Abstract Trichotillomania is a chronic impulse control disorder characterized by pulling out one’s own hair, resulting in noticeable hair loss. Prevalence is 1% and 3.5% among older adolescents and young adults. Onset in pre- or mid-adolescence appears to be the norm, yet the research literature involving pediatric samples is particularly sparse. Studies suggest very early onset pulling may co-occur with other self-soothing behaviors. A 6-year-old child presented with 3-year history of scalp hair loss secondary to hair pulling. Mother noticed pulling hair from the right side of the scalp region while watching TV, sitting alone and while lying down on the bed before sleeping. She pulls out the hair and rolls it on her left thumb and sucks the thumb. Family members tried to reduce the behavior by covering her head with a cap, trimming her hair short and tonsuring her hair nine times, but most of these efforts were futile. With an uneventful antenatal and perinatal period, there was no history suggestive of comorbid depression, anxiety, attention-deficit hyperactivity disorder, or autism spectrum disorder. Family history of similar complaints was present in the elder sibling. Physical examination revealed diffuse, nonscarring, predominantly right temporoparietal alopecia. Both pediatric and dermatological consultations supported that hair-pulling was not due to another medical condition. Diagnosis of Trichotillomania was made. Treatment included habit reversal training, behavior modification program with a positive approach for thumb-sucking, and was started on fluoxetine 10 mg and was gradually titrated to 20 mg over 2 weeks. Significant reduction of symptoms was observed in 4 weeks. Practicing psychiatrists should be aware of the possibility of trichotillomania in very young children. This shows adequate response to behavioral therapy targeting associated soothing behaviors and treatment with a selective serotonin reuptake inhibitor.
Abstract Genital self-mutilation is a rare psychiatric emergency, most often linked to schizophrenia, with limited reports in affective disorders. We describe a 60-year-old man with recurrent depressive disorder with psychotic features who developed mood-congruent delusions of guilt and nihilism, believing that his genitals were decaying and required removal. This led to self-inflicted scrotal injury and unilateral orchiectomy. Clinical features favored psychotic depression over schizophrenia. Treatment with antidepressants and antipsychotics resulted in full remission. This case highlights Klingsor syndrome in psychotic depression and underscores the importance of early identification of high-risk delusional themes to prevent irreversible self-harm and morbidity.
Abstract Normal pressure hydrocephalus (NPH) is a reversible cause of dementia, classically presenting with Hakim’s triad of gait disturbance, cognitive impairment, and urinary incontinence. Psychiatric symptoms are often secondary; they tend to be mild neurosis and usually follow the classical triad. We report a 58-year-old male who initially presented with severe psychosis characterized by auditory hallucinations, delusions, and thought broadcast, followed later by gait imbalance, memory disturbances, and urinary urgency. MRI brain revealed ventriculomegaly (Evans index 0.44), and a normal cerebrospinal fluid (CSF) analysis confirmed idiopathic NPH. Following high-volume CSF tapping, there was marked improvement in neuropsychiatric symptoms, with Positive and Negative Syndrome Scale scores reducing from 48 to 20 within a week. This case highlights that psychosis can be an early and predominant manifestation of NPH and that timely CSF diversion procedures can result in both neurological and psychiatric recovery.
Abstract Background: Catatonia is a severe neuropsychiatric syndrome characterized by marked psychomotor retardation. Catatonia is associated with high morbidity and mortality in children; however, much of the understanding comes from the adult subset of the population. The diagnosis and management of pediatric catatonia pose unique challenges. This study looks into an exclusive cohort of catatonia in the pediatric age range. The profiling of this cohort and tracking their diagnostic trajectories will add to the current evidence pool to help establish a consensus guideline for early evaluation and management of pediatric catatonia in a low-resource setting. Methodology: The 2-year clinical data were gathered retrospectively using purposive sampling from the database of the child and adolescent psychiatry outpatient registry of a tertiary care center based in South India. Results: A total of 15 pediatric presenters were included in the sample. The average age was 14.6 (2.26) years. There were 8 (53%) male patients. The diagnostic trajectories in pediatric catatonia were heterogeneous. Seven patients retained their initial diagnosis. Among ten cases presenting with melancholic depressive features, six retained a depressive disorder diagnosis, while others evolved to bipolar disorder, obsessive–compulsive disorder, and neurodegeneration with brain iron accumulation. Of two psychosis cases, one evolved to schizophrenia, and one was diagnosed with NMDAR encephalitis. Three had organic etiologies: B-cell acute lymphoblastic leukemia with steroid-induced mood disorder, seronegative autoimmune encephalitis, and one of unknown cause. The average time to reach a final diagnosis in evolving cases was 9 months (standard deviation = 11.6), highlighting diagnostic complexity. There were 9 (60%) patients with a comorbid diagnosis of neurodevelopmental disorder (intellectual disability and autism spectrum disorder). There was a significantly elevated risk of catatonia in the sample with neurodevelopmental disorders ( P < 0.0001). Conclusions: It is essential that the clinical and investigative markers be defined separately for neurotypical and neurodiverse populations, especially with profound intellectual delay and autism. The diagnostic trajectories of presenters vary, but initial clinical assessment and investigation protocols need to be unified for the acute management of catatonia.
Abstract Psychiatric manifestations in adolescents are often misattributed to developmental or psychosocial stressors, especially in limited-resource settings. Wilson’s disease (WD), a rare autosomal recessive disorder of copper metabolism, may present solely with psychiatric symptoms, delaying diagnosis and worsening prognosis. We report two cases of a 14-year-old girl and a 17-year-old boy from rural Odisha, who presented with psychotic and behavioral symptoms, eventually diagnosed with WD. In this case series, we have discussed on the barriers to diagnosis and the early red flag signs suggestive of a neurological pathology of such symptoms. Case 1: A 14-year-old female, with previously good academic performance and normal social development, presented with a 9-month history of fearfulness, crying spells, poor appetite, school refusal, and behavioral regression. She was initially misdiagnosed as having a major mental disease, showed signs of psychomotor slowness, mutism, and poor attentiveness, and responded somewhat to antipsychotic medication before getting worse once again. WD was confirmed by a thorough medical examination that showed a Kayser–Fleischer (KF) ring on slit-lamp examination and low serum ceruloplasmin (24 mg/dL). Case 2: A 17-year-old male from a rural background with nil contributory past, family, and personal history presented with insidious onset continuous course and deteriorating progress of 1½-year history of irrelevant talk, muttering to self, suspiciousness, and impulsive behavior provisionally diagnosed as a case of psychosis unspecified and treated with tablet olanzapine 5 mg/day. After few days, he presented with extrapyramidal symptoms such as bradykinesia and generalized rigidity which did not resolve on adding tablet trihexyphenidyl 6 mg/day or discontinuing antipsychotic. His urinary copper was high, serum ceruloplasmin – 0.1 g/dl (normal > 0.2 g/dl), and KF ring was positive. The patient was given the diagnosis of WD and was prescribed tablet penicillamine 500 mg/day. In conclusion, these two cases explain how vital it is to take metabolic factors into consideration when adolescent patients present with psychiatric signs and symptoms, especially in clinical settings with limited resources. This study also highlights the necessity of collaborative pediatric, neurologic, and psychiatric care in unusual psychiatric presentation.
