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Successful treatment using combined electroconvulsive therapy and oral paliperidone for clozapine-resistant schizophrenia: A case report
- C. I. Varlam, V. Dionisie, G. Andrișca, M. Manea
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- Journal:
- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, p. S1018
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Introduction
Clozapine is considered to be the most efficacious antipsychotic drug for treatment-resistant schizophrenia (TRS). Despite this, up to 70% of patients with TRS have a poor response to adequate treatment with clozapine. In order to overcome clozapine-resistance schizophrenia (CRS), a number of adjunctive therapies, including pharmacological and non-pharmacological options, have been attempted.
ObjectivesThe objective of this paper is to highlight the efficacy of the combined electroconvulsive therapy (ECT) and oral paliperidone as a successful treatment in clozapine nonresponders suffering from schizophrenia.
MethodsWe present the case of a 22-year-old female, with four years psychiatric history, which was admitted to our clinic for psychotic behavior, psychomotor agitation, verbal negativism, auditory hallucinations. During hospitalization, the patient presented behavioral disorganization, auditory, visual and tactile hallucinations, ideo-verbal barriers, poorly systematized delusional ideation (of guilt, mysticism, contamination, possession), episodes of catatonic stupor, rigidity, waxy flexibility, bizarre postures, false recognitions. Corroborating evidence, we established the diagnosis of undifferentiated schizophrenia. We initiated treatment with clozapine up to 450 mg/day and amisulpride up to 600 mg/day.
ResultsCombined treatment strategy of clozapine and amisulpride for six weeks showed no amelioration in our patient, with additional side-effects. Also, in the last four years, she had been treated with several atypical antipsychotics, which had not achieved substantial improvement. Considering that our patient did not present an adequate clinical response and the catatonic symptoms were accentuated, we decided to progressively reduce the doses of clozapine by 50 mg/day until elimination, to initiate paliperidone 12 mg/day and to conduct ECT three times a week, performing a total of six sessions. The bilateral electrode placement and brief pulse stimuli (800 mA; 8 s, 30 Hz) were applied under analgo-sedation, with no sustained severe adverse events. After performing ECT, the patient presented a favorable clinical evolution, with a decreasing trend until the remission of psychotic symptoms.
ConclusionsTRS was diagnosed based on the poor response to more than two kinds of atypical antipsychotics and CRS was established after the combination of clozapine and amisulpride failed to decrease persistent positive symptoms, associated with worsening of the negative symptoms. Combined therapy with paliperidone and ECT proved to be greatly effective in improving symptoms for our patient. Switching from clozapine to a previously untried atypical might be of benefit in TRS. Also, adjunctive ECT can be efficacious in CRS. Augmentation with ECT may result in a faster response, which is particularly useful among patients with high risks of self-harm.
Disclosure of InterestNone Declared
Exploring the limits of generalized dissociative amnesia: A case report
- C. I. Varlam, V. Dionisie, R. Movileanu, G. Andrișca, A. Roșu, M. Manea
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- Journal:
- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, p. S1101
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Introduction
Dissociative amnesia (DA), one of several dissociative disorders, is characterized by the inability to recall autobiographical information that is inconsistent with normal forgetting. Generalized amnesia is a rare subtype of amnesia distinguished by the acute onset of complete loss of memory for one’s life history, in which the patients may lose semantic knowledge, procedural knowledge or personal identity.
ObjectivesThe objective of this paper is to highlight that the diagnosis of generalized DA can be controversial and a comprehensive history, as well as collateral information, are essential for an accurate diagnosis.
MethodsWe present the case of a 37-year-old female, with no premorbid medical illness and one year psychiatric history which was admitted to our clinic for severe deficits of the memory and attention functions, emotional lability, social withdrawal, strong socio-professional dysfunctionality, altered behavior marked by the subjective changes of memory and thinking processes, affective ambivalence towards parents, mixed insomnia. The hetero-anamnesis revealed that our patient presented two fugues during the last 4 months. During her mental status evaluation, she showed temporal and spatial orientation, demonstrative attitude, spontaneous speech centered on her mental suffering, euthymic disposition, delusional ideas with somatic content, intermittent and inconstant facial motor stereotypes.
ResultsMultiple neurological examinations were performed, all being within normal limits. The magnetic resonance imaging of the brain identified an enlarged adenohypophysis and a possible microaneurysm that do not correlate with the symptoms. The endocrinological investigations invalidated the suspicion of acromegaly. The psychological examination suggested the tendency to mask less acceptable feelings, inadequacy, rigidity, the presence of conflicts of a sexual nature, regression to an infantile stage, with a deficit of concentrated attention. The emergent symptoms and signs were resistant, failed to resolve with antidepressant and antipsychotic medication and continued to persist across all settings. Corroborating evidence, we established the diagnosis of DA.
ConclusionsDA represents a controversial diagnostic entity that incorporates elements of psychogenic fugue states, repressed memory, traumatic amnesia, and conversion. Some clues in the history such as psychological traumas can support a diagnosis of DA rather than medical causes. As with most other psychiatric disorders, it is important to rule out organic causes first before considering psychiatric etiologies. A thorough sequential history and collateral information are key components in effective diagnosis and management of this condition. In the absence of a favorable response to psychotropic drugs, psychotherapy represents the best treatment approach for DA.
Disclosure of InterestNone Declared
Radiocarbon level in the Atmosphere of Ramnicu Valcea, Romania
- I Faurescu, C Varlam, I Vagner, D Faurescu, D Bogdan, D Costinel
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- Journal:
- Radiocarbon / Volume 61 / Issue 6 / December 2019
- Published online by Cambridge University Press:
- 25 November 2019, pp. 1625-1632
- Print publication:
- December 2019
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This paper presents radiocarbon (14C) variations in the atmosphere from Ramnicu Valcea, Romania. The samples were collected in the vicinity of the Experimental Pilot Plant for Tritium and Deuterium Separation (PESTD) from the Institute of the Cryogenics and Isotopic Technologies (ICSI) placed about 10 km south from the Ramnicu Valcea city (Romania), in the Govora industrial area. This facility is an experimental project in the national nuclear energy research program, which has the aim of developing technologies for tritium separation from heavy water. It should be noted that in the Govora industrial area operates a 315 MW coal-fired thermoelectric power plant and two chemical plants. In order to determine radiocarbon activity in the atmosphere, samples were collected monthly by absorption of CO2 into sodium hydroxide (NaOH) at Ramnicu Valcea. In addition, control materials (tree leaves, wild vegetation, and grapes), known activity standards, and process blanks (marble) were analyzed. Radiocarbon measurements were performed using the direct absorption method and liquid scintillation counting. The measured Δ14C levels varied between –57‰ and 61‰. The results have a decreasing trend, but due to local influence caused by the continuous production of fossil CO2, we cannot observe Δ14C seasonal variations.