Reframing delusional infestation: perspectives on unresolved puzzles

Delusional infestation (DI), a debilitating psychocutaneous condition, featured as a false fixed belief of being infested accompanied by somatosensory abnormality, behavior alteration, and cognitive impairment. Although management of primary causes and pharmacotherapy with antipsychotics and/or antidepressants can help to alleviate symptoms in most patients, the underlying etiology of DI still remains unclear. Morgellons disease (MD), characterized by the presence of cutaneous filaments projected from or embedded in skin, is also a polemic issue because of its relationship with spirochetal infection. This review aims to discuss the following topics that currently confuse our understandings of DI: 1) the relationship of real/sham “infestation” with DI/MD; 2) behavior alterations, such as self-inflicted trauma; 3) neuroimaging abnormality and disturbance in neurotransmitter systems; and 4) impaired insight in patients with this disease. In discussion, we try to propose a multifactorial approach to the final diagnosis of DI/MD. Future studies exploring the neurobiological etiology of DI/MD are warranted.

Circulating T-cell subsets discrepancy between bipolar disorder and major depressive disorder during mood episodes: A naturalistic, retrospective study of 1015 cases

AIMS

We aimed to investigate whether peripheral T-cell subsets could be a biomarker to distinguish major depressive disorder (MDD) and bipolar disorder (BD).

METHODS

Medical records of hospitalized patients in the Department of Psychiatry, the First Affiliated Hospital, Zhejiang University School of Medicine, from January 2015 to September 2020 with a discharge diagnosis of MDD or BD were reviewed. Patients who underwent peripheral blood examination of T-cell subtype proportions, including CD3+, CD4+, CD8+ T-cell, and natural killer (NK) cells, were enrolled. The Chi-square test, t-test, or one-way analysis of variance were used to analyze group differences. Demographic profiles and T-cell data were used to construct a random forest classifier-based diagnostic model.

RESULTS

Totally, 98 cases of BD mania, 459 cases of BD depression (BD-D), and 458 cases of MDD were included. There were significant differences in the proportions of CD3+, CD4+, CD8+ T-cell, and NK cells among the three groups. Compared with MDD, the BD-D group showed higher CD8+ but lower CD4+ T-cell and a significantly lower ratio of CD4+ and CD8+ proportions. The random forest model achieved an area under the curve of 0.77 (95% confidence interval: 0.71-0.83) to distinguish BD-D from MDD patients.

CONCLUSION

These findings imply that BD and MDD patients may harbor different T-cell inflammatory patterns, which could be a potential diagnostic biomarker for mood disorders.

Efficacy of Quetiapine Monotherapy and Combination Therapy for Patients with Bipolar Depression with Mixed Features: A Randomized Controlled Pilot Study

Effective pharmacotherapy of bipolar depression with mixed features defined by DSM-5 remains unclear in clinical treatment guidelines. Quetiapine (QTP) and valproate have potential treatment utility but are often inadequate as monotherapy. Meanwhile, the efficacy of combination therapies of QTP plus valproate or lithium have yet to be verified. Hence, we conducted a randomized controlled pilot study to evaluate the efficacy of QTP monotherapy in patients with bipolar depression with mixed features defined by DSM-5 and compared the combination therapy of QTP plus valproate (QTP + V) versus QTP plus lithium (QTP + L) for those patients who responded insufficiently to QTP monotherapy. Data was analyzed according to the intent-to-treat population. Generalized linear mixed model was performed by using "nlme" package in R software. A total 56 patients were enrolled, among which, 35 patients responded to QTP alone, and 11 and 10 patients were randomly assigned to QTP + V and QTP + L group, respectively. Nearly 60% enrolled patients responded to QTP monotherapy at the first two weeks treatment. No statistically significant difference in efficacy between QTP + V and QTP + L was observed. In conclusion, QTP monotherapy appeared to be efficacious in patients with bipolar depression with mixed features, and for those who responded insufficiently to QTP, combining with either valproate or lithium appeared to have positive effects.

Reliability and Validity of THINC-it in Evaluating Cognitive Function of Patients with Bipolar Depression

PURPOSE

The THINC-integrated tool (THINC-it) as a brief screening tool can assesses cognitive impairment in patients with major depressive depression (MDD). Here, we aim to evaluate the reliability and validity of the THINC-it in a bipolar depression (BD-D) group in comparison with a healthy control (HC) group.

MATERIALS AND METHODS

Both groups were matched according to age, gender, years of education, and IQ. All participants completed the THINC-it test, including Spotter, Symbol Check, Codebreaker, Trails, and the Perceived Deficits Questionnaire for Depression-5-item (PDQ-5-D). The concurrent validity and internal consistency of the THINC-it test were analyzed, and 30 healthy controls were randomly sampled to retest THINC-it to verify the reliability of the THINC-it retest. The correlation between THINC-it and Hamilton Depression Scale (HAMD-17) and Sheehan Disability Scale (SDS) was also analyzed.

RESULTS

Fifty-eight patients with BD-D and 61 HCs were included for final analysis. There were significant mean difference (MD) standard errors (SE) between two groups in PDQ-5-D, Spotter and Codebreaker (all P<0.01), Trails (P=0.015). There was no significant difference in Symbol Check (MD (SE)=-0.01 (0.18), P=0.938; 95% CI=-0.38 to 0.35). The Cronbach's α of PDQ-5-D was 0.640. The intraclass correlation coefficient (ICC) was between 0.440 and 0.757. The highest concurrent validity was PDQ-5-D (r=0.812, P<0.001). PDQ-5-D was positively correlated with HAMD-17 and SDS score (P<0.01). The objective test had no significant correlation with HAMD-17 and SDS scores (P>0.05).

CONCLUSION

This study found that THINC-it can accurately present the cognitive impairment of patients with BD-D. It can be potentially applied in assessing the cognitive function of patients with BD-D although Symbol Check may not accurately reflect the level of cognitive function. The concurrent validity and retest reliability are lower than expected, we need to further increase the sample size to study.

The Chinese Version of Oxford Depression Questionnaire: A Validation Study in Patients with Mood Disorders

Background

Emotional blunting is prevalent in patients with mood disorders and adversely affects the overall treatment outcome. The Oxford Depression Questionnaire is a validated psychometric instrument for assessing emotional blunting. We aimed to evaluate the reliability and validity of the Chinese version of the ODQ (ODQ) in Chinese patients with mood disorders.

Methods

136 mood disorders patients and 95 healthy control participants were recruited at the First Affiliated Hospital of Zhejiang University, School of Medicine. Patients were assessed using the ODQ, Beck Depression Inventory-II (BDI-II), and Montgomery-Asberg Depression Rating Scale (MADRS). Internal consistency reliability and test-retest reliability were analyzed. Confirmatory factor analysis and correlation analysis were used to evaluate construct and convergent validity.

Results

A total of 136 patients with mood disorders and 95 healthy controls participated in this study. Cronbach α values were 0.928 (ODQ-20) and 0.945 (ODQ-26). Test-retest reliability coefficients were 0.798 (ODQ-20) and 0.836 (ODQ-26) (p<0.05); intraclass correlation coefficient values were 0.777 (ODQ-20) and 0.781 (ODQ-26) (p<0.01). The score of ODQ was positively correlated with BDI-II and MADRS (r=0.326~0.719, 0.235~0.537, p<0.01). The differences in the ODQ scores between the patient and control groups were statistically significant.

Conclusion

The reliability, structural validity, and criterion validity of the ODQ applied to patients with mood disorders meet the psychometric requirements, and the scale can be used to assess emotional blunting in Chinese patients with mood disorders.

An Integrative Model of In-Hospital and Out-of-Hospital Nursing Care for Non-Suicidal Self-Injury: A Narrative Review

Background: Non-suicidal self-injury (NSSI) refers to the intentional and repeated physical trauma of an individual without explicit suicidal intent, which has negative effects on the physical and mental well-being of an individual, especially for adolescents. Timely and accessible nursing care may play an important role in the survival and rehabilitation process of NSSI. Methods: In this review, we systematically discuss the nursing care of NSSI behavior and provide recommendations based on an integrated nursing model for NSSI management. Results: As reported in previous studies, a variety of factors can contribute to NSSI behavior, such as personality traits, current psychological status, history of mental illnesses, as well as family and social factors. In-hospital care is the most necessary and effective care during acute episodes of NSSI behavior. To effectively manage inpatients with NSSI behaviors, nurses should first understand the motivation of NSSI, and provide comprehensive and multi-level care through nurse-patient communication, individualized psychological care, and multidisciplinary cooperation with other professionals. While the purpose of out-of-hospital nursing is to reduce the frequency of NSSI behaviors by screening high-risk individuals, providing psychological support, promoting health education, and improving self-awareness. Conclusions: An integrative model of in-hospital and out-of-hospital nursing care can help improve the clinical management and long-term prognosis of patients with NSSI and minimize the risk of suicidal ideation or suicidal behavior.

Discovery of new genetic loci for male sexual orientation in Han population

Epidemiological studies have demonstrated that the genetic factors partly influence the development of same-sex sexual behavior, but most genetic studies have focused on people of primarily European ancestry, potentially missing important biological insights. Here, we performed a two-stage genome-wide association study (GWAS) with a total sample of 1478 homosexual males and 3313 heterosexual males in Han Chinese populations and identified two genetic loci (rs17320865, Xq27.3, FMR1NB, Pmeta = 8.36 × 10-8, OR = 1.29; rs7259428, 19q12, ZNF536, Pmeta = 7.58 × 10-8, OR = 0.75) showing consistent association with male sexual orientation. A fixed-effect meta-analysis including individuals of Han Chinese (n = 4791) and European ancestries (n = 408,995) revealed 3 genome-wide significant loci of same-sex sexual behavior (rs9677294, 2p22.1, SLC8A1, Pmeta = 1.95 × 10-8; rs2414487, 15q21.3, LOC145783, Pmeta = 4.53 × 10-9; rs2106525, 7q31.1, MDFIC, Pmeta = 6.24 × 10-9). These findings may provide new insights into the genetic basis of male sexual orientation from a wider population scope. Furthermore, we defined the average ZNF536-immunoreactivity (ZNF536-ir) concentration in the suprachiasmatic nucleus (SCN) as lower in homosexual individuals than in heterosexual individuals (0.011 ± 0.001 vs 0.021 ± 0.004, P = 0.013) in a postmortem study. In addition, compared with heterosexuals, the percentage of ZNF536 stained area in the SCN was also smaller in the homosexuals (0.075 ± 0.040 vs 0.137 ± 0.103, P = 0.043). More homosexual preference was observed in FMR1NB-knockout mice and we also found significant differences in the expression of serotonin, dopamine, and inflammation pathways that were reported to be related to sexual orientation when comparing CRISPR-mediated FMR1NB knockout mice to matched wild-type target C57 male mice.

Executive function and its relation to anatomical connectome in homosexual and heterosexual men

Background

Sexual orientation has been suggested to affect executive function, of which the neurobiological basis is still largely unknown. In this study, we explored the interrelationship between neuropsychological characteristics in homosexual and heterosexual men and their anatomical connectome by graph theoretical analysis.

Methods

Fifty-three homosexual and 47 heterosexual males underwent diffusion tensor magnetic resonance imaging (MRI) and neuropsychological assessments. Whole-brain anatomical networks were constructed using white matter tractography, performed on the diffusion tensor imaging data. Neuropsychological tests included the Wisconsin Card Sorting Test (WCST), the Continuous Performance Test (CPT) and the Trail-Making Test (TMT).

Results

The cognitive performance of homosexual men was significantly poorer than their heterosexual counterparts in terms of WCST total correct responses. Anatomical connectome analysis revealed a lower (P=0.001) anatomical connectivity between left PoCG and left SMG (P=0.003) in homosexual men as compared to heterosexual men. Linear regression analyses showed that the WCST total correct responses score was significantly linked with sexual orientation (P=0.001). The anatomical connectivity strength between left PoCG and left SMG was also shown to be significantly correlated with sexual orientation (P=0.039) and education (P=0.047).

Conclusions

Our study demonstrated the differences in the performance of WCST and anatomical connectome of large-scale brain networks between homosexual and heterosexual men, extending our understanding of the brain's circuitry and the characteristics of executive function in men of different sexual orientation.

Relationship between serum concentration and clinical response of quetiapine in adolescents and adults with bipolar disorders in acute stage: a prospective observational study

BACKGROUND

It is found that there are great differences in the efficacy of quetiapine at the same dose in many patients with bipolar disorders. Therefore, therapeutic drug monitoring (TDM) is a valuable tool for guiding treatment with quetiapine. The aims of this study were to assess the relationship between serum concentration and clinical response of quetiapine in adolescents and adults with bipolar disorders in acute stage.

METHODS

The study design was prospective and observational. Within the naturalistic setting of a routine TDM service at the First Affiliated Hospital, Zhejiang University School of Medicine. Psychiatric symptoms were assessed using the HAMD (Hamilton Depression Scale), YRMS (Young manic rating scale) and CUDOS-M (Clinically Useful Depression Outcome Scale-Mixed Subscale). The decline of HAMD and YMRS scores was were used to assess clinical outcome of bipolar disorders respectively.

RESULTS

169 inpatients (23.7 % male, 76.3 % female) were enrolled in the study. We found that there was a strong correlation between quetiapine serum concentrations and clinical outcomes (r_s = 0.702, p < 0.001). While, quetiapine daily dose was not correlated with clinical outcome. We found that when the quetiapine serum level is >146.85 ng/ml in depression episodes patients could obtain a satisfactory treatment effect after 2 weeks of hospitalization.

CONCLUSIONS

We found a significant positive relationship between serum concentration and clinical outcome, and also determined the serum concentration of quetiapine for the treatment of bipolar depression.

Topiramate precipitating a manic episode in a bipolar patient comorbid with binge eating disorder: A case report

RATIONALE

Topiramate is a novel antiepileptic drug that is used as an adjunctive in the treatment of partial and secondary generalized seizures. In recent years, psychiatrists have paid more attention to topiramate as a mood stabilizer and as an agent for treating eating disorders, especially in binge eating disorder (BED) and bulimia nervosa.

PATIENT CONCERNS AND DIAGNOSES

Herein, we report a case of topiramate precipitating a manic episode in a bipolar patient comorbid with BED, who complained of emotional instability and binge-eating behaviors.

DIAGNOSES

In this patient, acute manic episode was induced by topiramate treatment at a daily dose of 75 mg for three days.

INTERVENTIONS

The dose of topiramate was decreased to 25 mg per day promptly, and the patient gradually became calm but the BED symptoms recurred, then the dose of topiramate was increased to 50 mg per day again. Meanwhile, the dosage of quetiapine was escalated up to 500 mg per night to stabilize her mood.

OUTCOMES

With a combination of quetiapine 500 mg per night and topiramate 50 mg per day, the emotion and eating problems of this patient concurrently improved.

LESSONS

These findings indicated that patients with a history of bipolar disorder and comorbid BED have a tendency to develop manic episode when taking topiramate. Careful monitoring of mood alterations after topiramate supplement to mood stabilizers is necessary in this population.

Scopolamine alleviates involuntary lingual movements: tardive dyskinesia or dystonia?

Cholinergic hypofunction was believed to be associated with the pathogenesis of tardive dyskinesia, and therefore, anticholinergic treatment might exacerbate the condition. We describe herein a middle-aged male with feeble chewing movements, involuntary rolling motions of the tongue, and abnormally tightened cheeks which developed after consuming different psychotropic medications. These symptoms did not improve after routine treatment for tardive dyskinesia, but responded well to anticholinergic agents, such as scopolamine and benzhexol hydrochloride. This case extended our understanding of the complexity of extrapyramidal effects and their pharmacologic management.

Laxative use and clinical correlates in hospitalized patients with obsessive-compulsive disorder: a retrospective descriptive study

BACKGROUND

Constipation is a common clinical problem with insufficient attention. Medication-emergent constipation is a rarely studied adverse reaction in patients with obsessive-compulsive disorder (OCD).

METHODS

In this descriptive study, we retrospectively investigated the prevalence of laxative use and its relationship with clinical characteristics in hospitalized OCD patients. A total of 51 OCD patients were included in the final analysis.

RESULTS

The proportion of patients using laxatives was 31.4%, and the commonly used laxatives were phenolphthalein tablet, lactulose and congrongtongbian oral liquid (a patent herbal medicine). In the laxative group, hospital stays were longer when compared to the nonlaxative group. Moreover, the dose of paroxetine was higher in patients treated with laxatives than in those without laxative use. Correlation analysis indicated that laxative use was positively associated with hospital stays, as well as the dose of paroxetine.

CONCLUSION

The current study provided a preliminary picture of constipation and laxative use in hospitalized OCD patients. Close monitoring and treatment of constipation are recommended in OCD patients with pharmacotherapy.

Fan the flame: trazodone-induced mania in a unipolar depressed patient with stable sertraline treatment

Depressed patients often complain of sleep disturbance. Routine antidepressive strategies sometimes fail to deal with this intractable issue. Indeed, the supplementation of sleep promoting antidepressants (eg, trazodone, mirtazapine, and agomelatine) is prevalent in clinical practice. However, the combination of different antidepressants may increase the affective lability. Herein, we document a patient with unipolar depression who was compliant with sertraline treatment and who dramatically switched to mania after adding trazodone as a sleeping aid. This case extended our understanding of the potential manic-switching risk when trazodone is used to promote sleep.

Predictive factors associated with disease recurrence in patients with severe intrahepatic cholestasis of pregnancy: a retrospective study of 118 cases

PURPOSE

To compare the clinical characteristics of pregnant women and perinatal outcomes with or without recurrent severe intrahepatic cholestasis of pregnancy (sICP), and identify possible factors associated with disease recurrence.

METHODS

A retrospective study of 164,603 deliveries was performed to identify pregnant women diagnosed with sICP in the previous pregnancy from January 2012 to December 2020. Eligible patients were divided into two subgroups according to the status of disease recurrence in the second pregnancy: recurrent severe ICP (r-sICP) and non-recurrent severe ICP (nr-sICP). Demographics, clinical characteristics, maternal and perinatal outcomes, and potential factors linked to disease recurrence were analyzed.

RESULTS

Totally 118 patients were enrolled and respectively classified into the r-sICP group (n = 63) and the nr-sICP group (n = 55). The proportion of hepatitis B virus (HBV) infection (HBsAg+, HBeAg+, HBcAb+) and early-onset ICP (<28 weeks) in the r-sICP group in the previous pregnancy were higher than those in the nr-sICP group. In the second delivery, neonatal outcomes in the r-sICP group were worse than those in the nr-sICP group. Logistic regression analysis of predictive factors for disease recurrence in the second delivery revealed that the combination of HBV infection and early-onset ICP in the previous delivery had the steepest receiver-operating characteristic (ROC) curve value 0.720 (95%CI: 0.629-0.812).

CONCLUSION

Patients with sICP displayed a higher recurrence rate in the second pregnancy. Being <28 weeks at the time of ICP diagnosis and having HBV infection in the previous delivery appear to be independent predictive factors for disease recurrence of sICP.

Shifting levels of peripheral inflammatory profiles as an indicator for comorbid multiple autoimmune diseases and bipolar disorder: a case report

Autoimmune diseases (AID) cause inflammatory changes in the peripheral blood, which might be a predisposing factor for the development of comorbid bipolar disorder (BD). The levels of peripheral inflammatory indicators and cytokines may also serve as potential biomarkers for predicting BD susceptibility and the efficacy of antipsychotics in patients with AID. Herein, we present the case of a 43-year-old female who has suffered from AID for over 16 years and was recently diagnosed with "bipolar and related disorder due to another medical condition".

Progress and Implications from Genetic Studies of Bipolar Disorder

With the advancements in gene sequencing technologies, including genome-wide association studies, polygenetic risk scores, and high-throughput sequencing, there has been a tremendous advantage in mapping a detailed blueprint for the genetic model of bipolar disorder (BD). To date, intriguing genetic clues have been identified to explain the development of BD, as well as the genetic association that might be applied for the development of susceptibility prediction and pharmacogenetic intervention. Risk genes of BD, such as CACNA1C, ANK3, TRANK1, and CLOCK, have been found to be involved in various pathophysiological processes correlated with BD. Although the specific roles of these genes have yet to be determined, genetic research on BD will help improve the prevention, therapeutics, and prognosis in clinical practice. The latest preclinical and clinical studies, and reviews of the genetics of BD, are analyzed in this review, aiming to summarize the progress in this intriguing field and to provide perspectives for individualized, precise, and effective clinical practice.