Premenstrual dysphoric disorder (PMDD) is a hormone-sensitive mood disorder characterized by cyclical psychiatric and physical symptoms that impair functioning. Despite inclusion in DSM-5 and ICD-11, PMDD is frequently misdiagnosed or overlooked due to clinical unfamiliarity, lack of structured assessment, and systemic minimization of hormone-linked distress. Women routinely face delays in diagnosis and often only receive definitive treatment through self-advocacy. This report describes a 35-year-old cisgender female with treatment-resistant PMDD, whose symptoms began after menarche and worsened over two decades. Despite multiple psychiatric and medical encounters, her condition was misattributed to obesity, mood disorders, or trauma. After a diagnostic delay and multiple first and second-line treatment failures, a trial of leuprolide acetate confirmed a hormonal etiology of her symptoms, and she subsequently underwent total hysterectomy with bilateral salpingo-oophorectomy. Although she experienced a severe depressive episode in the immediate postoperative period, she has since remained in sustained symptom remission on an SSRI and estrogen replacement. This case demonstrates the need to recognize cyclic symptom patterns and potential hormonal etiology in treatment-resistant mood disorders.
Hallucinogen persisting perception disorder (HPPD) is a rare psychiatric diagnosis encompassing a range of perceptual disturbances caused by the lingering effects of hallucinogens. There are two major subtypes of the disorder: HPPD I and II. HPPD II is considered a more severe form that is generally longer-term, distressing, and requiring more intense treatment. In the limited available literature, many of the affected patients have multiple psychiatric comorbidities. The following case describes a 24-year-old college student, WA, who was diagnosed with HPPD II along with comorbid bipolar I disorder and generalized anxiety disorder. WA presented with an escalation of manic symptoms, psychosis, and two lysergic acid diethylamide (LSD) uses prior to hospitalization. He was treated with olanzapine, leading to mood stabilization and remission of psychosis. Post treatment, WA continued to experience perceptual disturbances and "visual snow." Medications clonidine and clonazepam were trialed for HPPD. While symptoms fluctuated in severity, they never fully resolved. Despite this, WA achieved acceptance of his symptoms, mood stability, and a functional recovery. WA's case is an example of the clinical complexity in accurate diagnosis and treatment of HPPD, including the distinction of the symptoms from psychosis. As LSD-assisted therapies continue to be investigated for conditions such as anxiety and depression, recognition and management of persistent adverse effects such as HPPD are becoming increasingly important in both psychiatric and general medical practice. This case demonstrates the limited effectiveness and lack of knowledge on HPPD treatments as well as the need for longitudinal assessments in management.
A 13-year-old adolescent male was referred for an interdisciplinary autism assessment. His complex medical history included a traumatic delivery (with drop in heartrate and nuchal cord), neonatal hyperbilirubinemia, diagnosis of profound congenital hearing loss, diminished bile ducts on liver biopsy at 1 month of age, and a seizure disorder. Later, he was diagnosed with a significant global developmental delay with minimal communication in any modality. The youth received cochlear implants at the age of 2 years but was unable to tolerate them. Despite early intervention services and multiple stays in urban academic medical centers, he was not considered for a diagnosis of autism because his problematic behaviors, sensory sensitivities, and social and communication delays were attributed to his hearing loss and intellectual disability. It was not until the age of 13 that he was confirmed to have autism via a comprehensive interdisciplinary assessment based on adapted, standardized, evidence-based tools and expert clinical observations. This case highlights the importance of understanding and identifying the differences between hearing loss related behaviors and possible symptoms of a co-occurring neurodevelopmental disorder as well as the peril of diagnostic overshadowing in children with hearing loss.
Clozapine is regarded as the most effective treatment for patients with treatment-resistant schizophrenia (TRS). However, serious adverse effects such as hyponatremia may necessitate discontinuation, leaving limited therapeutic alternatives. This case report describes a middle-aged male with chronic schizophrenia who developed clinically significant hyponatremia during clozapine titration, leading to its discontinuation prior to achievement of therapeutic serum concentrations. Despite prior antipsychotic trials with haloperidol, asenapine, olanzapine, and chlorpromazine, the patient had persistent auditory hallucinations and paranoid delusions. Given the patient's clozapine intolerance and persistent psychosis, a course of bifrontal electroconvulsive therapy (ECT) was initiated three times weekly over a 24-day inpatient series. The patient demonstrated progressive reduction in auditory hallucinations and paranoid ideation throughout treatment, with resolution of hallucinations and marked improvement in paranoia by discharge. Treatment was well tolerated, with only mild transient headaches and no clinically significant cognitive adverse effects observed on serial mental status examinations. At 5 months post-ECT, he remained free from readmission and without recurrence of his positive symptoms. This case highlights the potential role of ECT as a therapeutic consideration for select patients with refractory psychosis when clozapine cannot be safely continued due to medically significant adverse effects such as hyponatremia.
Introduction:Obsessive-compulsive disorder (OCD) is a chronic psychiatric condition that frequently presents with comorbid depressive disorders. For patients exhibiting treatment-refractory OCD and concurrent depressive disorder(s), there is growing clinical interest in the noncompetitive N-methyl-D-aspartate (NMDA) receptor antagonist ketamine as a rapid-acting intervention. This case report describes a 27-year-old female patient with severe, treatment-refractory OCD and comorbid depressive symptoms, detailing her response to a single intramuscular (IM) ketamine administration. Case Presentation:The patient's primary compulsion was that of handwashing, which she would partake in for ~6 h per handwashing session at the time of the first ketamine administration. This occurred daily over a 3.5-month period, wherein a single day would consist of up to 18 total hours of handwashing. These extreme compulsions resulted in severe in-home isolation, precluding in-person psychotherapy and employment. Despite ongoing management by an independent telepsychiatrist, the patient reported no symptom relief from her prescribed regimen of fluoxetine (80 mg) and alprazolam (1 mg, four times daily)-a pharmacotherapeutic approach that may have been clinically suboptimal given the potential for high-dose benzodiazepines to exacerbate obsessive-compulsive symptoms. Given the severity of her condition, she subsequently pursued treatment at an unaffiliated outpatient ketamine clinic. Conclusion:Following a single IM ketamine administration, the patient experienced an acute, ~97% reduction in handwashing duration (from 6 h sessions to 5-10 min sessions) sustained over a 10-day period. This observation highlights an acute change in the patient's primary compulsive behavior. However, concurrent pharmacotherapy may confound the results, and prospective controlled trials are required to fully evaluate the efficacy of this intervention.
Refractory or unexplained chronic cough (RUCC) is a cough lasting more than 8 weeks that persists despite guidelines-based evaluation and treatment, either because no cause is identified or because the cough continues after appropriate treatment of identified conditions. It can significantly impair functioning, sleep, and quality of life. Guideline-supported options remain limited. We report on a case of RUCC that was very effectively treated with low-dose sublingual buprenorphine. This partial μ-opioid agonist can offer greater safety and lower misuse liability compared to full opioid agonists or tramadol. Further study of this treatment option is warranted.
Tardive dyskinesia (TD) is a cluster of symptoms affecting orofacial, truncal, and extremity regions following prolonged exposure to antidopaminergic agents and may be life-threatening in severe cases. It is most commonly observed in patients receiving long-term antipsychotic treatment, such as individuals with schizophrenia. Lurasidone is a relatively novel antipsychotic that has been reported to induce tardive syndromes in patients with schizophrenia and bipolar disorder and has also been used as an augmentation strategy in treatment-resistant schizophrenia. In this report, we present an intriguing case in which TD improved following the addition of lurasidone to the patient's existing treatment, accompanied by a reduction in negative psychotic symptoms. The patient's Abnormal Involuntary Movement Scale (AIMS) score decreased from 20 to 8-9 after the initiation and subsequent dose increase of lurasidone. Additionally, the Positive and Negative Syndrome Scale (PANSS) total score decreased from 171 to 148, with particularly notable improvement in the negative symptom subscale. The beneficial effect of lurasidone on TD is hypothesized to be related to various receptor interactions of the current treatment, as well as 5-HT2A antagonism and preferential modulation of dopamine turnover in the prefrontal cortex rather than the striatum, as also observed with clozapine. Further studies are warranted to elucidate the underlying mechanisms of this phenomenon.
Developmental trauma is a primary etiological factor in dissociative identity disorder (DID) and may lead to misdiagnosis due to symptom overlap with other psychiatric and neurological conditions. This case report describes an adolescent male with pronounced narcissistic vulnerability. The patient’s background features an inconsistent parenting style—characterized by both overprotection and severe criticism—and significant paternal pressure to achieve academic success and embody an idealized, wise persona. Chronic exposure to these psychosocial stressors is hypothesized to have contributed to acute narcissistic rage, potentially associated with dissociative identity fragmentation. The initial clinical presentation involved functional neurological symptoms, which progressed to distinct identity states with amnesia. Treatment focused on supporting the patient’s disrupted grandiose self-structure through an empathetic, mirroring psychotherapeutic approach. This intervention was associated with a marked reduction in dissociative symptoms. Further research is needed to clarify the complex role of narcissistic vulnerabilities in the development of dissociative identity presentations.
Selective serotonin reuptake inhibitors (SSRIs) are widely used as first-line treatments for major depressive disorder (MDD) and anxiety disorders, with common adverse effects, including sexual dysfunction, anxiety, insomnia, and appetite changes, although seizures have also been reported, particularly in the presence of risk factors such as older age, family history of epilepsy, neurological comorbidities, and high antidepressant dosages. We describe two patients who developed generalized tonic-clonic seizures associated with SSRI therapy. The first case is a man with SSRI-resistant MDD and multiple medical comorbidities who experienced five generalized tonic-clonic seizures while receiving various antidepressants. The second case is a woman with generalized anxiety disorder (GAD) who developed two generalized tonic-clonic seizures temporally related to paroxetine use. In both cases, extensive investigations, including laboratory tests, electroencephalogram (EEG), CT, and MRI, yielded normal results, suggesting a potential drug-associated etiology. Both patients were subsequently switched to the atypical antidepressant agomelatine, which was followed by a complete cessation of seizures and marked improvement in mood and anxiety symptoms. These observations underscore the need to consider seizures as a potential adverse event of SSRIs and suggest that agomelatine could be considered an alternative pharmacological option for patients at risk of antidepressant-associated seizures.
Hemomania is a proposed term for incontrollable urges to see, release, or ingest blood which is not a formally recognized diagnostic entity. This behavioral phenomenon overlaps with nonsuicidal self-injury (NSSI), impulse control disorders, and elements of clinical vampirism. We present the case of a 22-year-old female with a longstanding history of bloodletting using syringes, blood ingestion, and collection. The patient collected blood in vials, sometimes mixed them with water and drank it. She also collected and consumed blood from other individuals and animals occasionally. These behaviors did not align with existing diagnostic categories, therefore, conceptualized within the proposed construct of hemomania. She had comorbid major depressive disorder with psychotic features, borderline personality disorder (BPD), and schizotypal traits. Her problems intensified following recent marital discord, which acted as a key emotional trigger. Treatment comprising pharmacotherapy and psychotherapy resulted in partial improvement of symptoms but relapsed within a few months. This case describes an atypical, chronic presentations of exceptionally rare pattern of behavior and highlights the conventional diagnostic and therapeutic challenges underscoring the need for precise diagnostic framing, thorough differential assessment, and individualized treatment approaches for such complex psychiatric presentations.
Priapism, a urologic emergency, is defined as a penile erection persisting longer than 4 h independent of sexual stimulation. While psychotropic medication-associated priapism is well documented, atomoxetine-associated priapism remains extremely rare. Atomoxetine is a norepinephrine reuptake inhibitor used in the management of attention-deficit/hyperactivity disorder (ADHD). We report the case of an Asian male in his late 20s with bipolar I disorder who had been treated with aripiprazole 7.5 mg daily for 6 months and developed sudden bilateral testicular pain, followed by a painful erection lasting more than 4 h, beginning 5 days after starting atomoxetine. He had no history of genitourinary trauma, malignancy, or concurrent medication or substance use. Clinical and laboratory evaluation were unremarkable, and detumescence occurred approximately 6 h after symptom onset without invasive intervention. Atomoxetine was discontinued the next day and no recurrence was reported at 4-week follow-up. Causality assessment using the Naranjo Adverse Drug Reaction Probability Scale yielded a score of 4 (possible) for atomoxetine. This case underscores the importance of counseling patients prescribed atomoxetine and other psychotropics about priapism and the need for urgent evaluation when erections persist for ≥4 h.
Autoimmune encephalitis (AE) represents a potentially reversible cause of subacute cognitive and psychiatric decline. When no autoantibodies are detected, seronegative AE remains diagnostically challenging, particularly among older adults presenting with new-onset neuropsychiatric symptoms. This report describes an older adult with recurrent episodes of confusion, aphasia, and psychosis whose diagnostic studies—including magnetic resonance imaging (MRI) and cerebrospinal fluid (CSF) analysis—were unremarkable. The individual had previously demonstrated substantial improvement after corticosteroid therapy and was again treated empirically with immunotherapy following psychiatric consultation. This case highlights the importance of maintaining a high index of suspicion for AE when standard serologic markers are absent and underscores the collaborative role of psychiatry and neurology in evaluating rapidly progressive cognitive and behavioral syndromes, which may present initially as primary psychiatric illness. Early consideration of autoimmune etiologies and prompt initiation of immunotherapy can significantly improve outcomes in patients with otherwise unexplained, rapidly progressive cognitive or behavioral syndromes.
Introduction:This case describes persistent delirium exceeding 18 months with prominent paranoid delusions in a 72-year-old woman with chronic hyponatremia, poststroke epilepsy, and alcohol use disorder. It highlights diagnostic and pharmacologic management challenges when standard agents carry prohibitive risks. Patient’s Main Concerns and Important Clinical Findings:A 72-year-old woman with a history of left hemispheric hemorrhagic stroke, poststroke epilepsy, and chronic alcohol use presented with acute confusion. Laboratory evaluation revealed severe hyponatremia (Na 122 mmol/L). Clinical findings included persecutory delusions, severe agitation with dangerous behaviors (attempting to leave moving vehicles, stabbing attempt), anxiety, insomnia, and fluctuating cognitive status with return to baseline between episodes. EEG demonstrated epileptiform discharges and generalized encephalopathy. Divalproex sodium levels at presentation were supratherapeutic (up to 127 mcg/mL). There was no evidence of prior dementia or progressive cognitive decline. Primary Diagnoses Interventions and Outcomes:The primary diagnosis was persistent delirium with multifactorial etiology. Interventions included hyponatremia correction, transition from divalproex to lacosamide, and initiation of mirtazapine, which was selected for its lower hyponatremia risk compared to other antidepressants, lower seizure risk compared to antipsychotics, and low deliriogenic potential. Sleep and anxiety improved with partial agitation reduction, though delirium persisted. Over 18 months, paranoid delusions evolved from episodic to continuous, creating treatment adherence barriers. Conclusion:This case underscores the potential for exceptionally prolonged delirium in medically complex older adults, diagnostic complexity in differentiating persistent delirium from ictal-related psychosis and other conditions, and individualized pharmacotherapy considerations. Early multidisciplinary intervention, capacity assessments, and caregiver support are critical.
Objective:To report a complex case of serotonin toxicity that evolved into a persistent neuropsychiatric syndrome, complicating the differential diagnosis between protracted toxicity, prolonged SSRI discontinuation syndrome, acute hepatic porphyria, and functional neurological disorder (FND). Method:We present the case of a 61-year-old male with a history of gastric sleeve surgery and major depressive disorder (MDD) who developed acute serotonin syndrome (SS) following the concomitant use of fluoxetine, buspirone, and linezolid. Results:While acute autonomic instability resolved upon cessation of serotonergic agents, the patient developed subacute, evolving neurological deficits. Workup revealed an SLC6A4 polymorphism and elevated urinary porphyrins, initially prompting Hemin therapy, though genetic testing for porphyria was negative. Tertiary evaluation at the Cleveland Clinic ultimately confirmed a diagnosis of FND, psychogenic non-epileptic seizures (PNES), and chronic migraine. Management remains challenging due to medication sensitivity, including recent parasomnias during a cautious trial of vilazodone. Conclusions:This case highlights the diagnostic complexity following SS in patients with altered gastrointestinal anatomy and genetic variances. It emphasizes how an acute organic insult-whether serotonin toxicity, prolonged SSRI discontinuation, or a combination of both-can serve as a physiological trigger for complex FND and PNES, requiring multidisciplinary management. The limitations inherent in single-case observations are discussed.
Background:Obsessive-compulsive disorder (OCD) is a chronic psychiatric disorder commonly treated with selective serotonin reuptake inhibitors (SSRIs) and, in more severe or resistant cases, clomipramine. Clomiphene citrate, a selective estrogen receptor (ER) modulator primarily used for infertility, is not indicated for psychiatric disorders but may influence neuroendocrine and serotonergic pathways. This case describes an unexpected improvement in OCD symptoms following the accidental prescription of clomiphene instead of clomipramine. Case Presentation:A 50-year-old woman with a longstanding history of anxiety and recurrent major depressive disorder (MDD) developed OCD symptoms after childbirth during her second pregnancy. Her symptoms previously responded well to sertraline, clonazepam, and clomipramine. After ~15 years of relative stability, clomipramine was discontinued because of anticholinergic side effects, resulting in relapse of obsessive-compulsive symptoms. A 3-month trial of sertraline 200 mg/day was ineffective. When clomipramine was intended to be restarted, a prescribing error led to clomiphene 25 mg/day being dispensed instead. The patient took clomiphene together with sertraline 100 mg/day and clonazepam 2 mg/night for 12 weeks. During this period, she experienced a dramatic and complete remission of her obsessive-compulsive symptoms, with an estimated reduction in Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score from 23 to ~7. No adverse effects were identified. After the error was recognized, clomiphene was discontinued, the incident was reported, and clomipramine was reintroduced, although the same degree of improvement was not reproduced. Conclusion:This case raises a speculative but clinically important hypothesis regarding the possible role of hormonal modulation in a subgroup of hormonally sensitive patients with OCD. However, causality cannot be established because hormonal measurements were unavailable and alternative explanations, including placebo effects, spontaneous symptom fluctuation, and concomitant medication effects, remain possible. Future studies should longitudinally assess OCD symptom changes during hormonally sensitive periods, ideally in conjunction with standardized clinical measures and hormonal biomarkers. The case also underscores the ethical and patient-safety importance of preventing medication errors.
Background:Bupropion is a norepinephrine-dopamine reuptake inhibitor (NDRI) and nicotinic antagonist. It belongs to the class of aminoketones and is commonly used to treat major depressive disorder (MDD) and to aid in smoking cessation. There is scarce literature on the sudden appearance of obsessive-compulsive symptoms (OCSs) in depressed patients that could be related to bupropion treatment. Case Series:We present four cases of bupropion associated with OCSs in patients with affective disorders. Patients reported no previous history of obsessive ideation or compulsion. Symptoms appeared after the start of bupropion treatment with a progressive increase in intensity. Upon discontinuation of the drug, there was a notable reduction in symptoms with a complete remission over time. Evaluation of obsessive and compulsive symptoms and evolution were assessed using the Yale-Brown obsessive-compulsive scale (YBOCS) and clinical global impression-severity (CGI-S) scale. Conclusions:The neurobiological basis for the development of OCSs associated with bupropion treatment is not yet fully understood; clinicians need to take these symptoms into account when prescribing bupropion. Further studies with a larger sample of patients with depression who are undergoing bupropion treatment are required to confirm this phenomenon.
Compulsive sexual behavior disorder (CSBD) is characterized by persistent difficulty controlling sexual urges and behaviors associated with marked distress or impairment. Population-based data indicate that ~8.6% of US adults experience distress related to difficulty controlling sexual urges, feelings, and behaviors, while large international screening studies suggest that ~5% of individuals may be at high risk for CSBD, yet only a minority seek treatment. Diagnostic classification remains challenging in early or evolving presentations and in patients with complex psychiatric and neurodevelopmental comorbidities. The International Classification of Diseases, 11th Revision (ICD-11) requires a 6-month symptom duration for formal diagnosis and specifies exclusion when symptoms are better explained by another mental disorder, substance use, or medication effects. Here we describe a man in his 20 s with bipolar I disorder, attention-deficit/hyperactivity disorder, anxiety, and intellectual developmental disorder (IDD), along with medical comorbidities, who was hospitalized for severe intrusive sexual thoughts associated with distress and safety concerns. Phenomenology suggested overlap between obsessive-compulsive disorder (OCD) with sexual obsessions and an emerging CSBD-like syndrome, with ego-dystonic intrusive cognitions alongside strong gratification-driven urges and restraint primarily driven by anticipated negative consequences. Given symptom severity and imminent risk of behavioral enactment, the presentation was conceptualized as an early CSBD-like syndrome despite not meeting the ICD-11 duration criterion. Symptoms remained acutely refractory despite multiple psychotropic optimizations; the most temporally associated improvement occurred after initiation of naltrexone, with marked improvement within 5 days and resolution of intrusive sexual thoughts by hospital day 16. Although concurrent medication changes preclude attribution to naltrexone monotherapy, the rapid response supports further investigation of reward- and impulse-targeted interventions for severe subthreshold presentations and highlights the need for clearer diagnostic frameworks and evidence-based guidance for acute management of diagnostically ambiguous compulsive sexual and sexual obsessive syndromes.
Herpes simplex virus type 1 (HSV-1) encephalitis can mimic neurodegenerative or structural disorders, particularly in older adults presenting with cognitive or behavioral symptoms. We report the case of a 73-year-old woman with progressive gait instability, urinary incontinence, and cognitive decline, which was initially attributed to normal pressure hydrocephalus (NPH). Despite transient improvement after two lumbar punctures and neuroimaging suggestive of significant ventriculomegaly, the patient’s symptoms progressed with increasing paranoia, hallucinations, and agitation. Psychiatric consultation worked up the NPH diagnosis and identified various behavioral abnormalities—such as fluctuating delirium and psychosis—inconsistent with classic NPH. After 20 days of admission, restructuring of the differential and extensive infectious and metabolic testing led to the identification of HSV-1 DNA in cerebrospinal fluid (CSF). The patient improved markedly with prompt acyclovir therapy. This case underscores the diagnostic overlap and mimicry between infectious and neurodegenerative processes and highlights the role of psychiatric input in reframing atypical neurocognitive presentations and expanding the differential of treatment-resistant NPH in the presence of inconsistent symptomatic progression.
Background:Testosterone-lowering medication (TLM) is used in severe cases of paraphilic disorders and problematic sexual behaviour, but its use in patients with intellectual disability is not well characterised. Method:A nationwide survey identified five male patients with intellectual disability who had received TLM in specialised outpatient clinics. Results:Four patients showed reduced problematic sexual behaviour during treatment; three relapsed after discontinuation. Adverse effects included osteoporosis, hypertension, depression and suppressed sexual development. Monitoring and access varied regionally. Conclusions:TLM may be effective in selected patients with intellectual disability but requires careful monitoring and ethical oversight.
Background:This case highlights the clinical complexity of caring for individuals with autism spectrum disorder (ASD) and severe intellectual developmental disorder (IDD), particularly in the context of prolonged mechanical restraint, psychotropic polypharmacy, and life-threatening somatic complications. It illustrates how a multidisciplinary and individualized neurobehavioral approach can lead to major clinical improvement despite an initially poor prognosis and limitations regarding intensive care. Case Presentation:Nathan is a 24-year-old man of Slavic origin with ASD and severe IDD who had been subjected to continuous mechanical restraint for 2 years and was receiving five concomitant antipsychotic medications. He presented with severe behavioral dysregulation in a context of chronic anxiety, marked communication limitations, recurrent aspiration pneumonia related to gastrostomy feeding, and adverse effects associated with antipsychotic treatment. He was referred to a specialized neurobehavioral unit, where a multidisciplinary team-including psychiatry, intensive care, palliative care, and ethics specialists-agreed on a conservative management plan. Antipsychotic treatment was streamlined to clozapine, fluoxetine was later introduced, and care combined nutritional rehabilitation, communication-focused support, and individualized psychoeducational, occupational, and psychomotor interventions in a highly structured environment. Oral feeding was gradually reintroduced, ultimately allowing gastrostomy removal, and restrictive measures were progressively discontinued. Overtime, his behavioral symptoms, emotional regulation, physical health, mobility, and overall quality of life improved markedly. Conclusions:This case underscores the importance of integrated multidisciplinary care in complex ASD/IDD presentations involving severe behavioral and somatic complications. Psychopharmacological simplification, environmental and communication adaptations, and individualized rehabilitation strategies were central to the improvement in both somatic outcomes and behavioral functioning. It also highlights the need to recognize prolonged mechanical restraint as a harmful and unsustainable management strategy in individuals with severe neurodevelopmental disorders.
