinations ( I cannot eat I have something yellow in my stomach, something that don t let me eat and don t want to leave from there ); delusions of persecution ( I m afraid of people, I do not want to go to school, not to sting me someone ); social isolation ( I m not in the mood to see someone, I want you to leave me alone, I want to sit alone ). Of the family history we keep in mind that on maternal line there is a third degree relative with post-traumatic mental disorder triggered in adolescence (death of her mother). Personal physiological history: First child coming from a pregnancy affirmative normal until birth, weight at birth=2900g, APGAR=7 (child with surrounded cord blood which required about 48 hours of O 2 -therapy). She was discharged after 5-6 days with good further adaptation. The psychomotor development in stages of age was normal. Personal pathological history: The patient was diagnosed a year ago with Basedow- Graves disease and was treated with Carbimazol 5mg 1 pill a day at the beginning of psychiatric manifestations. Living and working conditions: The patient is a student of a prestigious high school with good academic results. She lives with her parents being their only child; although she has her own room which she has arranged with her mother, for several months she sleeps with her mother, saying that she cannot sleep alone. History: From the anamnesis we notice that social withdrawal has gradually begun about two months, but symptoms have increased in the last 3 weeks. Parents connects the beginning of the manifestations by an incident with traumatic potential for their daughter (her
3 boyfriend proposed her to maintain intimate relationships, however she refused him, but this gesture shocked her). At the beginning, 3 weeks ago the patient was hospitalized to the pediatric department where she was investigated and were denied various organic disorders. Psychic examination: On admission, the patient came accompanied by her mother. Mimics and gestures, less mobile, were in accordance with ideas. The general aspect was of a careful teenage girl, proper hygiene, but her mother said: She was more stylish, more elegant, she make up, now she is just so just needs. The patient seemed scared, she looked suspicious to other people. Mental contact was made with difficulty, slowness in responding to questions and she repeatedly said: I wish to stay in one place, I do not want to see anyone, I do not want anyone to ask me anything, I have the impression that people want to hurt me, it s like a fear. From historical data provided by the parents we noted that: at the beginning she said that she s afraid of people, that she has a fear, she wants to go with someone at school. She was no longer so cheerful, she was more solitary and quiet Then she started to feel sick from the stomach, with nausea and the refusal to eat. The patient had perception disorders: auditory and interoceptive hallucinations, pathological illusions: I hear more voices. They are like some evil women. Sometimes they talk to me, say that it's over with me, that I'm ready They, sometimes talk to me, especially at night, it s not a dream, I am awake. I m afraid of them. The description of voices was often accompanied by neurovegetative manifestations (clammy hands, pallor, sweating) and heat sensation, by sick starting from the stomach and ending in her fingertips; I heard an evil bird, she was at my window, I was afraid of her, I knew it was something bad, but I don t know what it was ; Sometimes I feel an unpleasant smell that my mother doesn t feel. It's always the same and it takes a lot.if I eat I feel that I have something round and yellow in my stomach, something that makes me sick, I cannot get rid of him.
4 Attention: spontaneous hiperprosexia ( she is always attentive to what is heard, sometimes she senses the door creaking and she slightly trembling ), voluntary hipoprosexia ( no longer focus on anything, it seems that nothing interests her, says her mother). Memory: We observed fixed hipomnezia; the evocation was made with difficulty. Mind disorders were mainly qualitative: injury and persecution delusions ( people want to hurt me, my classmates are bad, and they want to sting me ). Poorly spontaneous speech, limited to simple sentences or words, the patient could answer with slowness to the questions, bradilalia. Thinking is marked by the presence of persecution ideation, tracking and injury, and also, by a high degree of suspicious and interpretation. The patient said: People want to hurt me, I m afraid, I do not want to see anyone, children stab me, I don t want to go to school. Activity / Affectivity: patient with anhedonia and low reversal affection for mother. From history we note that the beginning of the symptoms is connected by family with the existence of a tense emotional situation related to the teenage relationship breakup with her boyfriend. The disposal of the patient is fluctuating, moving from sadness, with tendency to verbal negativism, to dysphoria, related to the presence of changes in perception. The patient said: When I hear those voices I run, I sit alone, I put my hands to ears, I want to get rid of all, not to hear them. I am afraid of them. We also note the tendency to behaviors with self destruction character and she explained them later: I want to die, I no longer support to be so he told me to cut my veins and I pulled the cannula cap I want to die The appetite was greatly reduced, with significant weight loss (5 kg before hospitalization and another 5 kg after the time of admission to psychiatry). The patient said: I don t eat it flows a taste of food and an unpleasant smell in my mouth, I rather not eat, I better receive perfusion, I better die
5 Patient had been complaining that he could not have a peaceful sleep: I have a restless sleep about 3 weeks, a dream a lot and bad, I do not rest, and those voices it s not a dream I m in bed, but I can t sleep. During hospitalization the paraclinic explorations have been continued, as it follows: Neurological exam (within in normal limits) and EEG exam (with low voltage trail without epileptiform abnormalities) and MRI performed later led to the exclusion of the organic disorders. MRI showed a left superior cerebellar herniation, relevant but not pathological. Endocrinology exam showed changes in antibodies: Anti- TPO = 238Ui/ml (<34) and Anti-thyroglobulin = 482Ui/ml (<115), generating the suspicion of chronic autoimmune thyroiditis and the decision to discontinue treatment with Carbimazol. Because of the possibility of certain demyelinisations in endocrine diseases it was, also made a cerebral CT scan which was normal, without significant abnormalities. Positive diagnosis: Axis I: Psychotic acute episode Axis II: Without significant items Axis III: Basedow-Graves disease Axis IV: Without significant items Axis V: GAF=40 (severe difficulties in social and professional functioning) Differential diagnosis: A. Organic disorders: were both denied by specific tests performed in our clinic, as well as earlier in the pediatric department, tumoral modifications, but also,
6 possible intoxication or type of infectious diseases (EEG, cerebral IRM, abdominal ultrasonographie, blood tests). B. Psychiatric disorders: -Psychiatric disorders in other endocrine diseases: it was considered that psychic symptoms can be partially explained by endocrine disorders, in the context of normal values of thyroid hormones. -Affective disorders: are difficult to infirmed at the time of presentation of this case. The installation sequence of symptoms is suggestive of an acute psychotic episode, although the evolution of the patient may be a mixed affective disorder. -Posttraumatic stress disorder and Dissociative disorder considered because of the emotional stressor event that the patient mentioned, was invalidated by a detailed history that has showed that social retraction, the ideation of persecution and anhedonia started before the mentioned incident; the symptoms were continuous and were not time intervals with normal psychological functioning. More than that, the patient had a favorable evolution and good tolerance under antipsychotic medication. -Social phobia: that could be taken into account from symptom onset was invalidated, the intensity of events leading to reconsideration diagnose, refusal to go to school appearing in the context of thought disorders. -Disharmonious personality development, considering all behavior and interrelation features, although some of criterion lacks ( the patient is under 18). Treatment During the first days after admission, the evolution was favorable, with almost complete remission of positive symptoms. She said: I m not so sleepy, I feel anxious, I have a fear, I d better stay in blanket. During hospitalization the patient presented urinating difficulties and decided to decrease the dose and then even change the treatment schedule, replacing the tricyclic antidepressant with one of SSRI class (sertraline), and then, even replacing the initial antipsychotic with another atypical antipsychotic (olanzapine).
7 The treatment was performed in first phase with butyrophenones which has been associated with tricyclic antidepressant, with favorable evolution in the first days, followed by the appearance of secondary reactions that generated the requirement change of treatment schedule. We choose for a combination of atypical antipsychotics drug class that was associated with antidepressant medication (SSRI) and mood stabilizers. Under this treatment schedule the evolution was slowly favorable with complete normalization of appetite, but with persistence of dispositional changes and thought disorders. Prognosis Positive prognostic factors were: Absence of other psychiatric disorders (first episode), Intensive positive symptoms (hallucinations, delusions), Existence of an adequate family support, Female gender. Negative prognostic factors could be related to the early onset as well as the premorbid personality: patient withdrawn without too many friends. Mother said that her friends were with her only for interest and that she does not actually have a real friend. In conclusion, we want to emphasize the particularity of the presented case, given by comorbidity with endocrine disorders which may be clinically expressed by psychiatric symptoms, putting problems to the clinician in the phase of differential diagnosis. Urinating difficulties secondary appeared in response to treatment, although rare, have created the requirement of therapeutic change, which significantly influenced the evolution of patient treatment.
8
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