#3116 Preliminary findings of visual hallucinations in organic psychosis: a meta-analysis

Objectives/AimsIn some cases, psychosis arises due to a secondary, or organic cause. Identifying these cases early on is important in ensuring these patients receive appropriate management, which may reverse the underlying cause. Determining whether the psychiatric phenotype differs in patients with an organic cause would be a major advance in the field. We sought to determine whether the presence and content of visual hallucinations was associated with an organic cause of psychosis.MethodsA meta-analysis of case-control studies was conducted. PubMed, OVID, MEDLINE, Embase, Psych INFO and Global Health databases were searched without date restrictions by two researchers using the keywords Psychos* AND Schizophreni* AND Visual hallucinat*. The inclusion criteria were a) reported frequency of visual hallucinations, b) categorisation of patients into having an organic or non-organic psychosis and c) publication in English. A random-effects model, following the DerSimonian and Laird method, was used to pool studies to generate overall odds ratios (OR) and 95% confidence intervals (CI).ResultsFifteen studies (890 organic and 955 non-organic psychosis patients) were included. Visual hallucinations were significantly associated with organic psychosis (OR = 3.17, 95% CI = 1.92, 5.24), however there was moderate between-study heterogeneity (I2 = 70%).In the 4 studies where content was reported (158 organic and 52 non-organic psychosis patients), visual hallucinations most frequently took the form of people in both organic (n = 76; 48.1%) and non-organic psychosis (n = 31; 59.6%). However, inanimate objects were significantly associated with organic psychosis (χ2(1) = 5.44, p = 0.020).ConclusionsVisual hallucinations are associated with organic psychosis. The presence of visual hallucinations, and in particular inanimate objects, may serve as a potential red flag for an organic psychosis. Findings have important clinical utility, as a simple and convenient bedside assessment to inform which patients would benefit from further neurological investigation.

Trials and tribulations of diagnosing and managing psychosis secondary to non-convulsive epilepsy

ObjectiveTo highlight the importance of reviewing diagnosis and management of refractory psychosis and to share that with the scientific community; and to also shed some light on the dilemma and challenges that professionals may face to diagnose and treat organic psychosis. In addition, to look at the possible similarity/dissimilarity in psychopathology between organic and primary psychosis and differences in opinions through presenting the history and course of illness of this patient.Case reportWe present the case of a 51-year-old female who had a 28-year history of treatment-resistant schizophrenia. She did not report or display any seizure activity, and an extensive investigation was unremarkable. The unusual nature of her psychopathology, which was predominantly visual hallucinations and somatic delusions, and the difficult to treat nature of her symptoms, prompted investigation with Electroencephalograph which demonstrated bilateral temporal lobe epileptic activity.DiscussionTreatment with divalproex sodium and discontinuation of antipsychotic medication achieved an excellent response, where her visual hallucinations and somatic delusions were both remarkably ameliorated.ConclusionThe differentiation between organic/secondary and functional/primary psychosis is an area of contention between psychiatrists and neurologists and also within each of these specialties.The myriad of psychopathology and associated treatment resistant psychotic symptoms that patients with non-convulsive epilepsy may experience should result in building a long desired bridge between neurology and psychiatry to collaborate in managing such cases.

A Case of Psychosis Due to Acute Hypocalcemia From Hypoparathyroidism

A 61-year-old female with past medical history of depression, hypoparathyroidism (hypoPtH), and hypothyroidism had disappeared from her home and was found wandering a few hours away with persecutory delusions, visual and auditory hallucinations. Serum calcium (Ca) was 6.3 mg/dL (range 8.6–10.2), albumin 3.7 g/dL (range 3.5–5.2) and ionized Ca 0.89 mmol/L (range 1.12–1.30). She was admitted and treated with Ca and calcitriol. Work-up for altered mental status was negative except for hypocalcemia (hypoCa) and scattered bilateral basal ganglia calcifications (BGC) with cortical and subcortical frontal lobe calcifications on CT. Psychiatry diagnosed delirium due to hypoCa. Acute psychosis resolved once Ca levels improved. Diagnosis of idiopathic hypoPtH was in 1997. Her regimen included Ca citrate 1500mg daily and 10 mcg of Forteo twice daily. She had skipped her medications for at least 2 days prior to presentation. Her medical records revealed that she was seen for severe depression, progressive gait abnormalities, slowed movements, and imbalance, in 2015. CT scan and MRI brain showed BGC. Her son gave a history of multiple admissions for psychosis, violence, delusions with agitation, and wandering at times when the patient was hypoCa, which was diagnosed as schizophrenia. Neuropsychiatric disturbances are commonly associated with hypercalcemia. Review of literature found a few case reports of psychosis and hypoPtH 1,2 BGC is common in hypoPtH. Psychotic symptoms due to BGC include auditory hallucinations, delusions of influence, paranoid states, and complex perceptual distortions.3,5 HypoCa is associated with cognitive impairment. Neurological manifestations tend to improve with Ca correction, but psychiatric symptoms do not improve substantially.4,5 Further studies are needed in hypoPtH with BGC to appropriately diagnose organic psychosis. This is important in management of the vicious cycle of psychiatric illness leading to noncompliance resulting in psychosis. Prevention of BGC will play a key role. References: 1. Finan M, Axelband J. This is your brain on calcium: psychosis as the presentation of isolated hypoparathyroidism. Am J Emerg Med. 2014;32:945.e1-4. 2. Ang AW, Ko SM, Tan CH. Calcium, magnesium, and psychotic symptoms in a girl with idiopathic hypoparathyroidism. Psychosom Med. 1995;57:299–302. 3. Burns K, Brodaty H. Fahr’s disease and psychosis. In: Sachdev PS, Keshavan MS, editors. Secondary schizophrenia. Cambridge: Cambridge University; 2010. p. 358–66. 4. Maiti A, Chatterjee S. Neuropsychiatric manifestations and their outcomes in chronic hypocalcaemia. J Indian Med Assoc. 2013;111:174–7. 5. Amara A, Novais C, Coelho M, Silva A, Curral R, Brandao I, Torres A. Organic psychosis due to hypoparathyroidism in an older adult: a case report. Braz. J. Psychiatry; 2016; 38(4)

Brucella-Induced Acute Psychosis: A Novel Cause of Acute Psychosis

Background. Infections have long been linked to psychosis and categorised within “secondary” psychoses. To date, there have been few reports of psychosis linked to brucellosis. This case report aims to present one such case. Case Presentation. A 31-year-old man was admitted to a general hospital with pyrexia, severe right upper quadrant pain, and an acute psychosis following a two-week holiday in South East Asia and the Mediterranean. Serological tests revealed that he had brucellosis. Following antibiotic treatment, the psychotic symptoms abated and he was discharged within ten days of hospitalisation. Conclusions. This case of organic psychosis highlights the importance of considering brucellosis as a rare cause of acute psychosis. The exact mechanism of Brucella-induced psychosis remains unclear.

Organic psychosis

“Psychosis” and “schizophrenia” are descriptive terms. They are not synonymous with each other. Now somewhat paradoxically, “functional” psychoses such as schizophrenia are distinguished from “organic” psychoses by the absence of brain pathology and/or a likely contributory medical condition. This approximates to a tautology, since ample research confirms brain changes in schizophrenia and medical comorbidities are common in patients with schizophrenia. That said, this chapter enumerates general considerations in the realm of organic psychosis and focuses on specific psychoses that may be particularly noteworthy, autoimmune encephalitis.

S102. DIAGNOSTIC CHALLENGES AT TIME OF INPATIENT ADMISSION: DIAGNOSTIC SHIFTS IN PATIENTS WITH FIRST EPISODE PSYCHOSIS

Background First episode psychoses (FEP) may present with diffuse symptoms and a broad range of clinical phenotypes, leading to difficulties in the early detection of the different pluripotent trajectories and consequently to instability of the diagnoses. The aim of this study was to assess the stability of diagnoses at time of admission compared to discharge in patients with FEP at a newly established early psychosis inpatient unit within a general psychiatric service in a general hospital. Methods Charts of all patients admitted to the early psychosis inpatient unit of the Clinical Division of Social Psychiatry of the Medical University of Vienna between 01.01.2016 and 31.03.2017 were reviewed. FEP was defined as a first presentation of affective, schizophreniform, acute polymorphic, organic or substance-related psychosis according to ICD-10. Results 127 patients were admitted during the said period, among whom 92 (72,4%) were diagnosed with a psychotic disorder at time of admission. 39,1% (n=36) of those had a FEP, whereof 58,3% (n=21) were diagnosed with schizophrenia spectrum psychosis, 27,8% (n=10) with affective psychosis, 11,1% (n=4) with substance-related psychosis and 2,8% (n=1) with organic psychosis as main diagnosis at time of discharge. In 50% (n=18) of FEP patients, diagnosis at time of admission was not maintained. 54,2% (n=13) of FEP patients who were admitted with a schizophrenia spectrum diagnosis had a shift in diagnosis at time of discharge, whereof 46,2% (n=6) were adjusted to another diagnosis of the same spectrum and 53,8% (n=7) to a diagnosis of either affective spectrum, substance-related psychosis or organic psychosis. 100% (n=2) of those with a persistent delusional disorder had a different diagnosis at discharge, as well as 56,3% (n=9=) of those admitted with a diagnosis of acute and transient psychotic disorders. Changes in the admission diagnoses of affective psychosis were necessary in 44,4% (n=4), whereof one half was adjusted to another diagnosis of the same spectrum and the other half to a diagnosis of the schizophrenia spectrum. Discussion The diagnostic instability in this study underlines the concept of the highly dynamic and changeable nature of psychopathology in the early stages and the pluripotent trajectories of psychosis. Furthermore, inadequate information available for specific diagnosis at time of admission as well as diagnostic uncertainty at the onset of psychosis could be implicated in the described diagnostic instability. The broad range of clinical phenotypes of early psychosis and the limitations of current diagnostic risk and identification approaches for the assessment of first episode psychosis indicate psychopathology conformed to a more dimensional rather than categorical model, as well as the need of a more dynamic model of prediction, such as the clinical staging model.