OUR INTERESTING SHORTLISTED ABSTRACTS

CASE STUDY: LATE DETECTION OF FACTITIOUS DISORDER-MUNCHAUSSEN’S SYNDROME WITH FEIGNED SCHIZOPHRENIA 

Vie Cheong Thong*#, Deshvin Kaur Amanjit Singh**, Sze Hung Chua**

*Department of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Malaysia;

**Hospital Mesra Bukit Padang, Kota Kinabalu, Sabah;

#Department of Psychiatry and Mental Health, Hospital Lahad Datu, Lahad Datu, Sabah 

Abstract 

Introduction: The Authors present a case illustrating factitious disorder, who was previously diagnosed as schizophrenia for 2 years, with a comorbidity of depressive disorder (unspecified) and obsessive-compulsive disorder.

Case Presentation: The factitious presentation involved exaggeration of symptoms, demanding and challenging behavior towards medical personnel, prolonging of sick role by refusing necessary intervention. Diagnosis of schizophrenia complicated patient’s condition when poly-pharmacy was introduced. The element of deception too provided difficulty in clinician to identify other comorbid psychiatric issue of depression and Obsessive Compulsive Disorder (OCD), with the suspicion of Borderline Personality Disorder.

Conclusion: We emphasize the importance of recognizing possible signs of deception through looking at the atypical presentation throughout the treatment course and consequences following the misdiagnosis. 

 Prevalence of Neuropsychiatric Presentations Observed in Patients Diagnosed with Neurosyphilis: A Meta-Analysis

Authors: Suneesa Som Sak1, Kai Li Teh1, Roovam Balasubramaniam1, Leong Tung Ong1

Presenter: Suneesa Som Sak

Affiliation: 1Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur.

Introduction: Neurosyphilis, a severe complication of syphilis arising from Treponema palliduminfection, is also known as the "great mimicker". This is due to its extensive spectrum of neuropsychiatric symptoms encompassing cognitive impairment, psychiatric symptomatology and neurological deficits. Hence, this study aims to investigate the prevalence of neuropsychiatric presentations observed in patients diagnosed with neurosyphilis.

Methods: We identified relevant studies via search engines (PubMed, Embase, Ovid SP, and SCOPUS) from inception up until to 30th April 2024. The prevalence was calculated as proportion. The pooled prevalence with 95% CI was calculated using the random-effects generic inverse variance method. Statistical analysis conducted using Cochrane Review Manager v5.4. 

Results: Thirty-nine studies reported neuropsychiatric presentations in neurosyphilis with a combined sample size of 2356 patients. The pooled prevalence rate of HIV co-infection in neurosyphilis patients was 37% (95%CI,23%-51%;16 studies). The total number of neuropsychiatric presentations investigated were 29. The most prevalent neurological presentations were fatigue (31%,95%CI,21%-42%;2 studies), ocular symptoms (29%,95%CI,19%-40%;23 studies), cognitive impairment (25%,95%CI,17%-33%;12 studies), memory deterioration (22%,95%CI,13%-30%;6 studies), and headache (22%,95%CI,15%-29%;24 studies). Other notable symptoms included paresis (18%,95%CI,13%-23%;19 studies), dizziness (17%,95%CI,11%-23%;6 studies), dementia (17%,95%CI,6%-27%;6 studies), delirium (15%,95%CI,8%-23%;10 studies), sensory abnormalities (15%,95%CI,9%-22%;10 studies), speech disorder (15%,95%CI,2%-21%;17 studies), dysphagia (14%,95%CI,1%-29%;2 studies), otic symptoms (14%,95%CI,8%-20%;15 studies) meningism (13%,95%CI,7%-20%;10 studies), lancinating pain (12%,95%CI,4%-20%;5 studies), and confusion (12%,95%CI,6%-17%;8 studies). The prevalence of psychiatric disorders among patients diagnosed with neurosyphilis was 22%(95%CI,11%-32%;7 studies). The prevalence for each psychiatric symptoms reported in neurosyphilis was as followed: psychosis 17%(95%CI,5%-28%;4 studies), behavioural disorders 11%(95%CI,5%-17%;8 studies), mood disorders 13% (95%CI,6%-20%;6 studies), delusion 9% (95%CI,2%-16%;6 studies), and hallucination 8% (95%CI,1%-17%;5 studies).

Conclusion: This meta-analysis highlights the neuropsychiatric presentations are commonly seen in patients with neurosyphilis. Hence, physicians should consider neurosyphilis as one of the differential diagnoses when patients presenting with neuropsychiatric symptoms. 

Recognition, Assessment, and Management of Tardive Dyskinesia: A Southeast Asian Expert Consensus

Roongroj Bhidayasiri1, Kok Yoon Chee2, Jin Kiat Ang3, Roger Ho4, Ahmad Shahir bin Mawardi5, Adhi Wibowo Nurhidayat6, Pongsatorn Paholpak7, Pornjira Pariwatcharakul8, Thitima Sanguanvichaikul9, Eng Khean Ung10, Natalia Dewi Wardani11, Brian Yeo12, Gilbert Madriaga13, Koh Jia Juan Tammy13, Christoph U. Correll14,15  

1Chulalongkorn Centre of Excellence for Parkinson’s Disease & Related Disorders (ChulaPD) Chulalongkorn University, Bangkok, Thailand, 2Department of Psychiatry and Mental Health, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia, 3Department of Psychiatry, Hospital Sultan Abdul Aziz Shah, UPM, Serdang, Selangor, Malaysia, 4Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 5Department of Neurology, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia, 6Department of Psychiatry, Faculty of Medicine, UIN Syarif Hidayatullah Jakarta, South Tangerang, Indonesia, 7Department of Psychiatry, Khon Kaen University, Khon Kaen, Thailand, 8Department of Psychiatry, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand, 9Department of Psychiatry, Somdet Chaopraya Institute of Psychiatry, Bangkok, Thailand, 10Adam Road Medical Centre, Singapore, 11Department of Psychiatry, Diponegoro University, Central Java, Indonesia,12Mount Elizabeth Medical Centre, Singapore, Singapore, 13Regional Medical Affairs Department, Mitsubishi Tanabe Pharma Singapore, Singapore, 14Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA, 15Department of Child and Adolescent Psychiatry, Charité – Universitätsmedizin Berlin, Berlin, Germany

Introduction: Tardive dyskinesia (TD), a movement disorder induced by dopamine receptor blocking agents (DRBAs), is not well recognized by most clinicians in Southeast Asia (SEA). Thus, guidance on assessment and management of TD is warranted. This consensus study aimed to provide recommendations on the assessment and management of TD in SEA. 

Methods: Thirteen experts from the fields of neurology, neuropsychiatry, and psychiatry from Southeast Asian countries participated in the consensus development via the Modified RAND-UCLA Appropriateness Method, consisting of a review of literature, drafting clinical scenarios with ratings (Likert Scale: 1-9), followed by a face-to-face meeting that led to the recommendations. 

Results: The expert panel recommended that patients taking DRBAs should be screened for TD every 6 months (Median [Mdn]: 9; Interquartile Range [IQR]: 9,9), regardless of the risk (Mdn: 8; IQR: 8,9). In cases where face-to-face physical consultation were not feasible, the panel agreed that TD could also be diagnosed (Mdn: 8; IQR: 7,9) or assessed (Mdn: 8; IQR: 8,9) during telemedicine video appointments. The panel also recommended vesicular monoamine transporter-2 inhibitors as the first-line treatment if available (Mdn: 9; IQR: 8,9). Other treatment options that were accessible in the region were also suggested, with consensus against anticholinergics. 

Conclusion: These regional consensus recommendations provide practical guidance intended for busy clinicians in their assessment and management of patients with TD.

Unveiling Neurological Intrigue: From Anxiety to Brain Tumor - A Case Report

Siti Nur Najibah Fauzi1, Nor Asyikin Fadzil1

Background: It is uncommon for psychiatric symptoms to be considered a manifestation of a brain tumor in the absence of neurological signs. Diagnosing a brain tumor can be challenging when a patient presents with another medical illness that has a similar psychiatric manifestation.

Case presentation: This case report details a 58-year-old male who presented to the emergency department with two weeks of symptoms of excessive worry, agitation, dysphoric mood, and worsening cognitive function as his first psychiatry encounter. Regular practice in psychiatry, where excluding organicity is a must in diagnosing any anxiety disorder, revealed a high thyroid function test in this patient. Hence, he was diagnosed and managed as an anxiety disorder secondary to hyperthyroidism. After one month on carbimazole, repeated thyroid function test turned normal. Despite treatment with a selective serotonin reuptake inhibitor (SSRI), benzodiazepine, and normalization of thyroid function tests, his anxiety symptoms worsened. As the condition progressed, neurological symptoms and signs appeared, leading to neuroimaging that revealed an unexpected intracranial mass at the left fronto-parietal region which had not been investigated during the initial presentation. The patient was referred to a neurosurgical team, and the tumor was surgically removed, resulting in a total subsidence of his anxiety symptoms. 

This case report describes a 58-year-old male who presented to the emergency department with a two-week history of excessive worry, agitation, dysphoric mood, and declining cognitive function, marking his first encounter with psychiatric care. In line with standard psychiatric practice, which requires ruling out organic causes when diagnosing anxiety disorders, the patient underwent a thyroid function test, which revealed hyperthyroidism. Consequently, he was diagnosed with anxiety disorder secondary to hyperthyroidism and started on carbimazole. After one month of treatment, his thyroid function returned to normal. Despite the use of a selective serotonin reuptake inhibitor (SSRI), benzodiazepine, and the normalization of his thyroid function, his anxiety symptoms worsened. As the illness progressed, neurological symptoms and signs emerged, prompting neuroimaging that revealed an unexpected intracranial mass in the left fronto-parietal region, which had not been investigated during the initial evaluation. The patient was referred to a neurosurgical team, and the tumor was surgically removed, resulting in the complete resolution of his anxiety symptoms.

Conclusion:This case highlights the challenges in detecting destructing operable causes of illness in patients presented with psychiatry symptoms, especially when the medical condition mimics the psychiatry presentation. It highlights the importance of considering brain imaging in the initial psychiatric evaluation, even though imaging services are readily accessible. This is especially crucial for patients presenting with sudden onset of psychiatric symptoms, not responding to psychiatry medication or late onset of illness without apparent life stressors.

Keywords: Brain tumor, Psychiatry symptom, Case report

1Department of Psychiatry, School of Medical Sciences, Universiti Sains Malaysia, Jalan Raja Perempuan Zainab II, 16150 Kubang Kerian, Kelantan.

Corresponding author: 

Nor Asyikin Fadzil, Department of Psychiatry, School of Medical Sciences, Universiti Sains Malaysia, Jalan Raja Perempuan Zainab II, 16150 Kubang Kerian, Kelantan . 

Randomized Controlled Trial Comparing the Effects of Deep Breathing Exercises, Aromatherapy, and Psychospiritual Therapy on electroencephalogram (EEG), Biometrics; Heart Rate Variability (HRV) signals Among Malaysian Workers

Dr Chong Siew Koon1, Dr. Nurnadiah Zamri2, Dr. Samhani Ismail2, Dr. Azimah Ismail2, Dr. Norsuhaily Abu Bakar2, Pn Siti Nurani Hj Hassan2
1Psychiatry and Mental Health Hospital Kuala Lumpur

2Faculty of Informatics and Computing, Universiti Sultan Zainal Abidin, Besut Campus, 22200 Besut, Terengganu, Malaysia

Abstract:

This study compares the efficacy of relaxation techniques using an objective approach by examining client responses to various therapies through electroencephalogram (EEG) and Heart Rate Variability (HRV) signals. Conducted in Kuala Terengganu, Malaysia, the study includes therapies such as aromatherapy, deep breathing exercises (DBE), and psychospiritual (ruqyah), alongside a control group. Key metrics such as HRV coherence ratio, EEG delta wave activity, Power Spectral Density (PSD), and duration of calmness are used to evaluate the efficacy of these interventions. Results indicate that DBE and aromatherapy are most effective in promoting relaxation, followed by psychospiritual therapy.

Methodology:

This Randomised Control Trial compares three forms of relaxation techniques—DBE, aromatherapy, and psychospiritual—using EEG and biometric recordings, including HRV and PSD. A control group not receiving any form of psychotherapy is also included. Recordings of the aforementioned parameters are taken before and after the implementation of relaxation techniques. Participants attend a single session lasting approximately 30 minutes. DASS-21, BDI, and BAI are used to ensure that participants have comparable baseline values. Inclusion criteria include those who consent to participate whilst those excluded are clients who score high on mental health screening which require prompt psychiatric referral and aid. The DBE focuses on deep breathing exercises, aromatherapy uses Melaleuca cajuputi oil extract, while psychospiritual therapy utilizes ruqyah recitations. A total of 152 participants completed the study over approximately two months. The effectiveness of each therapy versus control is measured by the duration of calmness, as recorded by EEG delta wave activity, HRV, and PSD analysis.

Results:

DBE achieved sustained calmness with an average duration of 250 seconds on EEG recording, followed by aromatherapy with an average of 200 seconds. Key findings include the high effectiveness of DBE, which showed the highest coherence levels and the longest duration of slow-wave activity, indicating strong potential for enhancing well-being and stress management. Aromatherapy demonstrated the greatest induction of deep relaxation, supported by the highest PSD value for delta waves.

Discussion:

These results suggest the potential for incorporating DBE and aromatherapy into therapeutic interventions for mental health management. These practices could also benefit workplaces by alleviating stress and enhancing relaxation among employees, leading to a more productive and satisfied workforce. Future studies should investigate combining different relaxation techniques within the same session for synergistic effects, explore additional therapies beyond the current ones, extend the duration of therapy sessions to assess long-term benefits, and test these interventions across various occupational groups to ensure their effectiveness in diverse work environments.

Huntington’s Disease vs Functional Parkinsonism: Diagnostic Conundrum Deciphered By DaT Imaging

Lukmanul Hakim Misron1, Siti Nor Fadhlina Misron2, Gouri Das3, Nur Khuzaimah binti Kasmat3

1Nuclear Medicine, Hospital Kuala Lumpur

2Hospital Permai

3Nuclear Medicine, Hospital Sultanah Aminah

Introduction:

For centuries, the conundrum faced by psychiatrists and neurologists is to differentiate between organic and functional movement disorder. With the advancement of medical technology, DaT (Dopamine Transporter) Imaging has been a useful tool to assist in ruling in or out diseases associated with reduced dopamine uptake in basal ganglia region indicating the damage to the cells. As basal ganglia involved in both the initiation up desired movement and inhibiting the undesired movement, the damage may cause the haphazard facilitation and inhibition of movement out of patient’s will. As Dat Imaging just find it roots in Malaysia past 3 three years, the case report illustrates the game changing role of Dat Imaging in Malaysia context.

Case Presentation:

A 47-year-old optometrist presented with involuntary hand movement that gradually worsening for two years. When she first presented, the movement was mistakenly diagnosed as Functional Parkinsonism. Due to the absence of other parkinsonism features and the variable amplitude and frequency of the hands movement, she was referred to neuropsychiatry with the suspiciousness of functional movement disorder. However, with the history of 3 successive generations of choreiform movement which presented around 40 years of age, the suspiciousness of Huntington’s disease was inevitable. The MRI brain was reported as normal. However the DAT Imaging shows reduced dopamine uptake at bilateral caudate and putamen consistent with Huntington’s Disease. She was treated with Risperidone and the chorea improved.

Conclusion:

The case illustrates the conundrum faced by psychiatrist in Malaysia as diagnosis determined the direction of management which is completely different between Huntington’s Disease and Functional Parkinsonism. DAT Imaging in Malaysia is a bless such as it helps the psychiatrist to decipher the codes in differentiating both conditions and treat the patients accurately.

Spirituality as an Executive Function of the Brain: A Neuroscience Perspective for a Holistic

Approach to patient-based Clinical Management Preferences EBM and Personalized

Medicine

Taufiq Pasiak

Research Centre for Regenerative Medicine and Neuroscience-UPN Veteran Jakarta

Spirituality has long been recognized as an essential element in human health. Several recent

studies have shown the positive role of spirituality on health; mental, emotional, and physical

well-being, and even in the amelioration of disease. However, understanding and measuring

aspects of spirituality in the medical world is often unstructured and complex to measure

objectively. In addition, there are still many different understandings among medical experts.

Evidence-based medicine (EBM), especially the aspect of patient preference and Personalized

Medicine, opens up opportunities to incorporate spirituality in Medicine. Personalized

Medicine emphasizes the importance of designing treatments based on each patient's unique

profile. By incorporating aspects of spirituality, we can offer more comprehensive and holistic

care while improving patient satisfaction and medication adherence.

Scientific evidence shows that spirituality can reduce stress, increase resilience, improve

quality of life, and support recovery from various illnesses. Studies show that patients who

engage in spiritual practices have better health outcomes and higher levels of life satisfaction.

Research also reveals that spiritual support can reduce symptoms of depression and anxiety,

improve medication adherence, and accelerate the recovery process.

This article introduces the concept of Transcendental Executive Function (FET) as an extension

of the previously recognized Executive Function or Conventional Executive Function (CEF),

which integrates dimensions of spirituality to create a more holistic, observable, and

measurable approach in clinical practice. Combining FET with the brain's executive function

framework allows us to identify and utilize the significant contributions of spirituality in

clinical health and healing. Brain structures such as the prefrontal cortex, anterior cingulate

cortex, basal ganglia, hippocampus, amygdala, thalamus, and parietal lobes support executive

functions, decision-making, planning, emotional regulation, and attentional control.

Integrating spirituality in the context of brain executive function improves the quality of

healthcare and reinforces a patient-centered and holistic medical approach. This article

proposes a comprehensive framework combining FET with brain executive function to

improve clinical interventions and patient health outcomes. With a deeper understanding of

how spirituality affects executive function, we can develop more effective and personalized

treatment strategies encompassing all aspects of a patient's health.

Keywords: Spirituality, executive function, neuroscience