The nice word to describe this is: "Belle indeference", this woman shows herself with an elegant indifference to a paralysis. The diagnosis.... can be excluded 2,3,4 because the clinical does not match: no delirium, no worry, no sadness. 1 would be if he was making a profit, if he was knowingly simulating and to make a profit he was faking his illness. This is not the case. Conversive would be if the symptom wanted to transmit something to us, that is to say, it was a metaphor of its internal world... The most exact in this case: 5.

The nice word to describe this is: "Belle indeference", this woman shows herself with an elegant indifference to a paralysis. The diagnosis.... can be excluded 2,3,4 because the clinical does not match: no delirium, no worry, no sadness. 1 would be if he was making a profit, if he was knowingly simulating and to make a profit he was faking his illness. This is not the case. Conversive would be if the symptom wanted to transmit something to us, that is to say, it was a metaphor of its internal world... The most exact in this case: [HIDDEN].

A 52-year-old woman comes to the emergency room with bilateral paralysis of the upper extremities that had started abruptly two hours earlier. In the interview she is smiling and says she does not understand why her family is so worried. The family refers that the day before her son had been arrested by the police for drug trafficking and they had not yet been able to contact him. Which of the following is the most likely diagnosis?

Filicide In Depressive Psychosis: Case Report Of An Emotionally Unstable Woman Slaughtering Her Two Children.

Filicide is the murder of a child by the parent. It is associated with various psychiatric and nonpsychiatric conditions. We herein present a case report of a filicide by an emotionally unstable mother suffering from depressive psychosis. A thirty years old woman previously treated for depression with psychotic features, having undergone electro-convulsive therapy and on oral medication three years ago was brought by the police for psychiatric assessment. She had slaughtered her two sons of 4 and 7 years of age three days ago without any guilt or remorse. She had low mood, irritability, crying spells, hopelessness and loss of sleep, appetite and sexual desires for the past six months along with the delusions of poverty and infidelity for the past two months. She was a chain smoker. Multiple deliberate self-harm and suicidal attempts were reported in the past two months. She had disturbed family life and multiple conflicts with the husband. Psychometrics revealed BDI score of 32, BPRS score of 39 and PCL-R score of 28. She was diagnosed as a case of depressive psychosis with emotionally unstable personality traits leading to impaired judgment and poor comprehension of the consequences of her actions. This case report highlights the importance of accurately and timely diagnosing and managing a mental health disorder in order to avoid the harm towards self and others.

Death of Natasha McKenna

Natasha McKenna (January9,1978February8,2015) was a 37-year-old African-American woman who died in Fairfax County, Virginia while in police custody. The catalyst event, extraction from her cell and being tasered while shackled, was captured on the video of the Fairfax County jail. During a team's efforts to extract the mentally ill prisoner, who resisted, they tasered her four times while she was restrained. No charges were filed against the deputies who tasered McKenna, but the case became the subject of a federal civil rights investigation because of several related issues. Early life At the age of 12, McKenna was diagnosed with schizophrenia, bi-polar disorder and depression. (Other sources say the diagnosis was made when she was 14 years old.) According to a family photograph, she was an honors graduate student from high school in Fairfax County. She had a 7-year-old daughter.

Erotomania revisited: thirty-four years later.

Erotomania (also known as De Clerambault's syndrome) is usually described as a rare delusional syndrome that characteristically involves a woman who believes that a man, typically of higher social, economic or political status, is in love with her. Two cases are reviewed here that have been followed for over 30 years, making these some of the longest, single-case longitudinal studies yet reported. De Clerambault's syndrome remains a ubiquitous nosological psychiatric entity with uncertain prognosis. In 1980, we reported in this journal one woman diagnosed as having erotomania. At that time, she had been followed for approximately eight years. She has now been studied for over 30 years. In De Clerambault's original work, as reported by Enoch and Trethowan, a woman whose chronic, erotic delusion remained unchanged was followed for 37 years. Despite some psychological advances, our original patient, like De Clerambault's, has remained essentially entrapped by her psychotic thought disorder and erotomania. A thorough review of the literature to date was contained in our 1980 article and so, to avoid repetition, we refer the interested reader to that reference. At this time, the original patient's history will be presented along with the course of her disorder and treatment implications. Secondly, another patient will be presented and her case reviewed. Finally, we will argue that this disorder is not as rare as has been claimed and call for the continued recognition of this syndrome as its own entity despite recent opinions that such use be discontinued.

[A case report of factitious disorder with hallucinations].

Although factitious disorder has been known for a long time, its diagnosis and treatment continue to be a problem. It is an uncommon condition associated with considerable morbidity and health care expenditure. We present a case of factitious disorder with hallucinations. A 37 year-old single woman has had auditory and olfactory hallucinations for six years. She had been diagnosed with schizophrenia, hospitalized for a short term, taking classical antipsychotic drugs for years. She has been performing her job as a teacher and living with her family. A suitable dose of atypical antipsychotic drugs was administered at a convenient time for her illness (Psychotic Disorder NOS) in psychiatric outpatient clinic of Kocaeli University. She was admitted to inpatient clinic twice in order to allow a clear diagnosis to be made. Psychotic disorder and temporal lobe epilepsy were ruled out. Borderline and histrionic personality traits were determined. Her complaints were unchanged over the course of treatment taking three years. She later started to come into the emergency department with anxiety symptoms, conversion like fits and suicide attempts; hospitalized for these complaints in another hospital. She was diagnosed with factitious disorder because of her unchanged complaints, her adding new complaints to the old ones, her complaints unrelated to psychosocial stressors, her ambitions to come to hospital, her increasing hospital dependence and having no prominent secondary gain. This case emphasizes the need for the careful observation of patients to prevent unnecessary investigations at the diagnosis and treatment stage and to establish a specific management strategy for the patients.

What's so unusual?

You're probably asking yourself, "What's so different about this case?" The patient was on the side of the road, explained what she was doing there, denied any injuries and refused treatment and transport. Sounds like a routine call--what's the big deal? But this case did not end after the patient signed a treatment refusal form and was asked by law enforcement to get back in her car and drive on. The EMS providers returned to their station, only to get called back 30 minutes later to the same spot they had just responded to, again for a "woman down." Upon this arrival, they found the same car on the side of the road, and a parked semi tractor trailer in a traffic [figure: see text] lane approximately 25 yards ahead of the vehicle. There was no damage to either vehicle, and providers noticed a familiar dog inside the woman's car. A police officer informed the providers that the woman, the driver of the vehicle, had jumped in front of the semi, as described by the truck's driver, and was hit at a very high rate of speed. The victim was deceased on the scene. Upon assessing the scene, providers confirmed that the victim was the same woman they'd responded to earlier. Several days after the incident, more information about the patient's medical history was released. She had been released on the morning of the accident from a mental health institution, where she'd been diagnosed as a manic depressive. Manic depression is a condition characterized by mood swings. For example, a patient might rapidly go from a state of euphoria to experiencing debilitating depression. Although this patient appeared fine on the exterior, she had been diagnosed with a severe psychological disorder. She presented as being alert, oriented and non-threatening moments before taking actions that led to her death. This case posed a significant challenge for the EMS providers because there was no clinical evidence that there was anything wrong with the patient. Moreover, the patient denied any past medical history. It was a lesson to all involved with this case: There is no such thing as a routine call.

Who rules the roost?

Adam's mother was concerned about her 3-year-old son's hyperactivity, violence, and activity level. Adam and his mom had recently moved into a shelter for pregnant women. The rest of the residents are primarily in their early 20s, whereas Adam's mom is 42. She had found about 3 months ago that she was pregnant. This was her fourth pregnancy, second with this father, and he had recently left her when she refused an abortion. Her other children are 22 and 24 and live out of state. She has a history of opioid addiction. She had been on methadone during Adam's gestation and had recently started on buprenorphine to treat her addiction during this pregnancy as well. Adam is here today for his 3-year-old checkup and you had not seen him for a year. Mom states that he has been healthy but has become progressively active over the last year. He is very angry about his dad leaving, and according to Adam's mother "blames her" for sending him away. They are living in 1 room at the shelter, and mom is finding it increasingly difficult to keep him busy all day. When she goes out looking for a job, he is very challenging at the shelter, and she constantly receives complaints that he is "too loud" in the common rooms. She feels like she is at the end of her rope with him, he is constantly climbing, bolting from her, and taking risks.When you examine Adam, you find a robust, healthy young boy. His eye contact is good, and he is socially related but does actively explore your office. When he begins taking the instruments off your wall, his mother sits passively watching him. When he begins playing with the faucet, she half heartedly tells him to "stop" but he looks at her and continues splashing. He then begins flicking the light switch on and off in the room with no response from mom. When you ask about discipline, mom states "nothing works." When you ask about supports, she states "I have nobody except Adam and the new baby now."Adam was born after an uneventful full-term pregnancy with his mother on 100 mg methadone daily. She denies cigarette smoking, drugs, alcohol, or other medications. Urine testing throughout was positive only for opioids. Motor milestones were achieved at the appropriate time. Language milestones at the 2-year-old visit consisted of 10 single words. Now, he has a 50 single-word vocabulary but no 2-word combinations. He primarily takes whatever he wants and has a tantrum if mom cannot figure out what he desires. Adam's medical history is unremarkable. Family history is significant for drug abuse by her father and mother; mental illness in the father's family consisting of bipolar disorder in several uncles. Where do you go from here?

Murder of T. Maniam

Execution of convicts On 16 February 2001, the three convicts - Venkatesan, Chandran and Julaiha - were hanged in Changi Prison at dawn. By then, Julaiha had one final wish before she was hanged, which was to see her daughters for the final time. However, she never got to fulfill her last wish as her daughters declined to visit her one last time. When asked in a documentary about why she did not go see her mother, Fairos did not give an explicit answer, but told the interviewer that her mother gave her and Sairah a father who loved them, and ultimately, she took her away from them. She stated that while she did not hate her mother, she despised what she has done.

Paraneoplastic Encephalopathy in a Patient With Metastatic Lung Cancer: A Case Study.

<bCASE STUDY</b RS, a 36-year-old female, presented to the emergency department (ED) of a large academic medical center upon the advice of her primary care provider because of 3 weeks of progressive mental status changes, weakness, and decreased oral intake. According to her husband, RS was diagnosed with stage IIIA large cell lung cancer 8 months earlier and was treated with concurrent chemotherapy (carboplatin, pemetrexed, and bevacizumab) and radiation therapy that was completed 4 months prior to admission. No other specific information about her treatment or outside health records was available. According to her husband, RS had been in her usual state of health until approximately 3 weeks prior, when she began having significant mental status changes. She first exhibited some difficulty finding words and later was noted to be putting food in a coffee maker. This spontaneously resolved after approximately 1 week; however, she rapidly developed slurred speech and began to make nonsensical statements. These manifestations also slowly improved but were followed by worsening speech deficit, difficulty walking, and impaired balance. During one of these episodes, she had an occurrence of incontinence. Her husband also noted an incident where her "eyes were beating back and forth and the left side of her face was twitching." RS also had periods (according to her husband) where she "did not seem to be interacting with her environment." These progressively worsened during the last week, and she completely stopped walking and talking 2 days prior to coming to the ED. According to her husband, RS had rheumatoid arthritis and no surgical history. Her family history was unknown except that RS's mother had "seizures." RS had reportedly not used tobacco, alcohol, or drugs, and she was sexually active with her husband. Home medications included transdermal fentanyl 12 μg/hr patch changed every 72 hours; oxycodone-acetaminophen tablets 5-325 mg, two every 4 hours as needed for pain; prednisone 10 mg, one tablet daily; and megestrol 40 mg/mL suspension, 20 mL once daily for appetite stimulation. RS was admitted to an inpatient medical oncology service and evaluated by the oncology advanced practitioner (AP) on her second inpatient day. Upon exam, RS was nonverbal except for moaning in response to painful stimuli and to her sister's voice. Her vital signs were normal. She appeared ill but well-nourished, and she was mildly diaphoretic. Neurologic examination revealed that her pupils were slightly sluggish but equal, round, and reactive to light. Extraocular muscle movements were intact, but she did not move her eyes in response to commands. She tracked the AP and family members around the room with her eyes. Cranial nerve examination was intact with the exception of cranial nerves IX, X, and XI, which were difficult to examine given her inability to cooperate and open her mouth. Motor examination revealed increased tone throughout and intermittent, inconsistent resistance to passive movement. She was seen to move all four extremities spontaneously although not in response to commands. Deep tendon reflexes were intact and equal in all extremities. Examination of other body systems was as follows: there was dry, peeling skin on her lips, but her mucous membranes were moist and free of erythema or lesions. Her lungs were clear to auscultation bilaterally. Her heart rate and rhythm were regular, there were no murmurs, rubs, or gallops, and distal pulses were intact. Her abdomen was nondistended with normally active bowel sounds in all four quadrants. Her abdomen was soft, nontender to palpation, and without palpable masses. There was no peripheral discoloration, temperature changes, or edema, and examination of her skin was benign. <bWorkup</b On admission to the emergency department, serum laboratory studies were unrevealing for any potential causes of encephalopathy. Kidney and liver function were normal, making diagnoses of uremic and hepatic encephalopathies less likely. Cultures of the urine and blood were negative. Samples of cerebrospinal fluid (CSF) were obtained via lumbar puncture and were unrevealing for any abnormalities. Computed tomography (CT) of the head without contrast was negative for any acute intracranial process. Ultrasound of the right upper quadrant revealed a single, nonspecific, hypoechoic hepatic lesion. Computed tomography scans of the chest, abdomen, and pelvis demonstrated the primary malignancy in the upper lobe of the left lung, as well as possible metastatic disease within the left lung, right lung, and liver, and widespread osseous metastatic disease. Magnetic resonance imaging (MRI) of the brain performed 1 day after admission demonstrated numerous scattered punctate foci of enhancement throughout the supratentorial and infratentorial brain parenchyma, measuring at most 3 to 4 millimeters in diameter. There was no significant mass effect or midline shift. A paraneoplastic panel was sent to an outside laboratory and returned positive for antivoltage-gated potassium channel (VGKC) autoantibodies. <bDifferential Diagnosis</b Clinically, RS was exhibiting signs of encephalopathy, a broad term that indicates general brain dysfunction, the hallmark of which is altered mental status. Diagnosing encephalopathy is challenging, as many differential diagnoses must be considered. The clinician must consider metabolic derangements, toxic and infectious etiologies, psychiatric disorders, and less commonly, prion disorders and progressive dementia. Cultures of RS's blood and urine as well as other specialized endocrine tests were negative, decreasing the likelihood of a metabolic or infectious cause for her presentation. The abnormalities on her brain MRI were reviewed by a neuro-oncology team, who felt that the faint, nondescript nature of the visualized lesions was not suspicious for metastatic disease. Sequelae of seizures was also considered by neuro-oncology but dismissed given a grossly normal prolonged electroencephalogram. Some encephalopathies are caused by autoimmune or inflammatory mechanisms, which are confirmed by the presence of autoantibody markers and/or clear response to immunomodulatory treatment (Vernino, Geschwind, & Boeve, 2007). These types of encephalopathies have been seen in patients with cancer and have thus been termed paraneoplastic. The presence of anti-VGKC antibodies on RS's paraneoplastic panel directed the inpatient medical oncology team toward a paraneoplastic neurologic disorder (PND) as the most likely diagnosis.

[A rare and little-known method of elaborating the loss of the object in melancholia].

The author presents a fully detailed report of the observation of two economically secure young women who were caught shop-lifting in a large department store; one woman was apprehended while suffering from depression, the other was caught just prior to the onset of a depressive episode. It is hoped that the details referred here may contribute to the insufficient data published on this subject up to the present. It is important to note that the thefts committed by these patients show the typical characteristics of "impulsive behavior". Furthermore, the impulse to steal may appear in various psychiatric conditions. Therefore, the author first considered the hypothesis that these thefts may have been computed during an acute dysthymic psychosis. Epilepsy was ruled out in both cases based on anamnestic data, electroencephalographic findings and, even after the administration of a pharmacological trigger, no epileptic symptoms appeared. These negative results prompted the author to propose a psychosemeiogenetic rapport between the depressive conditions and the thefts. Considering basic information regarding the psychodynamic of impulsive behavior in general, and that manifested in the course of melancholia in particular, the author confronts the problem of the psychosemeiogenesis of the impulsive to steal in the depressed patient. In order to understand this problem, the author proposes several interpretative hypotheses (equivalence of suicide or "parasuicide" according to Deshaies; attempt to give a concrete reason for the "feeling of guilt"; conduct to symbolically compensate the loss of the "object"). Following an in-depth, critical discussion, the author concludes that the "parasuicide" hypothesis is most accurate in the case of the first patient, whereas "compensation" more adequately explains the second. In conclusion, the interest that these cases present in the forensic medical sphere is also brought to light.

A 9-Year-Old Girl With Persistent Obsessive and Compulsive Behaviors in a Primary Care Pediatric Practice.

Chloe is a 9-year-old gal whose mother made an initial visit to a new pediatrician for concerns about her behavior. Chloe is apprehensive about the visit and frequently hides behind her mother.Her parents first noticed Chloe becoming angry and more emotional 3 years ago, which her parents did not initially understand. However, over the past year, she has started to have more worries and unusual behavior.Chloe and her mother report that when she walks through doorways, she will almost always go back and walks through again. At home, she will walk through doorways multiple times and at school, she will pretend she forgot something so her friends do not notice. She often will not walk downstairs and occasionally her mother has to carry her. Clothes are problematic for Chloe. If her father touches something of a specific color and then touches Chloe, she will have to change her clothes or take a shower. Sometimes, she will never be able to wear those clothes again. She had a recent episode where she could not stop tapping a red paper, because if she stopped, she said it would burst into flame. During the 2 weeks before the pediatric visit, symptoms increased to the point that she is now refusing to go to school. When she stays home, she lays in 1 place all day.Chloe is a fourth grade student. The family does not report academic concerns. She has friends. She denies any appetite or sleep problems. She endorses periods of sadness, lack of energy, and decreased interest in social activities, mostly because she worries and is embarrassed. She kept her behaviors hidden from her 5 siblings for the past year, and she talked only to her mother about them. She is worried her friends might discover her behaviors.The family history is notable for multiple paternal family members with anxiety and bipolar disorder and depression on mother's side. A few months ago, Chloe's family adopted a 7-year-old child with special needs from China.Her growth, vital signs, and physical examination are unremarkable. Her mother filled out the Short Mood and Feelings Questionnaire and the Screen for Child Anxiety-Related Emotional Disorders, which both had elevated scores.

Delusional disorder: retrospective analysis of 86 Chinese outpatients.

Patients who visited the psychiatric outpatient service of Chang Gung Medical Centre, Tao-Yuan, Taiwan during an 8-year period were studied retrospectively. Among the 10,418 outpatients, 86 (0.83%) were diagnosed as having DSM-IV delusional disorder (DD), including 61 (70.9%) with persecutory type, 12 (14.0%) with the mixed type, seven (8.1%) with jealous type, two (2.3%) with somatic type, two (2.1%) with unspecified type, one (1.2%) with erotomanic type, and another one with grandiose type. The ratio of women to men was 0.86. The mean age at onset was 42.4 +/- 15.41 years, with women being older than men. Thirty-seven cases (43.0%) presented with depressive symptoms at their first visit. Subjects were divided into four groups: persecutory type, jealous type, mixed type and others. There were no significant differences between the four groups in terms of gender, age at onset, time-lapse before seeking psychiatric help, the presence of hallucination or the presence of depression.

A 9-year-old girl with persistent obsessive and compulsive behaviors in a primary care pediatric practice.

Arwa Saleh

Later life and published writing Salih's depression at the failure of the revolutionary Left's promise and the reality of Egypt in the 1980s led her to break away from the party. She later left for Spain. She wrote in this period, reflecting on her bitterness with the organizations she was once involved with, the sexual exploitation that women suffered within communist organizations and the behaviour of male intellectuals within the party and movement. In work later published posthumously, she wrote that she had received psychiatric treatment while she was away. Her first manuscript (which was lost and never published) and a posthumously published autobiographical text 'Strolling: Daydream of a Lonely Rover' was dedicated to patients in psychiatric clinics. She later also published an Arabic translation of Tony Cliff's 1984 book Class Struggle and Women's Liberation.

Cases from the Osler Medical Service at Johns Hopkins University.

A 50-year-old African American woman presented with bilateral lower extremity pain, a history of falls during the past several months, and personality and behavior changes. She had been in good health until approximately 5 months before admission, when she began to fall with increasing frequency, often while going down a flight of stairs. She described these falls as her "legs giving out" and feeling very heavy and unsteady. There was no head trauma or loss of consciousness. Her daughter noticed that her gait had become somewhat unsteady during the last several months. Her family also noted a change in her personality at this time. Previously, she had been a very tidy person who took great care with her appearance, who was working as a customer service representative. However, she had become less social and very withdrawn. She had been observed putting on dirty clothes after showering, as well as eating constantly. The patient denied any fevers, chills, night sweats, headaches, vision changes, or tinnitus. She also denied any rashes, muscle pain, or intolerance to heat or cold. There was no history of seizure disorder or depression. Her past medical history was notable only for hypertension and being a passenger in a motor vehicle crash 1 year before admission. She denied any alcohol, tobacco, or illicit drug use, and had no travel history other than coming to the United States, as she was originally from Trinidad. On physical examination, she was a moderately obese African American woman with a flat affect, psychomotor slowing, and alopecia of the scalp. She was alert and oriented to person, place, and time, but had a score of 26 out of 30 on the Mini-Mental State Examination. She lost points only for recall; she had no difficulty with serial 7s. Her cranial nerves were intact and her speech was fluent, although sparse, and she did not make any paraphasic errors. Her muscle strength was 5/5 in both the upper and lower extremities. Reflexes were 2+ in the upper extremities and 1+ in the lower extremities, and toes were downgoing bilaterally. She had intact sensation to light touch and pinprick, but markedly diminished proprioception of her lower extremities bilaterally. She had a wide-based gait with a positive Romberg sign and was markedly ataxic. Rectal examination yielded a positive guaiac test with brown stool, normal tone, and no masses. The remainder of the physical examination was normal. Laboratory studies revealed pancytopenia with a hematocrit of 22.7% and a mean corpuscular volume of 118.2 fL. A peripheral smear that was performed on admission, prior to transfusion, revealed macrocytic red cells and hypersegmented neutrophils.

Cheong Chun Yin

of his or her gender, a mentally ill drug trafficker can serve a mandatory life sentence without caning, and secondly, her age being above fifty and it would not be legal for offenders (often the males) above fifty years old to be caned. Pang was likely the third drug trafficker on death row to have her sentence commuted due to a mental illness after Dinesh Pillai Reja Retnam and Wilkinson Primus in March and October 2014 respectively, and both were also, like Pang, diagnosed with depression at the time they committed their respective crimes.

Dynamic Gender Presentations: Understanding Transition and "De-Transition" Among Transgender Youth.

The following clinical scenarios are composite cases that illustrate clinically important phenomena based on several patients. Jamie is a 19-year-old who was assigned a female gender at birth and had a history of major depressive disorder in remission. She presented to her primary care physician, psychiatrist, and psychotherapist reporting dysphoria related to gender and requesting gender-affirming hormone therapy. Jamie had symptoms for at least 6 months consistent with DSM-5 criteria for gender dysphoria. After full clinical assessment by her therapist, psychiatrist, and primary care physician, her integrated care team initiated gender-affirming hormone therapy and provided close follow-up from her mental health providers. For 13 months, Jamie was treated with testosterone, changed her pronouns to he/him/his, and began wearing traditionally masculine clothing. Throughout this period, she remained engaged in regular care with her psychotherapist, who was experienced in providing gender-affirming care. Eventually, Jamie informed her care team that after the trial of testosterone and much reflection, she had come to understand her identity as a queer woman and wished to discontinue hormone therapy. Jamie reported being pleased about the hormone therapy trial, because this allowed her to clarify her gender identity. She did not regret her social affirmation or any physical changes that occurred during this process, such as fat redistribution and minor facial hair growth, in the context of otherwise being healthy. Lupita is a 23-year-old who was assigned a male gender at birth and had a history of major depressive disorder and panic disorder. At 18 years of age, after a comprehensive evaluation, she initiated gender-affirming hormone therapy with her primary care provider, changed her name to "Lupita," changed her pronouns to she/her/hers, and started wearing more traditionally feminine clothing. That following year, she started attending college and faced continual gender-based harassment from other students as a result of her gender-nonconforming physical appearance. Her college health services were not affirming of her gender and referred to her repeatedly by her birth name and with he-series pronouns. Lupita became demoralized and after 5 months decided to de-transition. She became progressively more depressed and attempted suicide in her sophomore year. Then she transferred colleges, found gender-affirming clinical providers, and resumed estradiol and spironolactone (an antiandrogen) therapy and her social affirmation through name, pronouns, and style of dress. Her mood improved dramatically and she was able to graduate from college. Lupita now presents seeking breast augmentation surgery.

Trent Reznor

Personal life During the five years following the release of The Downward Spiral in 1994, Reznor suffered from depression; his condition was worsened by the death of his maternal grandmother, who had raised him. He began abusing alcohol, cocaine, and other drugs, and successfully completed rehab in 2001. He said in a 2005 Kerrang! interview, "There was a persona that had run its course. I needed to get my priorities straight, my head screwed on. Instead of always working, I took a couple of years off, just to figure out who I was and working out if I wanted to keep doing this or not. I had become a terrible addict; I needed to get my shit together, figure out what had happened." In contrast to his former suicidal tendencies, he admitted in another 2005 interview that he is "pretty happy".

Weeding Out the Justification for Marijuana Treatment in Patients with Developmental and Behavioral Conditions.

Alex is a 13-year-old adolescent with high-functioning autism spectrum disorder, attention-deficit/hyperactivity disorder (ADHD)-combined type, anxiety, and depression. He has been resistant to engaging in therapy and treatment with various medications has been unsuccessful. Alex's parents are concerned about his anxiety, isolation, oppositional behaviors, academic underachievement, truancy, and substance use. A recent altercation with his stepfather led to a police intervention and a brief removal of Alex from the home. Alex previously used alcohol and other drugs; at present, he reports that his current drug use consists of frequently smoking pot. Alex states that he uses marijuana to relieve his anxiety and does not understand why this is problematic as marijuana is now legal in his state.Kevin is a 24-year-old adult man with diagnoses of autism spectrum disorder, mild intellectual disability, and schizoaffective disorder. He has a long history of challenging and problematic behaviors including aggression toward self and others, property destruction, inappropriate sexual behaviors, elopement, emotional outbursts, anxiety, and suicidal ideation. Past diagnoses include bipolar affective disorder, depression, and intermittent explosive disorder. Kevin is notably obese and somnolent. His current medications include 8 psychotropic medications, 3 antiallergy medications, levothyroxine, and a fish oil supplement. His father reports that medications have gradually been added and dosages increased over time. Two weeks ago, his new psychiatrist initiated a trial of medical marijuana. His father hopes that the marijuana will allow Kevin's other medications to be decreased or discontinued.Linda is an 11-year-old girl with high-functioning autism spectrum disorder, anxiety, and ADHD-inattentive subtype. Anxiety has been her most impairing condition, and Linda has been responding well to a treatment with cognitive behavioral therapy and a selective serotonin reuptake inhibitor. She is also working with her therapist on strategies to address her symptoms of ADHD. Linda has had no side effects from her medication and she and her family have been pleased with her progress. At a follow-up appointment, her mother brings an article from the lay press authored by a parent who claims that marijuana "saved" her autistic son. Linda's mother asks if marijuana should be considered for her daughter.

Not My Presidents Day

curb" in the street was pushed to the ground by police, had his arms pinned to his back, and was then pepper-sprayed in the face; and a woman was shoved to the sidewalk and then shot by police with "pepper balls". A 66-year-old woman was also tackled and hurt by the police when she attempted to shield her 72-year-old friend from being pushed. Several of the people arrested were minors, with six young people including a 14-year-old being cited. The adults were arrested on charges of disorderly conduct in the second degree, with one man also being charged with resisting arrest and giving false information to the police.

[Psychiatric manifestations of a new variant of Creutzfeldt-Jakob disease. Apropos of a case].

The new variant of Creutzfeldt-Jakob disease (nvCJD) was first described in the UK in 1996 (16). The nvCJD differs from sporadic, genetic and iatrogenic CJD. Creutzfeldt-Jakob disease is closely associated with an abnormal isoform PrPSc of a cell-surface glycoprotein, prion protein (14). Molecular analysis suggests that nvCJD is caused by the same prion strain as bovine spongiform encephalopathy (BSE) (4, 10). To the end of September 2000, there have been 82 cases of nvCJD in the UK. We report the second French case of nvCJD to our knowledge (5, 13). This 36 year old woman was referred by a local general practitioner with a 6 month history of psychiatric symptoms of major depressive disorder. According to her family, the patient had suffered from personality change for several months before the onset of depression including apathy, emotional lability, infantile affect. There was no history of health problems. As she was admitted to the psychiatric department of our hospital in Paris suburbs, she presented a major depressive disorder. There were no specific psychiatric features allowing distinction from common depressive disorders, except a marked emotional lability. The patient's condition progressed rapidly within the following days. She presented memory impairment and disorientation. Drug treatments, clomipramine (125 mg/day) and venlafaxine (200 mg/day), were used with no benefit. She presented subsequently transient delusions and auditory hallucinations, fleeting for some hours. The predominant delusional themes were somatic type and pregnancy. The delusions were concomitant with delusions of the onset of cognitive impairment. The patient tested negative for the P 14.3.3 protein in the CSF. Computed tomography scan of the brain did not show any relevant abnormality. The electroencephalogram showed non specific slow wave activity. The neurological symptoms developed 7 months after the onset of depressive symptoms including ataxia, myoclonus, excessive daytime drowsiness, headache. After the onset of neurological symptoms, the illness progressed rapidly over the next 2 months with cognitive impairment, particularly memory impairment, myoclonus, ataxia, incontinence of urine and progressive immobility leading to dependency. CSF tests were negative. She was referred to a neurology department where the diagnosis was confirmed by brain biopsy (detailed elsewhere). The patient died in a state of akinetic mutism. The clinical features of our patient were consistent with previous descriptions of nvCJD, mainly those of the National CJD Surveillance Unit studies (17): early psychiatric symptoms, prolonged duration of illness (median: 14 months), earlier age at death, compared with sporadic CJD. Psychiatric symptoms occur in the clinical course in about a third of cases of sporadic CJD (3). In contrast, of the 35 cases that have died of nvCJD identified in the study by Will et al. (17), 34 suffered from early and prominent psychiatric symptoms, mainly depression and anxiety. In most of the patients, the first symptoms were psychiatric. Drug treatment was used in most cases, some patients had a transient improvement (18). The patient without psychiatric symptoms reported by the NCJDSU (17) was emotionally labile. Infantile affect and emotional lability, found in our patient, are frequently reported in other studies (1, 18). Schizophreniform disorders have been described during the clinical course, with auditory and visual hallucinations and paranoid delusions (17, 18). The insomnia and excessive daytime drowsiness our patient presented have been described in similar cases (18). Investigations are important to rule out alternative diagnoses. EEG records do not show periodic triphasic complexes as in sporadic CJD. The P 14.3.3 protein in the CSF is positive in half the cases of nvCJD (17). First neurological symptoms developed 6 months after the onset of psychiatric symptoms including ataxia, myoclonus and persistent painful sensory symptoms (17, 18). In most of the cases, MRI brain scans show bilateral pulvinar high signal (17), found subsequently in our patient and detailed elsewhere (13). The terminal stages are progressive cognitive impairment, helplessness and akinetic mutism. The first symptoms of this patient were purely psychiatric and difficult to distinguish from common psychiatric disorders. Clinical surveillance of human prion disease is crucial in France, as in UK. The link with BSE has dramatically highlighted the need for neurological and neuropsychological precise investigations.

Emily Horne

Cautions and verdicts In August 2004, Horne was cautioned by the police for two cases of bigamy. Her first sentence for bigamy was handed down by Ipswich Crown Court around 2004, when she was sentenced to six months in prison. In June 2009, she was charged again, this time at Minshull Street Crown Court in Manchester. The court passed sentence on 27 July 2009; she was given a ten-month jail sentence, suspended for two years, since the court learned that she was diagnosed with bipolar disorder and was under medication. In 2011, Horne was arrested and tried for trying to obtain prescription drugs by posing as her seventh husband. Found guilty, she was due to be sentenced on 20 January 2012, but the verdict was postponed pending psychiatric evaluation. On 20 March 2012, she was handed a 12-month community order with supervision. The judge also imposed a 28-day electronically tagged curfew from 7pm to 7am. References

Importance of Trauma-Informed Practice in Evaluation of Children Diagnosed with Autism Spectrum Disorder.

As part of a multidisciplinary adoption support clinic, Erin, a 5-year-old girl, adopted approximately 6 months before the clinic visit, presents for postadoption evaluation. Erin was born at full term. Her birth history was significant for reported maternal treatment for liver failure during pregnancy. Her previous medical history included hospitalization for a viral illness at age 2 months, recurrent ear infections, and a fractured forearm. Family history was significant for a maternal history of bipolar disorder, depression, anxiety, borderline personality disorder, and concern for substance abuse; a paternal history of attention-deficit/hyperactivity disorder (ADHD) and depression; and full biological brother with a history of ADHD and oppositional defiant disorder. Erin and her brother lived with their parents until she was approximately 3 years old. At that time, there were concerns for poor hygiene, inconsistent medical care, poor school attendance for her brother, financial instability, and significant neglect. Erin was reportedly confined to her crib for hours at a time. She and her older brother were removed from the home because of concerns for significant neglect and placed into foster care. Approximately 3 months after foster placement, Erin underwent testing because of concerns for abnormal behaviors and possible developmental delays. Symptoms included poor sleep, repetitive behaviors such as head banging, delayed speech that primarily involved grunting, and lack of toilet training. She was hyperactive and aggressive and had poor caregiver attachment. On evaluation, she was small for age, poorly groomed, and easily distracted with poor eye contact and did not tolerate interactions with examiners. Neuropsychological testing consisted of symptom checklists and caregiver interview only because she did not tolerate diagnostic testing. She was diagnosed with autism spectrum disorder and global developmental delay with intellectual and language impairments. Over the following year, Erin was transitioned to a second foster family and was subsequently adopted. She received speech, occupational, and physical therapy, along with trauma-informed therapy. She made significant gains in multiple domains and was able to graduate from trauma-informed therapy after 1 year. On examination, Erin greets you with appropriate eye contact and reports that she is feeling "good." She is verbal and interactive with her brother and parents. She looks to parents for support when asked to participate in the physical examination. She does not display any significant repetitive behaviors. Erin's parents are concerned that her initial diagnoses of autism spectrum disorder and global developmental delay do not accurately reflect her current level of functioning and are afraid she may have been misdiagnosed. How would you proceed with next steps to address these diagnoses?

The Woman Who Came Back

The local townspeople become suspicious and paranoid, believing that Lorna caused the illness of young Peggy, Matt's niece. Desperate to prove that there is nothing supernatural affecting the town or the woman he loves, Matt discovers the personal journal of Elijah Webster. Inside are the details of how Webster forged confessions of witchcraft to further his political standing. Matt hurries to show Lorna the journal, but finds her house being vandalized by some of the townspeople and Lorna fleeing in hysterical terror. Lorna hallucinates and falls into the river. Matt saves her and, in the process finds the body of the old woman. Now believing that she'd been a victim of superstition, Lorna stays in town and marries Matt. Cast Production The Woman Who Came Back was shot at Chaplin Studios in April 1945. The film was developed under the working title The Web.

"Is It Her Hormones?": Psychiatric Diagnoses and Polycystic Ovarian Syndrome.

Beth, whom you have cared for in your primary care practice since she was born, is a 15-year-old adolescent girl with no prior psychiatric history who developed significant symptoms of clinical depression, associated with self-injurious behavior (cutting on wrists, arms, and thighs). She denied any known precipitant for her depression.She is a ninth grade honors student in the gifted program at a local high school and is described as a talented musician, playing multiple musical instruments as well as soccer and basketball. She has good family support, was sociable, and had several close friends. She denied any history of trauma and denied ever using recreational drugs or other mood-altering substances.At this visit, she reported feeling "sad and anxious." Family history was significant for maternal depression, which persisted through her teens and twenties. Her older sister had been diagnosed with Social Anxiety Disorder. Beth reported anhedonia, fatigue and irritable mood, lack of motivation, impaired concentration, and anxiety related to failing grades.You decide to begin medication because of the severity of her symptoms, and 1 week after starting fluoxetine 10 mg, she reportedly overdosed on an unknown quantity of acetaminophen. Within a few days of switching to escitalopram (due to persistent gastrointestinal complaints while taking fluoxetine), she developed homicidal ideation. She reported feeling grandiose, empowered, invincible, elated, and "crazy," although she never demonstrated or endorsed psychotic symptoms. She became fixated upon the idea that she could kill someone and "get away with it." At the time she tried to suffocate a peer with her hands, she was described as having "a glazed over look in her eyes." Moods were now described as alternating between depressed and elated, with mood shifts occurring every few days. These symptoms did not improve after the antidepressant medication was discontinued.Subsequently, patient was admitted for acute psychiatric care, at which time she was described as depressed, but with an "expansive and irritable" mood, and with obsessive suicidal ideation. She had developed a plan to hang herself in the home. She started to believe that her mother was trying to give her "poison." She reported panic attacks and said that she wanted to be in the hospital where she could feel "safe." She claimed to have an "entity inside of her body who was a bully" and who was "taking over her body" and stated that he put her hand over her peer's mouth, as she watched.Psychological testing included the Minnesota Multiphasic Personality Inventory-Adolescent, showed significant paranoia, bizarre mentation, and poor reality testing. Along with interview and observation, it was determined that patient met criteria for the DSM-IV-TR clinical diagnosis of Other Specified Bipolar Disorder, with psychotic features.Aripiprazole was initiated at a dosage of 2 mg; however, moods were still described as fluctuating between extremes every few hours. It was discontinued after reaching 5 mg due to affective blunting. Risperidone 0.5 mg twice daily helped patient to feel and act "more like herself"; however, she continued to report significant depression. The addition of lamotrigine 25 mg daily, in addition to individual Dialectical Behavior Therapy, finally led to improvement of mood and a gradual return of her normal baseline, with reportedly stable emotional, social, and academic functioning.The patient's mother remained convinced that this adolescent's mood instability was caused by underlying hormonal problems so you refer her to endocrinology. Beth developed puberty at age 8, with menses occurring on average of twice yearly. She was found to have elevated free testosterone level of 8.6 (reference range, 1.2-7.5). She was of normal weight (body mass index = 21.85 kg/m) and did not manifest acne, male pattern hair thinning, or hirsutism. Thyroid functions, 17-OH progesterone, follicle-stimulating hormone/luteinizing hormone, and estradiol were within normal limits. Prolactin elevation (46.3) was assumed to be due to Risperidone. Patient refused ovarian ultrasound.After starting oral contraceptives to establish monthly menses, patient's emotional and behavioral symptoms continue to remain stable. After Beth decided on her own to discontinue psychotropic medications, she continued for 17 months following her initial visit to remain free of neuropsychiatric symptoms.Now that her symptoms seem resolved; you wonder what the medical diagnosis for Beth was? You wonder if "hormones" may have caused or contributed to her psychiatric presentation.

Deanna Laney murders

Five mental health experts were consulted in Laney's case: two each by the prosecution and defense, and one by the judge. All of them arrived at the conclusion that she suffered from psychotic delusions which made her unable to know right from wrong at the time of the killings. A Smith County court found her not guilty by reason of insanity. She was committed to Kerrville State Hospital for eight years until her release in May 2012. However, she is subject to a list of conditions, including that she have no unsupervised contact with minors and submit to regular drug tests to ensure that she takes required medication. See also Other cases of filicide in Texas: John Battaglia Darlie Routier Andrea Yates Yaser Abdel Said is accused of filicide References The Dallas Observer. "Psycho Mom," January 20, 2005. Retrieved on May 29, 2007. USA Today. "Texas woman who killed kids acquitted," April 4, 2004. Retrieved on May 30, 2007.

Trichotillomania: Bizzare Patern of Hair Loss at 11-Year-old Girl.

Trichotillomania (TTM) is defined by the Diagnostics and Statistic Manual of Mental Disorders, 4th edition (DMS-IV) as hair loss from a patient`s repetitive self-pulling of hair. The disorder is included under anxiety disorders because it shares some obsessive-compulsive features. Patients have the tendency towards feelings of unattractiveness, body dissatisfaction, and low self-esteem (1,2). It is a major psychiatric problem, but many patients with this disorder first present to a dermatologist. An 11-year-old girl came to our department with a 2-month history of diffuse hair loss on the frontoparietal and parietotemporal area (Figure 1). She had originally been examined by a pediatrician with the diagnosis of alopecia areata. The patient`s personal history included hay fever and shortsightedness, and she suffered from varicella and mononucleosis. Nobody in the family history suffered from alopecia areata, but her father has male androgenetic alopecia (Norwood/Hamilton MAGA C3F3). The mother noticed that the child had had changeable mood for about 2 months and did not want to communicate with other persons in the family. The family did not have any pet at home. At school, her favorite subjects were Math and Computer Studies. She did not like Physical Education and did not participate in any sport activities during her free time. This was very strange because she was obese (body-mass index (BMI) 24.69). She was sometimes angry with her 13-year-old sister who had better results at school. The girl had suddenly started to wear a blue scarf. The parents did not notice that she pulled out her hair at home. Dermatological examination of the capillitium found a zone of incomplete alopecia in the frontoparietal and parietotemporal area, without inflammation, desquamation, and scaring. Hairs were of variable length (Figure 1). There was a patch of incomplete alopecia above the forehead between two stripes of hair of variable length (Figure 2). The hair pull test was negative along the edges of the alopecia. Mycological examination from the skin capillitium was negative. The trichoscopy and skin biopsy of the parietotemporal region of the capillitium (Figure 3) confirmed trichotillomania. Laboratory tests (blood count, iron, ferritin, transferrin, selenium, zinc, vitamin B12, folic acid, serology and hormones of thyroid gland) were negative. We referred the girl for ophthalmologic and psychological examination. Ophthalmologic examination proved that there was no need to add any more diopters. The psychological examination provided us with a picture in which she drew her family (Figure 4). The strongest authority in the family was the mother because she looked after the girls for most of the day. She was in the first place in the picture. The father had longer working hours and spent more time outside the home. He worked as a long vehicle driver. He was in the second place in the picture. There was sibling rivalry between the girls, but the parents did not notice this problem and preferred the older daughter. She was successful at school and was prettier (slim, higher, curly brown hair, without spectacles). Our 11-years-old patient noticed all these differences between them, but at her level of mental development was not able to cope with this problem. She wanted to be her sister's equal. The sister is drawn in the picture in the third place next to father, while the patient's own figure was drawn larger and slim even though she was obese. Notably, all three female figures had very nice long brown hair. It seemed that the mother and our patient had better quality of hair and more intense color than the sister in the drawing. The only hairless person in the picture was the father. The girl did not want to talk about her problems and feelings at home. Then it was confirmed that our patient was very sensitive, anxious, willful, and withdrawn. She was interested in her body and very perceptive of her physical appearance. From the psychological point of view, the parents started to pay more interest to their younger daughter and tried to understand and help her. After consultation with the psychiatrist, we did not start psychopharmacologic therapy for trichotillomania; instead, we started treatment with cognitive behavioral therapy, mild shampoo, mild topical steroids (e.g. hydrocortisone butyrate 0.1%) in solution and methionine in capsules. With parents' cooperation, the treatment was successful. The name trichotillomania was first employed by the French dermatologist Francois Henri Hallopeau in 1889, who described a young man pulling his hair out in tufts (3-5). The word is derived from the Greek thrix (hair), tillein (to pull), and mania (madness) (5). The prevalence of TTM in the general adult population ranges from 0.6% to 4%, and 2-4% of the general psychiatric outpatient population meet the criteria for TTM (2-5). The prevalence among children and adolescents has been estimated at less than 1% (5). The disease can occur at any age and in any sex. The age of onset of hair pulling is significantly later for men than for women (3). There are three subsets of age: preschool children, preadolescents to young adults, and adults. The mean age of onset is pre-pubertal. It ranges from 8 to 13 years (on average 11.3 years) (2-5). The occurrence of hair-pulling in the first year of life is a rare event, probably comprising <1% of cases (5). The etiology of TTM is complex and may be triggered by a psychosocial stressor within the family, such as separation from an attachment figure, hospitalization of the child or parent, birth of a younger sibling, sibling rivalry, moving to a new house, or problems with school performance. It has been hypothesized that the habit may begin with "playing" with the hair, with later chronic pulling resulting in obvious hair loss (2). Environment is a factor because children usually pull their hair when alone and in relaxed surroundings. The bedroom, bathroom, or family room are "high-risk" situations for hair-pulling (5). Men and women also differed in terms of the hair pulling site (men pull hair from the stomach/back and the moustache/beard areas, while women pull from the scalp) (3). Pulling hair from siblings, pets, dolls, and stuffed animals has also been documented, often occurring in the same pattern as in the patient (5). Genetic factors contributing to the development of TTM are mutations of the SLITRK1 gene, which plays a role in cortex development and neuronal growth. The protein SAPAP3 has been present in 4.2% of TTM cases and patients with obsessive-compulsive disorder (OCD). It may be involved in the development of the spectrum of OCD. A significantly different concordance rate for TTM was found in monozygotic (38.1%) compared with dizygotic (0%) twins in 34 pairs (3). The core diagnostic feature is the repetitive pulling of hairs from one`s own body, resulting in hair loss. The targeted hair is mostly on the scalp (75%), but may also be from the eyebrows (42%), eyelashes (53%), beard (10%), and pubic area (17%) (3,5). There are three subtypes of hair pulling - early onset, automatic, and focused. Diagnostic criteria for TTM according to DSM-IV criteria are (2,3,5): 1) recurrent pulling of one`s hair resulting in noticeable hair loss; 2) an increasing sense of tension immediately prior to pulling out the hair or when attempting to resist the behavior; 3) pleasure, gratification, or relief when pulling out the hair; 4) the disturbance is not better accounted for by another mental disorder and is not due to a general medical condition (e.g., a dermatologic condition); 5) the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The differential diagnosis includes alopecia areata (Table 1) (6), tinea capitis, telogen effluvium, secondary syphilis, traction alopecia, loose anagen syndrome, lichen planopilaris, alopecia mucinosa, and scleroderma (2-5). Biopsy of an involved area (ideally from a recent site of hair loss) can help to confirm the diagnosis (5). On histologic examination, there are typically increased numbers of catagen and telogen hairs without evidence of inflammation. Chronic hair pulling induces a catagen phase, and more hairs will be telogen hairs. Pigment casts and empty anagen follicles are often seen. Perifollicular hemorrhage near the hair bulb is an indicator of TTM (2). Complications of TTM are rare, but they comprise secondary bacterial infections with regional lymphadenopathy as a result of picking and scratching at the scalp. Many patients play with and ingest the pulled hairs (e.g. touching the hair to lips, biting, and chewing). Trichophagia (ingestion of the hair) can lead to a rare complication named trichobezoar (a "hair ball" in stomach). This habit is present in approximately 5% to 30% of adult patients, but it is less frequent in children. Patient with trichophagia present with pallor, nausea, vomiting, anorexia, and weight loss. Radiologic examination and gastroscopy should not be delayed (2,4,5). The management of the disease is difficult and requires strong cooperation between the physician, patient, and parents. The dermatologist cannot take part in the therapy, strictly speaking, but without the psychological, psychopharmacologic, and topic dermatologic treatment a vicious circle will be perpetuated.

Joshua Huddy

Early life Huddy was born November 8, 1735, to a prosperous family in Salem County, Province of New Jersey, the oldest of seven brothers. His grandfather, Hugh Huddy, was a well-known judge in Burlington. Huddy spent most of his early life in Salem, where he was considered rebellious and a troublemaker. He was disowned by Quakers in Salem in 1757 for his "disorderly" conduct. His "rough ways" continued into adulthood; he was tried and convicted several times for crimes including assault and theft and repeatedly had financial difficulties. He was forced to sell a 300-acre (1.2 km²) plantation in Salem to pay his debts and was forced into debtor's prison for a time. In 1764, he married his first wife, the widowed Mary Borden, by whom he had two daughters, Elizabeth and Martha, before her death.

[Factitious disorders in dermatology: Value of the dissociative state concept].

Factitious disorders in dermatology consist of intentionally self-inflicted skin lesions that vary in morphology and distribution and occur on surfaces readily accessible to the patient's hands. They tend to be a chronic condition that waxes and wanes according to the circumstances of the patient's life. Patient management poses a particular challenge to the clinician and the prognosis is considered poor. The aetiopathogenesis of factitious disorders in dermatology is not completely understood. We present a case in which we suggested the occurrence of factitious behaviour during a dissociative state, and we briefly describe our diagnostic and therapeutic approach. A 48-year-old unemployed woman was referred to our department of psychiatry by her dermatologist for suspected factitious disorder. The patient was diagnosed with diabetes mellitus type 1 and had been hospitalized repeatedly for confirmed diabetic ketoacidosis. The onset of the disease was related to marital discord with her spouse. Numerous skin lesions had appeared on her face, arms, legs, neck and back. These lesions resulted in multiple hospital admissions and in amputation of her left leg. The condition had worsened considerably after her separation from her husband. During the initial conversation, the patient was unable to provide a clear history of the disease. She denied any knowledge of the circumstances in which these skin lesions appeared, and she did not admit self-infliction. Her mood was depressed and her speech was slow. We suspected that our patient was herself causing her skin lesions while in a dissociative state. Several arguments militate in favour of our hypothesis, particularly her history of childhood maltreatment and the association of traumatic life events with simultaneous deterioration of the skin. The explanation of the dissociative mechanism helped us to strengthen the therapeutic relationship. Within a few days, we noted a slow regression of the lesions, but the patient was still unable to explain how the lesions had occurred. The pathophysiology of factitious disorders in dermatology is poorly understood. It has strong ties with other psychiatric disorders, and according to several authors, skin lesions occur in dissociative states, after which patients do not remember how the skin change started. Management of this disease is challenging. An improved understanding of its mechanisms may enhance the prognosis for this particular group of patients.

Cheong Chun Yin

In the same trial and court, much to the relief of her relatives in court, 60-year-old Pang Siew Fum was also given an approval of her re-sentencing application despite failing to meet the criteria of a courier, as psychiatrists assessed and found Pang to be suffering from major depressive disorder which sufficiently impaired her mental responsibility. After Pang's lawyers presented the medical report to the court, Justice Choo accepted that Pang should not be hanged based on her diminished responsibility. Hence Pang, by gaining eligibility under the alternative re-sentencing criteria, was re-sentenced to life imprisonment from the date of her capture, and no caning was imposed due to her being a female. Even if Pang was a male, she would not face caning as well because firstly, regardless of his or her gender, a mentally ill drug trafficker can serve a mandatory life sentence without caning, and secondly, her age being above fifty and it would not be legal for offenders (often the

Maintaining Safety and Planning for the Future.

Kevin is a 12-year-old boy with autism spectrum disorder, intellectual disability (nonverbal IQ scores in mid-40s), and attention-deficit/hyperactivity disorder who has been followed up by a developmental-behavioral pediatrician (DBP) and a child psychologist for medication and behavioral management since he was 4 years old. Kevin was placed in the care of his great-great-aunt shortly after he turned 2 years of age because of concerns of neglect. She is now his legal guardian.Kevin is predominately nonverbal but does use a few single words to make requests or label items. He attends a public school and receives full-time special education support. He has a personal care assistant (PCA) who provides in-home support 5 to 6 days/wk for 3 to 4 hours at a time. The PCA is working on toilet training, using a "clock-training" approach, and also takes Kevin outdoors to play or on short outings during her visits. In his free time, Kevin prefers to watch cooking shows on television.Over the past year, Kevin's behaviors have become more concerning. There have been several episodes of Kevin waking up during the early morning hours and going to the kitchen to "cook." After one of these episodes, his guardian was not aware that Kevin had woken up until the next morning when she found a concoction of corn starch, coffee grounds, cottage cheese, and powdered drink mix in the blender. Kevin had also woken up during the night and ventured out of the house into the back yard. His guardian had woken up immediately as the alarm system sounded when he opened the outer door from the house to the yard.A door alarm was added to Kevin's bedroom door so that his guardian would be alerted when he leaves his bedroom; however, the alarm is not used consistently because there are times when the alarm cannot be found at bedtime. Kevin's guardian was able to obtain a GPS device for him to wear on his shoe from the local police department. He wears this without resistance every day.Kevin's guardian is in her mid-70s, and she has had several health issues over the past 2 to 3 years. There are no other family members who are willing or able to care for Kevin if his guardian were no longer able to. The DBP and child psychologist have encouraged Kevin's guardian to explore long-term residential care options with the state agency that provides support for individuals with intellectual disabilities and with Kevin's insurance provider, but the guardian is very reluctant to do this. She fears that Kevin will be removed from her care or placed in a "home" where someone will "do bad things to him."What else would you recommend or actions would you take to support Kevin's guardian in ensuring Kevin's safety and planning for his future care?

Rose Spector

Among her many judicial opinions, her dissent in Twyman v. Twyman is often studied in family law. In that case, the majority opinion was authored by then-justice John Cornyn, adopting the Restatement of Torts standard for intentional infliction of emotional distress, but Justice Spector dissenting, arguing that in this case, award of damages to the wife for the proven abuse of the wife by her husband should be upheld under the standards for negligent infliction of emotional distress that had been thought to apply at the time of the lower court's verdict. References Sources Twyman v. Twyman, 855 S.W.2d 619 (Texas 1993). An Unusual History of Women Serving on the Texas Supreme Court Interview with Rose Spector, UTSA Oral History Project Cossman's The Story of Twyman v. Twyman: Politics, Tort Reform, and Emotional Distress in a Texas Divorce, in Carol Sanger, Family Law Stories

[A 63-year-old woman with muscle weakness, myotonia, and parkinsonism].

We report a 63-year-old woman who presented myotonia and parkinsonism. The patient was well until 15 years of the age when she noted that the ring finger of her left hand at times flexed when she did not intend to do so. She noted weakness in her left upper extremity at the age of 40, and difficulty in relaxing her hand grip at 45. She had an onset of tremor in her right foot at age 50, which was followed by difficulty in gait and hand writing. She was admitted to Juntendo University Urayasu Hospital when she was 63-year-old. Her mother, two sisters, and a son were affected with similar muscle weakness and myotonia. Although some of them developed stooped posture in the late stage of the disease, none of them had overt parkinsonism. General physical examination was unremarkable. Neurologic examination revealed an alert and oriented woman with some recent memory loss. She had bilateral ptosis, facial weakness, and a masked face. Myerson's sign was present. Her speech was small and monotonous. The sternocleidomastoid muscles were markedly atrophic and weak. The remaining of the cranial nerves were intact. She walked in small steps with freezing with support. She showed bradykinesia, retropulsion, and resting tremor in her right leg. Slight distal dominant weakness was noted in both upper and lower extremities more on the left. No cerebellar signs were noted. Muscle stretch reflexes were within normal limits in the upper extremities and diminished in the lower limbs. Sensation was intact. Routine laboratory findings were unremarkable. Cranial CT scan and MRI revealed slight cortical atrophy and leukoaraiosis. She responded to levodopa and she became able to walk by herself. She was transferred to another hospital one month after her admission. She had several bouts of airway obstruction with one episode of respiratory arrest. She expired six month after the transfer. The patient was discussed in a neurological CPC, and the chief discussant arrived at the conclusion that this patient suffered from myotonic dystrophy and Parkinson's disease which set in later years. Postmortem examination on the iliopsoas muscle revealed uneven muscle fiber diameters, central nuclei, and type 1 fiber predominance; the pathologic finding was consistent with myotonic dystrophy. The substantia nigra showed marked cell loss and Lewy bodies in the remaining neurons. The finding was consistent with Parkinson's disease. In myelin stain, diffuse myelin pallor was noted in the cerebral white matter which was the pathologic substrate of leukoaraiosis in this patient. Combination of these two disorders have never been reported in the literature to our knowledge. It appears to be that the coincidence is just a by-chance phenomenon, but it seems interesting to note that accelerated aging process appears to be present in both myotonic dystrophy and Parkinson's disease.