Recurrent Episodes of Paraphilic Behavior Possibly Associated With Olanzapine and Aripiprazole Treatment in a Patient With Schizophrenia

Differentiating Between Sexual Offending and Violent Non-sexual Offending in Men With Schizophrenia Spectrum Disorders Using Machine Learning

Forensic psychiatric populations commonly contain a subset of persons with schizophrenia spectrum disorders (SSD) who have committed sex offenses. A comprehensive delineation of the features that distinguish persons with SSD who have committed sex offenses from persons with SSD who have committed violent non-sex offenses could be relevant to the development of differentiated risk assessment, risk management and treatment approaches. This analysis included the patient records of 296 men with SSD convicted of at least one sex and/or violent offense who were admitted to the Centre for Inpatient Forensic Therapy at the University Hospital of Psychiatry Zurich between 1982 and 2016. Using supervised machine learning, data on 461 variables retrospectively collected from the records were compared with respect to their relative importance in differentiating between men who had committed sex offenses and men who had committed violent non-sex offenses. The final machine learning model was able to differentiate between the two types of offenders with a balanced accuracy of 71.5% (95% CI = [60.7, 82.1]) and an AUC of .80 (95% CI = [.67, .93]). The main distinguishing features included sexual behaviours and interests, psychopathological symptoms and characteristics of the index offense. Results suggest that when assessing and treating persons with SSD who have committed sex offenses, it appears to be relevant to not only address the core symptoms of the disorder, but to also take into account general risk factors for sexual recidivism, such as atypical sexual interests and sexual preoccupation.

Aripiprazole and its adverse effects in the form of impulsive-compulsive behaviors: A systematic review of case reports

Aripiprazole is an efficacious treatment for both the positive and negative symptoms of schizophrenia and is also commonly used as a mood stabilizer. It is associated with better tolerability compared with other antipsychotics. However, there are reports of patients who experience problem gambling, hypersexuality, obsessive-compulsive symptoms, and other impulsive and/or compulsive behaviors as a result of aripiprazole administration and/or dosage increase. We aimed to do a systematic review of case reports published in this regard. After screening more than 6000 titles and abstracts in ten scientific search engines, we found 35 related records comprising 59 cases. The majority of cases (n = 42, 71.18%) were male, the mean age was 33.83 years (± 13.40), and the average daily dose of aripiprazole was 11.63 mg (± 6.94). The results of our review showed that the most frequently published impulsivity adverse effect of aripiprazole is gambling, followed by hypersexuality, obsessive-compulsive symptoms/disorder, problem eating, trichotillomania, problem shopping, and kleptomania. These symptoms were experienced both by patients who had previous problems in these areas and those who did not. In the majority of cases, the symptoms appeared within 30 days after aripiprazole administration started and ceased within 30 days of its discontinuation and/or dose decrease. Clinicians should be aware of impulsivity adverse effects, monitor them, and educate both patients and the family about them.

Hypersexuality during treatment with cariprazine in a patient with schizophrenia? A case report

BACKGROUND

Cariprazine is a third-generation antipsychotic with a unique mechanism of action. It functions as a partial agonist with high affinity for dopamine D2 and D3 and serotonin 5-HT1A receptors, an antagonist for 5-HT2A (moderate affinity) and 5-HT2B (high affinity) receptors. It binds to histamine H1 receptors and has a low affinity for 5-HT2C and alpha 1A-adrenergic receptors and no affinity for muscarinic (cholinergic) receptors. Among the troubling side effects, symptoms related to impulse control, such as hypersexuality, pathological gambling, compulsive shopping, compulsive eating etc., have been reported with the use of antipsychotic medications. However, no reports have been published regarding impulse control symptoms associated with cariprazine. We report a case of cariprazine-induced hypersexuality in a patient with schizophrenia, which was resolved by discontinuation of the medication.

CASE PRESENTATION

A 67-year-old Caucasian woman with schizophrenia was admitted to the hospital inpatient unit after she discontinued olanzapine and psychotic symptoms reappeared. Prior to that, she was in remission, taking olanzapine for approximately one year. After discontinuation, she experienced auditory hallucinations with persecutory delusions and became anergic and withdrawn, with blunted affect. Olanzapine was reintroduced, as it was proven successful in her past treatments. However, since there were no changes, especially in negative symptoms, cariprazine was added. Seven days after the introduction of cariprazine, the patient developed compulsive sexual behaviour. Therefore, cariprazine was discontinued, and the hypersexual behaviour was resolved.

CONCLUSIONS

In this case report, we describe hypersexual behaviour that could potentially be induced by cariprazine. As a single case study, conclusions cannot be drawn. Controlled studies are warranted to better determine causality and the significance of this possible side-effect of cariprazine.

The World Federation of Societies of Biological Psychiatry guidelines on the assessment and pharmacological treatment of compulsive sexual behaviour disorder

OBJECTIVES

The current guidelines aim to evaluate the role of pharmacological agents in the treatment of patients with compulsive sexual behaviour disorder (CSBD). They are intended for use in clinical practice by clinicians who treat patients with CSBD.

METHODS

An extensive literature search was conducted using the English-language-literature indexed on PubMed and Google Scholar without time limit, supplemented by other sources, including published reviews.

RESULTS

Each treatment recommendation was evaluated with respect to the strength of evidence for its efficacy, safety, tolerability, and feasibility. Psychoeducation and psychotherapy are first-choice treatments and should always be conducted. The type of medication recommended depended mainly on the intensity of CSBD and comorbid sexual and psychiatric disorders. There are few randomised controlled trials. Although no medications carry formal indications for CSBD, selective-serotonin-reuptake-inhibitors and naltrexone currently constitute the most relevant pharmacological treatments for the treatment of CSBD. In cases of CSBD with comorbid paraphilic disorders, hormonal agents may be indicated, and one should refer to previously published guidelines on the treatment of adults with paraphilic disorders. Specific recommendations are also proposed in case of chemsex behaviour associated with CSBD.

CONCLUSIONS

An algorithm is proposed with different levels of treatment for different categories of patients with CSBD.

Diagnostic Difficulties and Treatment Challenges of a Young Patient With Severe Acute Psychosis and Complete Recovery

First break psychosis in young adults is sometimes presented as a dichotomous model of organic or substance-induced etiology or a primary psychiatric disorder on the schizophrenia spectrum and related disorders. In this case of a young adult with a typical age of onset for psychotic symptoms also presenting with cannabis use, excessive vaping, history of COVID-19 illness, pineal cyst, and extreme elevation of blood pressure, the diagnostic certainty decreases. Increased risk of progression to schizophrenia in individuals with cannabis use disorder and genetic loading has been extensively reported in the literature. Clinicians may face significant diagnostic and treatment challenges when managing a patient with severe psychotic symptoms. For the clinicians acutely managing such patients facing these exact questions of unknown certainty in progression to full-blown schizophrenia, we highlight a case of severe acute psychosis and complete recovery on a first-generation antipsychotic and mood stabilizer. 

Low-dose clozapine-related seizure: A case report and literature review

BACKGROUND

Treatment-resistant schizophrenia is a severe form of schizophrenia characterized by poor response to at least two antipsychotic drugs and is typically treated with clozapine. However, clozapine lowers the epileptic threshold, leading to seizures, which are severe side effects of antipsychotics that result in multiple complications. Clozapine-related seizures are generally considered to be dose-dependent and especially rare in the low-dose (150-300 mg/d) clozapine treated population. Due to clinical rarity, little is known about its clinical characteristics and treatment.

CASE SUMMARY

A 62-year-old Chinese man with a 40-year history of treatment-resistant schizophrenia presented to the Emergency Department with symptoms of myoclonus, consciousness disturbance and vomiting after taking 125 mg clozapine. Upon admission, the patient had a suddenly generalized tonic-clonic seizure lasting for about half a minute with persistent disturbance of consciousness, fever, cough and bloody sputum, which was considered to be low-dose clozapine-related seizure. After antiepileptic and multiple anti-infection treatments, the patient was discharged without epileptic or psychotic symptoms.

CONCLUSION

Our aim is to highlight the early prevention and optimal treatment of clozapine-related seizure through case analysis and literature review.

A Case of Hypersexuality in a Patient Receiving Aripiprazole for Schizophrenia

Aripiprazole is an antipsychotic with partial agonist activity at the dopamine D2 receptor which may lead to compulsive behaviors including hypersexuality. The case presented is of a 24-year-old male with schizophrenia who developed hypersexuality symptoms after initiation of aripiprazole. Cessation of the aripiprazole led to a reduction in hypersexual behaviors. Clinicians should be aware of compulsive behaviors including hypersexuality with aripiprazole use and consider discontinuation of aripiprazole treatment in patients suffering from hypersexuality.