Neuropsychiatric Disturbance in Huntington’s Disease: Approach to Management

Introduction Huntington’s Disease (HD) is an autosomal dominant, neurodegenerative condition with a prevalence of 10.6-13.7 per 100,000, caused by the trinucleotide CAG (cytosine, adenine, guanine) repeat expansion in the HTT gene. HD is characterized by a range of motor, cognitive, and psychiatric symptoms, the latter of which usually manifest prior to the onset of motor or cognitive disturbances. Amongst psychiatric symptoms, changes in personality are most common, followed by depression. Psychosis has a higher prevalence in those with early-onset HD. Objectives This case report aims to demonstrate an apporach to the management of neuropsychiatric disturbances in HD as well as expose the need for development of an evidence-based apprach to treatment. Methods PubMed was searched for the criteria Huntington’s Disease AND Psychosis, with a secondary search for Management of Psychosis in Huntington’s Disease. Results The patient is a 54-year-old male with no psychiatric history and reported past medical history of Huntington’s Disease, diagnosed one month ago. He was brought to the Psychiatric ED due to agitation and disorganized behavior at home. On admission, he demonstrated disorganized behavior, grandiose delusions, neurocognitive deficits, and reported auditory hallucinations. With the initiation of tetrabenazine and risperidone his psychiatric symptoms improved and he was able to be discharged to a long-term care facility. Conclusions Literature is scarce regarding treatment of psychiatric manifestations of HD. We catered our approach towards safe and effective symptoms management in a multidisciplinary manner. Further research is required to reach an evidence-based consensus as well as develop specific guidelines for managing psychiatric conditions related to HD. Disclosure No significant relationships.

Introduction: Glaucoma is a heterogeneous group of conditions which result in optic neuropathy and visual defects, majorly linked with the increase of intra-ocular pressure (IOP). It is known that psychotropic drugs have been implicated in drug induced angleclosure glaucoma, mostly through its anti-cholinergic effect. Objectives: Systematize the drugs most and least implicated in its appearance and worsening and understand the care needed on prescribing.
Methods: A search on Pubmed database was made having in consideration the Mesh Terms Glaucoma and Psychotropic Drugs and its different classes. Specific searches were made when appropriate on different platforms. Results: Implications on the appearance and worsening of glaucoma are clear for tricyclic antidepressants. The evidence is not clear for SSRIs, SNRIs and mirtazapine, but they might be related with increased IOP. Other classes of antidepressants seem to be of lower risk. Antipsychotics do not seem to be greatly associated with angle closure, although there are some case reports. There are descriptions of the potencial use of haloperidol, anti-convulsive mood stabilizers, with exception of topiramate, melatonin and antidementia drugs on the treatment of this condition. In practice, benzodiazepines do not seem to precipate angle-closure. Methamphetamines are contraindicated. Eletroconvulsive therapy its an option. Conclusions: Although not prevalent, angle-closure glaucoma can have serious implications and culminate in irreversible blindness. In patients with known risk-factors its important to have it on consideration at the time of the prescription and warn on seeking immediate help if having acute ocular pain, redness and/ or cloudy vision. Introduction: Huntington's Disease (HD) is an autosomal dominant, neurodegenerative condition with a prevalence of 10.6-13.7 per 100,000, caused by the trinucleotide CAG (cytosine, adenine, guanine) repeat expansion in the HTT gene. HD is characterized by a range of motor, cognitive, and psychiatric symptoms, the latter of which usually manifest prior to the onset of motor or cognitive disturbances. Amongst psychiatric symptoms, changes in personality are most common, followed by depression. Psychosis has a higher prevalence in those with early-onset HD.
Objectives: This case report aims to demonstrate an apporach to the management of neuropsychiatric disturbances in HD as well as expose the need for development of an evidence-based apprach to treatment. Methods: PubMed was searched for the criteria Huntington's Disease AND Psychosis, with a secondary search for Management of Psychosis in Huntington's Disease.

Results:
The patient is a 54-year-old male with no psychiatric history and reported past medical history of Huntington's Disease, diagnosed one month ago. He was brought to the Psychiatric ED due to agitation and disorganized behavior at home. On admission, he demonstrated disorganized behavior, grandiose delusions, neurocognitive deficits, and reported auditory hallucinations. With the initiation of tetrabenazine and risperidone his psychiatric symptoms improved and he was able to be discharged to a long-term care facility. Conclusions: Literature is scarce regarding treatment of psychiatric manifestations of HD. We catered our approach towards safe and effective symptoms management in a multidisciplinary manner. Further research is required to reach an evidence-based consensus as well as develop specific guidelines for managing psychiatric conditions related to HD. Introduction: Severe mental disorders experience premature mortality mostly from physical causes. When a patient with a history of bipolar disorder is admitted to the emergency room (ER) for psychiatric symptoms, these are routinely interpreted as a psychiatric disturbance. However, a careful history should be performed to correctly interpret key clinical information to rule out somatic etiology and establish adequate diagnosis. Objectives: To describe a patient whose presenting symptoms were misdiagnosed as psychiatric relapse, rather than serious somatic comorbidity debut. Methods: A 70-year-old man, with a history of type I bipolar disorder and multiple cardiovascular conditions, was admitted to the ER for self-referred nervousness, depressed mood, insomnia, and suicidal thoughts. Symptoms had greatly worsened the previous week to his consultation with paroxysmal episodes of severe anxiety, feelings of strangeness, and sensations of unpleasant odors. Results: During observation, the patient was found lying down with loss of consciousness, urinary incontinence, and amnesia of the event. Generalized tonic-clonic seizures were observed by neurologists while mental status examination was being performed. After symptoms were oriented as having a neurological etiology, the patient suffered cardiac arrest and defibrillation was required. After admittance to the intensive care unit and inpatient cardiology care, the patient was discharged from the hospital with the diagnosis of ventricular fibrillation due to drug-induced QT prolongation.
There was no evidence of mixed depression or seizures once the cardiac dysfunction was identified and treated. Conclusions: The psychiatric symptoms were the clinical manifestation of a generalized seizure-like activities that were attributed to transient cerebral hypoperfusion secondary to ventricular fibrillation. Introduction: What do patients talk during a clinic evaluation? What do they report besides referring physical complaints? It is crucial to value 'hidden' symbolic issues under a conversation between patient and his/her doctors and nurses. Elderly people are at increased risk of developing Chronic Obstructive Pulmonary Disease (COPD) that requires the management of associated emotions. In advanced stages, they need to use Long-term Home Oxygen Therapy (LTOT) as part of treatment. Patients perceive difficulties with its use, generating anguish. Objectives: To explore meanings of emotional experiences as reported by patients regarding LTOT, seen in a public university outpatient service. Methods: Qualitative design. Semi-directed interviews with openended questions were carried out with seven elderly patients at Pulmonology Outpatient Clinic at General Hospital at University of Campinas, diagnosed with COPD and using LTOT in period 2019 to 2020. Data were analyzed using Content Analysis with the support of Webqda software. COREQ checklist was used. Results: Three categories emerged from interviews: (1) Changes of self-image perception with great dissatisfaction in not recognizing their selves physically. (2) Sadness with social isolation and feelings of awkwardness regarding themselves. (3) Affective aspects bringing the need to re-mean old family supports. Conclusions: Simply listening to reports of emotional complaints implies only a description of a clinical condition of the psychic sphere. Elderly patients with COPD bring psychological representations of their clinical condition that call for a symbolic interpretation. If such patients become aware of hidden meanings, they can better manage their fears and other uncomfortable feelings.