9th International Congress on Psychopharmacology & 5th International Symposium on Child and Adolescent Psychopharmacology

0040 The First Episode of Psychosis with Intense Occupation of Reiki Özge Şahmelikoğlu Onur, Merve Çukurova, Sevda Bağ, Suat Yalçın, Cansu Çakır Şen and Çağatay Karşıdağ Bakırköy Research and Training Hospital for Psychiatry, Neurology, and Neurosurgery, 3rd Psychiatry Department, Istanbul, Turkey E-mail address: ozge_sahmelikoglu@hotmail.com

spontaneously. After that we reduced and ceased oral aripiprazole. We switched therapy to clozapine. She stayed in hospital for 6 weeks. İn this 6 weeks OGC did not reappear. As a partial agonist of D2 receptors aripiprazole has low propensity for extrapyramidal side effects include oculogyric crisis. OGC occurred after 3 weeks administration of aripiprazole. And we reduced and ceased oral aripiprazole. Introduction of a new agent or increasing of an existing agent may associated with risk of OGC. In conclusion, case outlines a significant side effect of aripiprazole, which clinician should be vigilant about initiating the medication. the purpose of discuss probable common etiopathogenesis. A 19 year-old male, was diagnosed KS after a detailed examination in order to admission to pediatrics due to delayed and absence of initial signs of puberty at his 13. He was on the treatment with hormone replacement. The patient presented to our outpatient clinic with hallucinations and delusions lasted for two years and suicidal thoughts also existed and he was hospitalized with a view of diagnosing and treatment. He was diagnosed psychotic disorder and olanzapine 5 mg/day was initiated then potentiated to 15 mg/day. Psychotic symptoms improved with the treatment, then he was discharged. Schizophrenia had been thought as a variant model of KS due to the similarities in between like trait defects, occurrence ratio, and sex distribution, and KAL-X gene mutation had been presumed in the pathophysiology of schizophrenia at first. It was thought that defect on this gene leads to impairment in GnRH releasing neurons migration and it was concluded as olfactory deficits in various severity and normal sexual development disruption. The defect in genes encoding the fibroblast growth factor receptor (FGFR) and fibroblast growth factor (FGF) which are responsible neurogenesis, gliogenesis, myelinogenesis and axonal overgrowth, are under-research in both KS and schizophrenia. This report aimed to contribute in the matter of similar molecular etiopathogenesis in both disease Abstract:0243 Suspicious Effect on Treatment and Prognosis of Schizophrenia: Ankylosing Spondylitis Mustafa Uğurlu a , Görkem Karakaş Uğurlu b , Emine Tuğçe Akçaer b , Serdar Süleyman Can b , Ali Çayköylü b and Zuhal Koç a a Department of Psychiatry, Atatürk Training and Research Hospital, Ankara, Turkey; b Department of Psychiatry, Yildirim Beyazit University School of Medicine, Ankara, Turkey E-mail address: zuhalkoc_19@hotmail.com ABSTRACT Ankylosing spondylitis (AS) is a common inflammatory disease. Several studies showed that rheumatic disorders had a higher risk of psychiatric comorbidity especially depressive disorder. But co-occurrence of psychotic disorder and ankylosing spondylitis is considered to be low in relation. Here we describe a case of schizophrenia and ankylosing spondylitis comorbidity. 24 year-old, male patient suffering from contamination and asymmetry obsessions presented to our outpatient clinic 6 years ago. His psychiatric symptoms dated after 7 months when diagnosed with ankylosing spondylitis. He complained of elaborate washing and checking rituals that interfered greatly with his daily life. His particular concern was with food contamination. Because of this appetite of patient was diminished and had social isolation. The symptoms were diagnosed with obsessive-compulsive disorder and put on treatment with sertraline. Due to treatment noncompliance, his treatment changed with fluoxetine. At the same time, patient's medical adherence of ankylosing spondylitis was poor. Patient's rituals began to consume several hours a day leading disturbance in functionality. According to reports, besides to obsessions patient had persecutory and referential delusions and psychomotor agitation, disturbance in judgement. After that patient had several hospitalizations was diagnosed with schizophrenia. Patient put on treatment with several antipsychotics especially injection form. At last visit; treatment changed to once-monthly paliperidone palmitate 100 mg injection, risperidone 5 mg/day and depakine 2000 mg/day. Patient psychotic presentation cleared after treatment but obsessional thoughts remained. Underlying mechanism of ankylosing spondylitis with psychotic disorder relation should be studied for providing comprehensive care to patients. Ankylosing spondylitis activity and general well-being of patient acts together with psychological status so psychiatric evaluation should keep in mind during the evaluation and management of patients with AS by clinicians.
It has become apparent that cerebellum is critical for many functions other than coordination of movement. It is related in regulation of cognition and emotion. Mega cisterna magna is described as developmental variation of posterior fossa. Although some case reports suggest that there is relationship between mega cisterna magna and some psychiatric disorders, its pathogenesis has not been fully understood. We present here a case series that consists of two cases of schizophrenia and a case of dementia and late onset psychosis associated with mega cisterna magna. Case 1: A 25 year-old, male patient with diagnosis of schizophrenia presented to clinic with complaints of having the fear of being killed, psychomotor agitation, aggression and poor treatment response. Brain MRI showed mega cisterna magna variation and frontal cortical atrophy. He had paroxysmal activity in EEG examination. Case 2: A 29 year-old, male patient with diagnosis of schizophrenia for 4 years. He was brought to clinic because of noncompliance to treatment. He had complaints of suspiciousness, fear of being chased and harmed by other people, restlessness and insomnia. Brain MRI showed mega cisterna magna variation. Case 3: A 76 year-old, male patient had been hospitalized with diagnosis of dementia and psychotic disorder 8 years ago. He presented to clinic with complaints of restlessness, insomnia, suspiciousness and memory impairment. In brain MRI, diffuse cortical atrophy and mega cisterna magna variation was reported. Mini mental state examination was performed and he had score of 17 of 30. He was discharged with diagnosis of dementia and late-onset schizophrenia. Functional and structural cerebellar abnormalities are considered that are associated with pathophysiology of schizophrenia. Beside structural changes, clinical studies showed there is altered corticocerebellar connectivity in these patients. It is suggested cerebellum has connection with several cortical regions via cortico-cerebellar-thalamiccortical circuit (CCTCC) and disruption in activity of this circuit leads to symptoms observed in schizophrenia. So, any abnormality in cognitive process results with 'cognitive dysmetria', characterized by variety of disorganization symptoms in schizophrenia. Tardive dyskinesia (TD) is one of the most prominent obstacles of treatment with not only first generation antipsychotics but also second generation's. TD creates appearance problems, functional problems and distorts the quality of life. To get the best result, the most detailed evaluation should be made. A 38 year-old male patient with schizoaffective disorder had been using several different antipsychotic drugs (risperidone, amisulpride, olanzapine, quetiapine, and thioridazine) since 17 years. He was diagnosed as TD since ten years and given biperiden, tetrabenazine, valproate, and clonazepam and clozapine treatments. Ataxia, contractions in the limbs, and dyskinetic and dystonic movements in the neck increased and became more severe, to hinder the daily function of the patient. He had attempted suicide by jumping from a height, two times and underwent an operation due to vertebral fracture 8 months ago. In that period clozapine was stopped and was started again 2 months ago. He had undergone 2 cures of Botox treatment. The ongoing therapy of the patient includes clonazepam 6 mg/day, vitamin E 800 mg/day, omega 3 capsule 1000 mg/day, clozapine 250 mg/day, quetiapine 300 mg/day, valproate 1250 mg/day, and mirtazapine 15 mg/day. When the patient had been questioned about his awkward movements, such as putting his head in the drawer and sleeping in that position, compressing his head in the drawer, and consciously bumping his head on hard objects, he had told that he was relieving in that way. In inpatient service, the movements of the patient were increasing during the family visits. In addition to severe movement disorder, it was observed there are some motions toward the purpose. Management of anger and depression controlled the motions. Psychiatric symptoms may improve TD. Secondary gains and coincidental conversion disorders should be evaluated carefully. Mega cisterna magna is a developmental variation of the posterior fossa characterized by the enlargement of the cisterna magna that is associated with various psychiatric conditions before. We want to describe visual and auditory hallucinations in a patient with mega cisterna magna. A 23 year-old man presented with the complaint of visual and auditory hallucinations which was insidious onset and continued for 1 year. Hallucinations were about his daily life, he has no delusions. He had no history of psychiatric and neurological disorders and no family history. His developmental history was normal, self-care was good, but his cognitive functions were impaired and he left his work. There was no alcohol or substance use. Physical and biochemical examination was normal. In the cranial MRI; mega cisterna magna and asymmetric lateral ventricles were detected. Cerebellum and vermis were intact. EEG was unremarkable. Olanzapine treatment has begun 10 mg/day for 2 months. The symptoms decreased by 80% controlled by PANNS score. The patient could begin to work again, mental and academic performance improved after the period following treatment. Mega cisterna magna has been described in association with schizophrenia and obsessive-compulsive disorder, manic episode, psychosis (delusional type), impulsive behaviors and recurrent major depression previously. For schizophrenia a model was suggested to explain "misconnections" between cortical regions and the cerebellum mediated through the thalamus (the cortico-cerebellar-thalamic-cortical circuit). Psychotic symptoms such as hallucinations may occur in this circuit. We observed a good response on slow-onset positive symptoms at the treatment dose of an atypical antipsychotic. The isolated mega-cisterna magna in this case can lead to less effect on the circuit, this may be the result of the good response. Mega cisterna magna may be associated that various psychiatric manifestations including psychosis. Olanzapine could be useful drug with its low side effects KEYWORDS Mega cisterna magna; visual auditory hallucinations; olanzapine Psychiatric disorders are common during pregnancy, affecting 15-29% of all pregnant women and pregnancy makes the treatment of psychiatric disorders very difficult. Because of the possible harmful effects of pharmacotherapy on the fetus during pregnancy, Electroconvulsive therapy (ECT) is used as another option in treatment and effective in several mental disorders. ECT has some reversible side effects and complications, but most of the complications are mild and limited. We aim to present a pregnant women with psychotic exacerbation who was resistant to antipsychotics and controlled symptoms with ECT. We also want to discuss relapsing symptoms shortly after ECT. A 25 year-old female patient was followed for 10 years with schizophrenia and she was taking Olanzapine 30 mg/day. Treatment of the patient was changed to Haloperidol 10 mg/day because of pregnancy planning. The patient was brought to the hospital by her family due to aggression and inappropriate behavior. It was learned that persecutory delusions and auditory hallucinations increased after the treatment change. The patient was hospitalized. Haloperidol 10 mg/day treatment was continued and ECT was planned. At the end of the 4th session, her complaints were decreased and at the end of the 7th session, all psychotic symptoms almost gone. There were no maternal and fetal complications after each ECT treatment. After treatment, she was discharged with haloperidol 10 mg/day while she was 36 weeks pregnant. She had labor at 38th week. It was learned that the patient had stopped taking pills for 2 days because of labor and her symptoms start again after the birth. Although ECT is a safe and efficient treatment choice during pregnancy, relapse and recurrence rate is still high in first year even if the antipsychotic treatment continues. Continuation and maintenance electroconvulsive therapy may be recommended in these cases. KEYWORDS Electroconvulsive therapy; schizophrenia; pregnancy treatment was stopped, and treatment with trazodone 50 mg/d was started; 15 days later, menstruation was detected. One months later, ACTH level was 37.2, BDI scores was 12, and BAI score was 16. During three months of follow-up, the patient has taken trazodone, her menstruations were regularly. Amenorrhea can be induced by a variety of drugs that affect ACTH levels, especially antidepressants, antipsychotics, cortisol derivatives, and chemotherapeutics. Clinicians should think of escitalopram as a probable cause of amenorrhea due to increased ACTH. Abstract:0437 It's Too Cold: A Case Report Fulya Gok, Seda Kiraz, Arif Cipil and Meliha Zengin Eroglu Department of Mental Health and Disease, Health Sciences University Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey E-mail address: fufubo@hotmail.com ABSTRACT Specific phobia is a feeling of fear or anxiety about certain objects or situations. Frigophobia is a type of phobia reported as a rare psychiatric syndrome, defined as being frightened by cold or cold things. In this case report, we aimed to share and discuss a case of frigophobia which can be defined as specific phobia according to DSM-5. A 53-year-old male patient with no previous psychiatric diagnosis presented to outpatient clinic with cold water-induced chill and tremor attacks. His attacks have been occurring only every 2-3 months in winter and continued for 4-5 hours. When the complaints of the patient started, he entered the bed, covered two quilts, tried to warm up with hot water bag and hair dryer. His physical and laboratory examinations, electrocardiography and electroencephalography were within normal range. His psychiatric examination revealed that he was wide-awake and that his orientation and cooperation were good. Psychomotor activity was normal. His mood was euthymic and affect was normal. Speaking speed and quantity were normal. Their associations were smooth, delusions and hallucinations were not detected. Low dose antidepressant was started to the patient. The patient's follow-up still continues. Frigophobia is considered under the heading of an anxiety disorder related to culture. The common clinical presentation is patients who are suffering from cold extremities, and then, with the onset of fear, covering themselves in layers of clothing, applying emollients, and staying near an fire in an effort to ward off the cold. They avoided foods considered to be "cool" and bathed only in the heat of the afternoon sun. Frigophobia is a rare type of phobia, defined as fear of cold or cold things. Management consists primarily of disease training, assurance and desensitization by exposure to cold stimulants, and short-term use of anxiolytic drugs when necessary.

KEYWORDS
Anxiety disorders; specific phobias; frigophobia; treatment of phobias Abstract:0234 Long-Acting Methylphenidate Treatment in an Adolescent Girl with ADHD and Primary Enuresis: A Case Report Melike Kevser Gül, Neslihan Taştepe, Esra Demirci and Sevgi Özmen Department of Child and Adolescent Psychiatry, Erciyes University, Kayseri, Turkey E-mail address: melikegul46@hotmail.com ABSTRACT Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder characterized, by a persistent and impairing pattern of inattention and/or hyperactivity/ impulsivity. Enuresis is a pathological state associated with the lack of a developed skill in controlling the urinary bladder, resulting in repeated episodes of involuntary micturition during sleep or waking. Enuresis is a common comorbid disorder in children with ADHD. The rate of enuresis in children with ADHD has been reported as about 30%. In this report, we present an adolescent girl with ADHD and primary enuresis that treated with long acting methylphenidate. A 13-year-old girl was referred to the outpatient clinic by her family with nocturnal bedwetting every night and daytime urinary incontinence. She had same symptoms during 8 years. She also had forgetfulness, difficulty listening and easily distracted. She was experiencing severe problems during making homework and listening classes. Both KEYWORDS Attention-deficit/ hyperactivity disorder; bedwetting; imipramine; long-acting methylphenidate; urination; primary enuresis the clinical interview and the parent and teacher reports were suggestive of an ADHD diagnosis. Until now, there wasn't any improvement with conditioning therapy and imipramine 50 mg/ day. We oriented the patient to nephrology and urology departments to detection organic etiology but the results had evaluated normally. Her condition was diagnosed ADHD and primary enuresis. For the treatment long acting methylphenidate drug 10 mg/day was chosen and two weeks later dose was increased to 20 mg/day. She had nocturnal bedwetting only once and no daytime wetting. The ADHD symptoms were decreased during this time. Our case supports the positive scientific findings about the association long acting methylphenidate and the treatment of ADHD with primary enuresıs. There are many hypotheses for to explanation of the effects of this medication in the treatment of enuresis and ADHD. But the relationship between the treatment of both these disorders has not been understood clearly yet. Abstract:0289 Attention-Deficit/Hyperactivity Disorder Due to Corpus Callosum Agenesis: A Case Report grade of elementary school, was treated with 10 mg methylphenidate daily regarding additional attention-deficit/hyperactivity disorder diagnosis. A few days later, she stated that she was seeing a lot of black images around her that were ambiguous. These images were evaluated as visual hallucinations and hallucinations passed immediately after the drug discontinuation. Subsequently, 18 mg of atomoxetine daily was started for the treatment of ADHD and 25 mg daily dose was reached after 10 days. Shortly after the atomoxetine dose was increased, the child started to shout that she heard some voices and her family reported that she talking and shouting to herself. These symptoms were considered as auditory hallucination and atomoxetine was also cut off. It is known that there are hallucinations at toxic doses and parenteral methylphenidate administration. There are also limited number of case reports reporting hallucinations, with the use of atomoxetine in therapeutic doses. Clinicians should be aware of the rare side effects of methylphenidate and atomoxetine, such as hallucinations, and should be more cautious when using medication in patients with developmental disorders who reported side effects before. Family history of psychosis, familial drug side effects such as hallucinations, and specific neurological tendencies of children diagnosed with social communication disorders should be considered carefully. Abstract:0078 Amitriptyline Abuse in a Patient with History of Alcohol Dependence Tricyclic antidepressant used to treat depression, anxiety, chronic neuropathic pain, fibromyalgia and insomnia. Amitriptyline is a tricyclic antidepressant which blocks norepinephrine and serotonin transporters and inhibits their neuronal uptake. Anticholinergic drugs have euphoric side effects. So they have higher risk for abuse these drugs. In this report we presented case of amitriptyline abuse in a patient with a history of alcohol dependence. A 47 year-old male patient, married, graduated from hıgh school. The patient has gone to the emergency service with his wife because of using 50 tablet of amitriptyline which is 25 mg. He has complained difficulty in speech, agitation, auditory and visual hallucinations, and distractibility. He consulted with psychiatry. The patient started to drinking alcohol with one beer and he has drunk every day since 20 year. He has been treated at alcohol and substance addiction treatment center. When he did not drink alcohol some symptoms appeared which were discomfort, insomnia, shaking hands, so he started to use drugs and bought amitriptyline 25 mg tablet. Day by day he potentiate amitriptyline and he get drugged 25 tablets in one day. When he used amitriptyline he feels good if he did not used drugs irritation and distractibility symptoms are increased. Bupropion 150 mg/day and risperidone 2 mg/day ordered to patient. During 3 months; the patient came to hospital regularly for control examination and he did not abuse amitriptyline. Antidepressant drugs do not cause addiction but some kinds of antidepressant drugs abused in literature. In this case report; we try to explain the patient abuse amitriptyline because of euphoria effects that has alcohol depended history. When the patient who misused amitriptyline apply to emergency service, the doctor must be aware of about misusing amitriptyline because of euphoria effects. These drug overdoses cause serious side effects and using them with alcohol increased toxicity risk.

KEYWORDS
Amitriptyline abuse; alcohol dependence; side effects ABSTRACT Isaacs' Syndrome (IS) is a peripheral motor nerve continuous hyper-excitability disorder manifesting with progressive muscle stiffness, involuntary continuous muscle twitching, muscle pain and cramping, sweating and decreased reflexes. Autoantibodies against voltagegated potassium channels block the activity of the channels and lead to nerve hyperexcitability with repetitive peripheral nerve discharges. Besides carbamazepine, phenytoin and gabapentin; psychotropic drugs such as dronabinol, antidepressants and benzodiazepines are also offered in the current literature for symptomatic relief in IS. We report a treatment-noncompliant IS patient with both synthetic cannabinoid and opioid use disorders with discussing possible medication effects of these substances on IS symptomatology. A 31 year-old male patient hospitalized due to his polysubstance use with his homicidal thoughts and behaviors without any psychotic symptom. He was diagnosed with IS, after spontaneous, continuous, visible muscle twitching at his 16. The diagnosis was confirmed with the electrophysiological studies and the presence of serum voltage-gated potassium channel autoantibodies. He was not adherent to the prescribed carbamazepine treatment and started to use psychoactive substances with opioids 10 years ago and continued using cannabinoids -including synthetic form-. He stated diminished complaints of muscle pain and spasticity with the use of cannabinoids and opioids. Carbamazepine 200 mg/daily was initiated and potentiated to 400 mg in order to treat both IS and impulsive substance use. Besides sodium channel blocking agents, recently, clinical improvement with the cannabinoid dronabinol was shown in IS, probably by its activator role on potassium channels and immunomodulatory effects through CB1 and CB2 receptors. It is also assumed that combination of cannabinoids and opioid analgesics exerts synergistic nociceptive effects. Substance use may provide antispastic and analgesic impacts in IS. Further studies would aid to reveal therapeutic mechanisms of psychoactive molecules in the management of IS, coherent with the current report. Synthetic cannabinoid receptor agonists are becoming increasingly popular as an abused agent. There is very little literature detailing the presentations of individuals who use synthetic cannabinoids. We present a case with loss of consciousness due to synthetic cannabinoid intoxication. A 25 year-old patient was brought to the emergency service after reportedly having state of stupor, tachycardia and fever for a week. His mother stated that he had been using this substance for six months and he had a history of cocaine, heroin and alcohol abuse for ten years. The physical examination showed that he would hold his arm in the abducted position placed by the examiner, then would slowly lower it. He had muscle rigidity in upper extremities. Neurological examination revealed hyperreflexia and dilated pupils. The electrocardiogram, hemogram, brain CT, and routine laboratory tests were within normal limits. EEG patterns were associated with encephalopathy. The urine toxicology screen for drugs of abuse, including THC metabolites, cocaine and heroin were positive. Patient received supportive treatment and he gained consciousness four days after admission to emergency service. He stated that he intentionally used synthetic cannabinoid, heroin and cocaine simultaneously in order to commit suicide. The clinical presentation of synthetic cannabinoid abuse consists of altered mental status, sinus tachycardia, seizures, central nervous system depression, anxiety, hallucinations. Most of these symptoms get better approximately after two to four hours. In our case patient recovered four days after the admission of multiple substance use. In conclusion, if patients have history of substance abuse, physicians should consider synthetic cannabinoid intoxication.

Intoxication; suicide; synthetic cannabinoid
Anticholinergic agents have been reported to be abused since 1980s. Abuse of those agents among adolescents has received relatively little attention compared to adults. Oxybutynin has relatively weaker anti-cholinergic effects which led to the view that it has lower potential for abuse. The patient was a seventeen year-old adolescent male who was brought to our department with complaints of "weight loss, change in behaviors and mydriasis". Upon questioning it was learned that he had been using at least 50 mg/day of oxybutynin without tolerance or withdrawal symptoms. The abuse had a waxing and waning pattern and coincided with interpersonal stressors. After he had started abusing oxybutynin his sleep and appetite were reduced and he lost 17 kg of weight within the last 10 months. The developmental history was notable for symptoms of hyperactivity, impulsivity and inattention prior to the onset of abuse. Mental status examination revealed reduced grooming, depressed mood with anxious affect. Sleep and appetite were reduced. Psychometric examinations with Beck Depression Inventory and Screen for Childhood Anxiety and Related Disorders revealed scores of 19 (moderate depressive symptoms) and 36 (anxiety symptoms above threshold); respectively. In accordance with the DSM-5 criteria he was diagnosed with other (or unknown) substance use disorder (oxybutynin), ADHD (Inattentive presentation). The depressive and anxious symptoms were judged to be secondary to oxybutynin abuse. He was started on atomoxetine 25 mg/day and quetiapine 25 mg/day and atomoxetine was gradually titrated to 60 mg/day. Oxybutynin abuse remitted within 4 weeks and both the patient and his parents reported improvement in academic and interpersonal domains as well as depressive and anxious symptoms. Clinicians should be aware of the abuse potential of oxybutynin especially by adolescents with unrecognized/ untreated ADHD and disruptive behavior disorders. Atomoxetine may be a viable choice for treatment of ADHD in those patients. Pregabalin is a new generation antiepileptic drug that exerts its effects by decreasing the release of neurotransmitters, such as glutamate, noradrenaline, and substance P. There have been studies conducted in recent years demonstrating the effectiveness of pregabalin could be beneficial in the treatment of drug and alcohol withdrawal. However, there have also been cases in which pregabalin dependence developed. The present case describes a male patient developed withdrawal symptoms following pregabalin abuse. The patient is a 26 year-old, married man who started on pregabalin in order to discontinue buprenorphine use than abused it and exhibited withdrawal symptoms when not using it. The patient reported a history of cannabis abuse and heroin dependence but had been abstinent from heroin since he was released from prison 1 year ago. He had been using this drug irregularly on his own. Than his pregabalin use became regular and he finally increased the dosage to 20 capsules of 300 mg/day. After admission to our inpatient clinic, while the intake of pregabalin was decreased, withdrawal symptoms such as insomnia, psychomotor agitation, tremor, irritability, heartburn, nervousness, anxiety and depressive symptoms were observed. The patient's urine drug test was positive for cannabis. The patient was diagnosed with substance abuse disorder, sedative, hypnotic or anxiolytic use disorder. As supportive medication diazepam was initiated. Paroxetine and risperidone was administered. We conclude that pregabalin displays a potential for abuse. The reward effect of pregabalin has been implicated in its potential for abuse. Although pregabalin is a promising drug for various psychiatric disorders, it should be used carefully in patients with a history of substance abuse. A woman with Marfan syndrome (MFS) will be discussed who also suffers from multiple substance use disorder and post-traumatic stress disorder. MFS is one of the most common inherited disorders of connective tissue with ocular, cardiovascular and musculoskeletal abnormalities. MFS displays a number of abnormalities of the thoracic and abdominal aorta, ranging from abnormal aortic stiffness to aortic aneurysm and dissection. The case is delivered to a psychiatry clinic after being raped and committing suicide by taking excessive doses of drugs. First, she got the diagnosis of post-traumatic stress disorder and multiple substance use disorder. She began to abuse cocaine, cannabis, ecstasy after the traumatic event. In addition clinicians noticed a disproportionate length of the upper limbs, advanced myopia and lens subluxation in both eyes of her. Transthoracic ECO presented aortic root dilatation and aortic insufficiency with mitral valve prolapses, so she had also the preliminary diagnosis of MFS. After she left the hospital she continued to abuse methamphetamine and cocaine until she was arrested. Among women with PTSD the most common comorbid disorders are depression or anxiety, followed by substance abuse disorder. PTSD may follow substance abuse, which may also mediate developing PTSD. It may also follow PTSD by serving as a "self-medication". Methamphetamine abuse is associated with structural and functional changes of hearts, leading to aortic dissection, cardiac hypertrophy, fibrosis, dilated cardiomyopathy, congestive heart failure and sudden death as the cocaine abuse abuse which is also associated with acute cardiovascular illness, including myocardial ischemia and infarction, aortic dissection and rupture, arrhythmias, myocarditis and vasculitis. We want to draw attention to the increased risk of cardiovascular complications by a women case with MFS who abuse substances like methamphetamine and cocaine.  [1-(l-phenylcyclohexyl) piperidine] (PCP) is a hallucinogenic drug that is capable of inducing psychosis. Phencyclidine (PCP) has many names -peace pills, angel dust, angel's mist, goon, hog, 2Ts etc.-and may be found as dilute powder alone or mixed with lysergide, amphetamine, cocaine, tetrahydrocannabinol, or mescaline. PCP functions primarily as an Nmethyl-D-aspartate (NMDA) receptor antagonist in the central nervous system, thus inhibiting activity at the NDMA sites. Severe NMDA receptor hypofunction can elicit clinical symptoms similar to psychotic disorders. Also, most common side effects of PCP are nystagmus, hypertension and hyperthermia. We reported here, a case of PCP-induced psychosis and successfully treated with quetiapine are described. A 34 year-old woman, single, university graduate, civil servant presents to our psychiatry department with complaints of persecution and reference delusions, restlessness, insomnia, auditory hallucinations particularly in the evening. The patient went to the herbal medicine shop because of the fatigue complaint and bought a different herbal mixture. However, she had psychiatric complaints two days later after receiving herbal mixture. There is no family history of mental illness. Physical examination is virtually unremarkable. At the admission, PCP was detected as a result of urine screening tests. After then, she was diagnosed to psychosis due to the substance abuse and started quetiapine 600 mg/day. Two weeks after treatment started, her symptoms completely improved. Hallucinogens include mescaline, phencyclidine and scopolamine, benztropine, trihexyphenidyl and biperiden. Among these, the most commonly abused substance is phencyclidine. Phencyclidine-induced psychosis lasts from 1 to 30 days with average 4 to 5 days. However, phencyclidine can be detected in screening tests up to 8 days. As a result, we present here a case using phencyclidine as involuntarily, and also eventually developing psychosis. At the end, all physicians should be aware of this substance when treating acute onset psychosis without any psychiatric history. Frontotemporal lobar degeneration (FTLD) is a heterogenic neurodegenerative disease which is seen with behavior changes or progressive language disorders. FTLD may present with insidious personality changes, impairment of interpersonal relationships and affectivity, depression, apathy, anxiety, euphoria, irritability. In this case report, we aim to draw attention to psychiatric symptoms of FTLD. A 53 year-old, graduated from university, married, retired, male patient applied with complications of unhappiness, unwillingness, future anxiety, reticence, dullness, withdrawal, indifference to usual hobbies. He also complained of sleeplessness, loss of appetite, loss of weight, heat burden during daytime, tremor in the hands and dull face. The patient was internalized. Psychological examination of the patients revealed; less caring of himself, slow and less speaking, obtuse affectivity, dysphoric mood; spontaneous attention was defected, immediate memory and cognitive functions were normal. Association of ideas was slow, thought context was poor. Neurological examination revealed decreasing of face mimics and jests and walking with small steps. MRI (Magnetic Resonance Imaging) detected bilateral atrophy in frontotemporal region. Patient was prediagnosed with FTLD by clinical signs and MRI report and he was consulted to neurology department. Treatment was settled as levodopa 250 mg/day and escitalopram 10 mg/day. Starting from the second day of treatment, movement of the patients fastened; dull face, sleeplessness and loss of appetite were resolved. Patient was externalized with the suggestions of neurology and geropsychiatry consultations. Even psychiatric signs of FLTD are seen often, studies evaluating the psychiatric disturbance prevalence are limited. Structural and functional imaging is supportive to behavioral variants of FTLD but psychiatric and behavioral signs without cognitive disturbance can be seen in prodromal period of KEYWORDS Frontotemporal lobar degeneration; depression; psychiatric symptoms FLTD. In this case presentation we thought of FTLD diagnosis in a subject presented with depression signs. In this context, we underline that psychological signs can cause to overlook a FLTD case. Abstract:0205 Abolition of Guardianship After Treatment of Neurosyphilis: A Case Report Gülşah Güçlü Çelme a , Mehmet Hamid Boztaş a and Fatma Sırmatel b a Department of Psychiatry, Abant İzzet Baysal University, Bolu, Turkey; b Department of Infectious Diseases, Abant İzzet Baysal University, Bolu, Turkey E-mail address: gulsahcelme@gmail.com ABSTRACT Neurosyphilis is caused by infection of the central nervous system of Treponema pallidum. Among its clinical presentations are meningovascular syphilis, tabes dorsalis and dementia paralytica and dementia is seen in more than 60% of psychiatric patients with neurosyphilis. In this case report, we wanted to present the patient who had taken under custody with dementia to be diagnosed with neurosyphilis, improvement of cognitive functions after the treatment and the abolition of guardianship. The patient was a 77 year-old woman. She presented to our outpatient clinic after she was referred by the health board for removal of her guardianship. In the patient history, in 2007, Trazodone was given with a diagnosis of "Sleep Disorder". In 2008, Donepezil and acetylsalicylic acid were began to the patient who consulted to neurology with diagnosis of "Dementia" after dysmnesia and loss of balance. Forgetting her children, leaving home unaware, getting lost, not to pay attention to cleanliness, eating with pouring foods, taking shower with help and becoming introverted were added over time. A guardian was appointed to her with the diagnosis of "Dementia" in petitioning for her custody in 2014. In 2015, she hospitalized with a diagnosis of neurosyphilis and treated with crystallized penicillin. Dysmnesia, concentration impairment, weakening of discernment with dementia also could be seen in prodromal symptoms and also cerebrovascular pathologies may occur. The patient's waist-leg pain, loss of balance and difficulty in walking provided laboratory tests with thinking the wide range of organic pathology and neurosyphilis is diagnosed. Penicillin has been the mainstay of treatment of neurosyphilis for decades. There is no gold standard for the diagnosis of neurosyphilis, but early diagnosis and treatment is important because it is thought to be a reversible form of dementia.  Creutzfeldt-Jacob Disease (CJD) is a rare, prion-associated neurodegenerative disorder that characterized by rapidly progressive dementia and neuropsychiatric symptoms. Neuropsychiatric symptoms are prominently but infrequently manifest in the symptomatology of CJD. Conditions like confusion, agitation, mood and behavioral disturbances, psychosis or depression are reported in concurrence. This report aimed to present a case of sporadic CJD with psychomotor agitation that required hospitalization. A 62-year-old female patient presented with behavioral changes. She had uncontrolled behavior and forgetfulness for approximately one year. She has been coming to follow ups about her dementia. She had brought to emergency room by her relatives for increase in her uncontrolled behaviors and loss of communication for one and a half month. Magnetic KEYWORDS Agitation; antipsychotics; Creutzfeldt-Jakob Disease; dementia resonance imaging (MRI) showed bilateral diffuse cortical diffusion restriction, bilateral increased signal of putamen and caudate. Electroencephalogram showed generalized periodic sharp wave complexes occurring every 1-2 seconds. Preliminary diagnosis of CJD was made and the patient was admitted to inpatient clinics for further evaluation. No myoclonus was seen while the patient was in clinic. The patient was agitated and low-dose risperidone was initiated. She was discharged after improvement in her behavioral disturbance with the neuroleptic treatment. Rapidly progressive cognitive deterioration is the main neuropsychiatric symptom of CJD. Behavioral disturbances such as agitation and aggression were frequently described in dementia with the presence of psychotic features, however, non-psychotic psychomotor disinhibition disturbances were also recognized in different dementia syndromes. Agitation and repetitive vocalizations were commonly considered as startle reactions in CJD and often coexisted with stimulus-sensitive myoclonus, particularly in the latter stages of the disease. Structural and functional deficits in the specific brain regions such as anterior cingulate were blamed for agitated behavior. Behavioral disturbances reduce life quality in CJD and appropriate management of the symptoms would lessen the burden on caregivers and health-care professionals.

Clinical Manifestation of Delusional Disorder in a Frontotemporal Dementia Case
Gülşen Kartalcı a , Ebru Yücel b and Şükrü Kartalcı a a Department of Psychiatry, Inonu University, Malatya, Turkey; b Department of Neurology, Inonu University, Malatya, Turkey E-mail address: drgulsen44@gmail.com ABSTRACT Frontotemporal dementia (FD) is a neurodegenerative disease characterized by progressive deficits in behavior, executive functions and speech. It commonly occurs in patients younger than 65 years. The disease can be confused with psychiatric disorders because of age of onset and distinctive behavioral features. This case involves the atypical presentation of a FD patient who presents with some delusions. A 59 year-old female patient who had a 2 years history of delusional disorder and with no known additional past psychiatric history, presented to our clinic with nervousness, decreased sociability, paranoid delusions, abusive speech, and anger. The patient also had an occasional complaint of forgetfulness. The two sisters of the patient had similar complaints at the same age, and they died at the age of 57 and 55. In the mental status examination; she was conscious, her speech and movement were slow, voice tone was low, thought content was poor and mostly composed of paranoid delusions, affection was limited, facial expressions decreased and she had no insight. Minor memory defects were detected. Her physical and neurological examination was normal. Standardized Mini Mental Test Score was 20/30. Cranial MR imaging revealed atrophy in the bilateral frontotemporal regions, secondary dilatation in central CSF fields (figure 1). 3 variants of FD have been described; frontal lobe, semantic dementia and progressive arrest aphasia. In our case, the clinical appearance was compatible with frontal lobe variant. This patient was previously followed up with the diagnosis of delusional disorder. The presence of cognitive impairments, imaging findings, and the presence of a similar disease history in her two sisters support the diagnosis of FD. In patients with atypical psychotic symptoms, inappropriate social behavior, and personality changes in late adulthood; performance of detailed neuropsychological evaluation and cranial imaging could be useful in differential diagnosis. Parkinson's disease can be defined as a neuropsychiatric disease which is basically a dismotility disease, often with affective cognitive and psychotic disorder. Some of Parkinson's disease symptoms are similar to depression symptoms and sometimes intertwined. The 30-40% of patients with PD have significant depressive symptoms. In this paper a depressive woman who presented Parkinson's disease will be discussed. A 46-years old woman followed for depressive symptoms such as low mood, altered appetite, loss of libido and psychomotor retardation for a year from our outpatient psychiatry clinic. She got duloxetine 60 mg/day for 4 months. During psychiatric follow up she complained from hoarseness, dysphagia, slowness of movement and thinking. Ear, Nose, and Throat (ENT) specialist's physical exams were within normal limits. Later bradykinesia, bradymimi, difficulty at walking added to her clinical appearance. After the evaluation of neurologist she diagnosed as Parkinson's disease. Cerebral tomography and magnetic resonance imaging were at normal limits. Although it typically develops after the age of 65, about 15% of people with the condition develop young-onset Parkinson disease before reaching age 50. Sometimes Parkinson's symptoms can start like psychiatric disease. So clinicians must be careful to neurologic diseases at young psychiatric population.  In older patients, depression and dementia may appear with different symptomatology. Particularly somatic complaints, which are unexplained, must be carefully examined in terms of an underlying physical and psychiatric disorders. The patient was a 73 year-old woman. Her relatives brought her to the psychiatry outpatient clinic with anal pain and related agitation. She was suffering from anal pain since 2004 when she had a head injury with a tile. For the days after that she had complaints of low mood, anhedonia, irritability, loss of appetite and insomnia. She used quetiapine and diazepam for those complaints and there was no response. She retired. Since 2004 she had been using sertraline, venlafaxine, fluoxetine, mirtazapine, moclobemide and olanzapine in separated times. In addition to the initial symptoms, she suffered from lack of self-care, social withdrawal, complaints of continuous anal pain, increased eating to prevent of the harm of the drugs to her body in 2016. She was admitted in our inpatient unit with those symptoms and after the first examination she was hospitalized due to agitation because of anal pain. She was indifference, apathetic and do confabulate instead of being depressed or unwilling. She had medically unexplained somatic complaints as anal pain or abdominal pain. The initiation of sleep disturbed with agitation. MMSE score was 16. Generalized atrophy and sulcal widening were detected in her Brain MRI. When asked to family to rethink about memory and cognitive symptoms, family realized the hints. In this case we want to remind some points in the elderly: 1) To screen neurocognitive functions regularly of patients, who are older than 65, is crucial. 2) Depression could be the initial scene of dementia. 3) Somatic signs must be evaluated in detail in psychiatric and physical manner. Dementia is a neurodegenerative disorder with the progressive memory decline. Dementia with Lewy bodies (DLB) is the second most common type of dementia after the Alzheimer's disease. Main features of the DLB are fluctuating cognitive symptoms, visual hallucinations and spontaneous parkinsonism. The patient was a 54 year-old married man, farmer, admitted to our psychiatry inpatient department with depressive mood, shouting during the sleep, attention disorder, anhedonia, persecutory delusions, and progressive memory decline. Also, on his neurological examination bradykinesia, rigidity, and tremor were detected. Cognitive examination showing impaired concentration, impaired verbal fluency, and impaired (executive) frontal system functions. He was diagnosed with depressive disorder and has been treated with escitalopram 20 mg/day and olanzapine 10 mg/day, over the past 12 months without much benefit. Therefore, his treatment was stopped. After then, we ordered vortioxetine 20 mg/day and aripiprazole 30 mg/day or the treatment of complaints in this patient. Initially, it was quite helpful for depression and several cognitive symptoms related with dementia. The diagnoses were revised to dementia with Lewy bodies with depressive disorder. Most causes of dementia such as Alzheimer's disease, vascular dementia, Wilson's disease, Parkinson's disease and neuroacanthocytosis also need to be carefully considered. It's known that, DLB which constituted to 20% of dementia patients is the second most common type of dementia. Main features of the DLB are fluctuating cognitive symptoms, visual hallucinations and parkinsonism like as the EPS. Other common symptoms including the fainting, recurrent falls, transient loss of consciousness or delirium, sleep disturbances, depression, anxiety symptoms, delirium, and antipsychotic hypersensitivity. Initially, depressive symptoms of the patients lightly improved. Unfortunately, this improvement did not continue, in the following days. Additionally, severe EPS were occurred. Our obese patient had sleep apnea syndrome. For this reason, many symptoms of sleep behavior disorder can be recognized late. It should be remembered that, cognitive function should be carefully assessed and will uncover organic disorders or the pseudodementia of depression. As a result, The patient's cognitive and functional status significantly improved. Our aim was to share these beneficial observations for similar patients. Arachnoid cysts are cerebrospinal fluid containing, usually with no clinical signs, determined by radiological examinations accidentally and space-occupying lesions. This article presents the treatment process of the arachnoid cyst and the disease, which was determined as the first episode of psychosis with 3 years duration of psychosis without treatment. A 17 year-old, male patient, first complaints started in the way of frequent hand washing, touching with fear of getting polluted by objects. Three years ago, thinking of being followed, skepticism, auditory hallucination, visual hallucination, carelessness, unhappiness, forgetfulness were added. Neuroimaging revealed an arachnoid cyst in the frontal region. The patient's treatment whose family support is inadequate and who has no insight was set as risperidone depot. After 1.5 months there was a decline in psychotic symptoms. There are many studies showing the relationship between psychotic findings and brain abnormalities. In our case, arachnoid cysts was seen in the size of 20×13 mm in the left frontal region. The other characteristic of the case is that despite the positive psychotic statement that has been going on for 3 years, it has not been treated. The duration of psychosis without treatment in psychotic episodes can be 1 to 2 years. This period can be even longer due to the deterioration of the socio-cultural environment and functioning of the person. The application for treatment is delayed due to the low sociocultural level in our case. It has been reported that atypical antipsychotics are a good option for psychotic disorders due to organic causes and short-psychotic disorder related to arachnoid cyst responding to risperidone treatment. Although the relationship between brain structural abnormalities and psychiatric manifestations cannot be clearly elucidated, first episode psychosis, atypical psychotic features, impaired cognitive abilities should lead us to investigate the organic causes of psychosis. . We report first time a case of treatment resistant schizoaffective disorder in a 23-year-old man with MSM which caused distractibility and atypical symptoms and was noticed by chance before electroconvulsive therapy (ECT) protocol. Our case is a 23-year-old single, male, patient who meets the DSM 5 criteria for schizoaffective disorder (bipolar type). He presented with paranoid thoughts, affective flattening, highly disorganized speech and behavior for the past 2 months and manic and depressive episodes in his history. The neurological exam did not reveal any changes, the Mini-Mental State Examination, EEG and biochemical results were evaluated as normal. The patient was admitted to our clinic because his symptoms were resistant to the medications, ECT was planned for. A giant arachnoid cyst was observed in the brain MR scans of the patient done after the pre-ECT protocol (Figure 1a-1b). The concurrence of MSM and schizoaffective disorder as detected by coincidence prior to ECT, or the contribution of cerebellum pathologies to the formation of psychiatric disorders or their effect on the clinical manifestation have been presented in this case report. Previously the association between MSM and psychiatric diseases such as psychosis mania, obsessivecompulsive disorder with schizophrenia and catatonia was presented as case reports, but the association between psychiatric symptoms and MSM still remains elusive because of the scarcity of sufficient data. It will contribute to the literature in terms of clarifying the relationships between organic brain lesions and psychiatric portraits.  Interaction of environmental, biological, and psychological factors is important in the development of trichotillomania and skin tract. While some clinicians assume that trauma and posttraumatic stress disorder may be related to the etiological basis of trichotillomania, very few research has examined this hypothesis up to date. A 20-year-old,single,graduated from high school, male applied to emergency psychiatric clinic with intense anxiety due to continuous hand washing, spending long time in shower and checking lower part of the trouser leg constantly. Patient was wearing shorts even in unfavorable weather because he constantly checked his lower part of trouser leg. During the examination, it was observed rarity of both lateral of eyebrows and in hairs on lower region of jaw. Patient expressed decrease in anxiety level after voice he heard during breakup of his hair. It was felt the need to deepen anamnesis to learn the presence of triggering stressors since all complaints had begun to increase for last 1 year. During interview, it was learned that about1year ago the patient lost his best friend in traffic accident. When he visited his friend, learned that his friend had lost his life with internal bleeding shortly after he was removed to the hospital. Patient expressed that since he had seen fragmented dead body of his friend, had never forgot that day and his friend was always in front of his eyes. It was learned that patient had hand tremors and sudden reactions even when he hear least noise. He said that he was hesitant to apply to hospital since it reminded him of event about his friend's accident and so he had come psychiatry emergency in place of outpatient clinic. Fluoxetine20 mg/day, risperidone 0.5 mg/day were prescribed for ruminations and anxiety. Studies suggest that prevalence of PTSD in trichotillomania may be higher than in general population and that more different type trauma story is related to duration of hair pulling period and location of bald area. The relationship between childhood trauma and dissociation is shown both retrospectively and prospectively. Amnesia and memory problems, hallucinations, and secondary psychiatric symptoms are common. The use of propranolol for the prevention and treatment of posttraumatic stress disorder and dissociative symptoms and the elimination of traumatic memories is reported. The effectiveness is controversial. Here we report symptoms of amnesia and confabulation following the use of propranolol in an adolescent who has dissociative disorder. A 13 year-old female adolescent, has normal developmental history. Six months ago, she had a car accident. There was no head trauma. Post-accident examination and brain imaging were reported as normal. After one month from the accident her psychiatric symptoms had started such as fear, anxiety about the accident, visual and auditory hallucinations, illusion, self-harming. The hallucinations are predominantly hypnagogic and hypnopompic. One month after the accident, fluoxetine and propranolol were started by an outpatient clinic. After medication treatment amnesia is occurred. She told her doctor she was exposed to sexual abuse by her brother. She was taken from the family by the social services. At first check in our clinic, she was confused about sexual abuse. She said she had rape images. She also said she was sexually abused by a boy when she was five years old. It was learned the information was not correct. The patient was diagnosed with dissociative disorder and depressive disorder. Propranolol was discontinued. Mirtazapine and risperidone were started. Amnesia, hallucinations and illusions were KEYWORDS Propranolol; dissociative disorder; amnesia; confabulation; adolescent; childhood trauma completely lost after two months. There was no images about sexual abuse. Risperidone was discontinued. Social services planned the adolescent girl to be sent to her family. In this case, we report that the use of propranolol may increase dissociative symptoms so that the propranolol use may not be appropriate in patients with dissociative disorder.

Abstract:0114
Postpartum Onset Skin-Picking Disorder Exacerbates with a Sexual Trauma: A Case Report Mustafa Kurt a , Çağdaş Öykü Memiş a , Bilge Doğan a , Doğa Sevinçok b and Levent Sevinçok a a Department of Psychiatry, Adnan Menderes University, Aydin, Turkey; b Department of Child and Adolescent Psychiatry, Dr. Behcet Uz Child Diseases and Surgery Research and Training Hospital, Izmir, Turkey E-mail address: mustafakurt61@outlook.com ABSTRACT Skin picking disorder (SPD), is characterized by repetitive and compulsive picking of skin, leading to tissue damage. SPD has been classified under obsessive-compulsive and related disorders title in DSM-5. Among young women, history of sexual abuse and rape in childhood were found to be predictors of SPD. Strong evidence suggests that women are at risk for the development of psychiatric disorders in the postpartum period. To our knowledge, there has been no report on postpartum onset SPD to date. We here report a case of SPD presented initially a postpartum onset and exacerbated following a sexual trauma long years after her delivery. A 43 year-old married female presented to psychiatry department with the complaints of excessive picking of skin of the fingers, forearms, abdomen and legs which occurred within the first month of her first delivery 12 years ago. Her SP exacerbated after a sexual assault three years ago. She also developed some posttraumatic symptoms such as flashbacks, hyperarousal, hypervigilance, nightmares and re-experiencing traumatic event. On the basis of current psychiatric examination, she received the diagnoses of SPD, PTSD, and major depression. She had no dermatological or infectious etiologies of the skin picking. She had not previously used any substance or other medications which might cause skin picking behavior. The occurrence of SPD in the postpartum period may be linked to extreme fluctuations in reproductive hormones. In our case, to give birth and experiencing a sexual trauma might have led to emotional and relational vulnerabilities. Developing SP symptoms might help her to cope with intrusive thoughts related to trauma. Future prospective research is necessary to clarify prevalence of SPD or other OCD-related or impulsive disorders during postpartum period. Particularly, it is noteworthy to examine the possible relationship between SPD and aggressive obsessions in future studies.  and pharmacotherapy-with selective serotonin reuptake inhibitors (SSRIs) and clomipramineare suggested treatment options for children and adolescents with this disorder. However, many patients do not respond to these treatment strategies. The augmentation of SSRIs or clomipramine with aripiprazole is reported to be an effective strategy for adults with treatment-refractor OCD. Nevertheless, studies on its use as monotherapy are limited in treating OCD in both children and adults. A 13 year-old girl was referred to our clinic with complaints of irritability and aggressive behavioral problems. She described being overwhelmed by obsessions that she could harm or kill her father and sister, and could have an incestuous relationship with them. In addition to frequently seeking reassurance and confirmation from her mother with regards to these issues, she took measure to prevent damage to her father and sister. Aripiprazole medication was started at 2.5 mg/day. The Childhood Yale-Brown Obsessive Compulsive Scale (CY-BOCS) and Clinical Global Impression-Severity Scale (CGI) were performed.CY-BOCS score was 26, and CGI score was 6 for OCD symptoms and 6 for aggressive symptoms in the initial assessment. At the first week of treatment, the aripiprazole dose was increased to 5 mg/day. CY-BOCS scale scores were 1and CGI scores decreased to 1 for OCD symptoms and 2 for aggressive symptoms in the eighth week of treatment. We present an adolescent patient has complaints of severe aggressive behaviors and moderate OCD symptoms. These symptoms disappeared following the administration of low dose aripiprazole monotherapy. Our case supports the notion that aripiprazole, which is mostly used for antipsychotic and anti-aggressive purposes in current practice, may be an option as monotherapy even at low doses in the treatment of children and adolescents with OCD due to both its effects on the dopaminergic system and serotonergic systems. The patients with Delusional Misidentification Syndromes (DMS) misidentify or reduplicates familiar individuals, objects, places or events. DMS have been rarely reported in patients with non-psychotic conditions. We here present an obsessive-compulsive disorder (OCD) case who exhibited a compulsion of misidentification. To our knowledge, this is the first case with OCD exhibiting a misidentification compulsion. A 33 year-old man was admitted in psychiatry ward suffering from substitution of some unfamiliar faces that seemed to be dangerous for his wife and children, with consecutively three different previously known person faces. Unless he did not substitute his face with these faces, he would not decrease his anxiety. His first obsessive-compulsive symptoms emerged at eight years-old with ordering/symmetry obsessions and compulsions. Five years later, he began to substitute the faces of subjects he thought as harmful, with three previously known people. He described a full remission with a treatment of fluoxetine, sertraline, and quetiapine for the next eight years. Two years ago, the compulsion of misidentification emerged as well as an exacerbation of ordering/symmetry obsessions and compulsions. His current score on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) was 38. His MRI scan, EEG and biochemical tests were normal. He was already started 75 mg/day of clomipramine, 100 mg/day of sertraline, 5 mg/day of aripiprazole, and 2 mg/day of haloperidol. Previously, it was reported that a woman with OCD had doubts about whether her husband, her parents, her cat, and even the city that she lived in had been replaced by identical-appearing duplicates. We here presented a case of OCD exhibiting compulsion of misidentification in order to expel and thus to control his harming and sexual obsessions. The association between forbidden thoughts and misidentification compulsions in our case might represent an example of an overlap between responsibility and threat in OCD patients.

Rukiye Ay
Malatya State Hospital, Malatya, Turkey E-mail address: rukiyeayy@gmail.com ABSTRACT Skin Picking Disorder includes skin lesions that are created by patients themselves. In this article we present a case of "skin picking disorder". A 42-year old female patient presented to the dermatology department due to an irregularly edged, occasionally crusted lesion in her palm. As a result of the examinations, she was referred to our polyclinic as a case with no dermatological cause. There was a constant scratching demand during the day. As a result of scratching, the wounds developed and she started to peel off the crust over the wounds repetitiously. When she tried to prevent herself, she would feel intense tension, irritability and when she picked the crusts, she would feel relief first, then guilt and regret. Her everyday work was hindered due to her being busy with picking. Complaints such as grief, crying, desire to be alone, insomnia have begun for the last one month due to not being able to stop herself and deteriorating relations with her social circle. There was no physical, mental illness in her medical record. She was diagnosed with "skin picking disorder" and "depressive disorder" according to DSM-5. Sertraline was started at 100 mg/day and add aripiprazole 5 mg/day. Her depressive symptoms disappeared completely at the next visit. She would be able to control herself even if there was a desire to pick. In DSM-5, skin picking disorder takes place in the category of 'obsessive-compulsive disorder and related disorders'. Clinical trials have reported that at least one axis 1 disorder is diagnosed in 57-100% of patients with skin picking disorder. It is a clinical picture that should be kept in mind since the risk of infection is high, that a psychiatric comorbidity usually accompanies and impairs the functionality of the person.

Gülser Karakoç, Ayşe Ender Altıntoprak and Hakan Coşkunol
Department of Psychiatry, Ege University School of Medicine, Izmir, Turkey E-mail address: gulser_karakoc@hotmail.com ABSTRACT Methamphetamine is a powerful, widely abused, addictive stimulant. The psychiatric effects of methamphetamine use are psychosis, suicide, craving, depression and obsessivecompulsive disorder (OCD). A 36 year-old man, with multiple-substance use disorder, presented to our clinic with a desire of quitting substance use. He was used cannabis, pregabaline, cocaine, alprazolam, alcohol, ecstasy before. Five years ago, he started methamphetamine via inhalation and he used it every day for five years. Three years ago, the patient was admitted to the addiction service with auditory and visual hallucinations, persecutory and reference delusions. Following the methamphetamine intoxication in August 2016, he was admitted to the addiction service with psychotic symptoms and selfdestructive behavior. He was discharged 1 month later and he did not use methamphetamine afterwards. For the last 4 months, the patient has significantly reduced the amount of substance and he has no psychotic symptoms. However, contamination and symmetry obsessions and cleaning and arranging objects compulsions have begun. He was admitted to the hospital in January 2017 and fluoxetine 20 mg/day, haloperidol 5 mg/day, quetiapine 800 mg/day, zonisamide 100 mg/day, bornaprine 8 mg/day treatment was started. Fluoxetine 40 mg/day and zonisamide 200 mg/day were increased in the follow-up. The patient's substance craving, obsessions and compulsions were diminished. The follow-up of the patient who is in partial remission continues in our clinic. Substanceinduced obsessive-compulsive disorder is considerably worse, and more difficult for the individual to control. Although substance-induced OCD is rare, the consequences can be severe. OCD is one of the psychiatric effects of methamphetamine use and abstinence. It is probable that treated OCD in methamphetamine users may relieve craving, and thus may prevent relapse. In this present, we report an adolescent diagnosed with treatment-resistant obsessivecompulsive disorder (OCD) who were treated with duloxetine. A 17 year-old girl came to our clinic with contamination obsessions, hand-washing compulsions, feeling dirty all the time. She believed if she hadn't washed her hands 15 times each day, she would have been ill. Her complaints began two years ago. She was followed in another clinic last year, and underwent 13 weeks of cognitive behavioral therapy and effective doses of appropriate medications prescribed including sertraline, fluoxetine, citalopram, clomipramine and aripiprazole, single or combined. She did not benefit from her prior treatment and stopped using medications. Her complaints worsened in the last three months and she referred to our clinic. She was diagnosed as OCD. Considering her prior treatment regimen, duloxetine 30 mg/day was prescribed and one month later its dose was increased to 60 mg/day carefully. After four weeks, there was little clinical response in her symptoms and there was no side effect. The duloxetine dose was increased to 90 mg/day. During the follow-up, she responded well to a dose of 90 mg/day. After six month of duloxetine treatment, there was significant improvement in OCD symptoms. She was tolerated duloxetine very well and there was no side effect. Duloxetine is a serotonin and norepinephrine reuptake inhibitor (SNRI). In this present, we report duloxetine markedly improved her OCD symptoms. The effect of serotonin blockade as well as noradrenergic blockade of duloxetine may be benefit on her symptoms. Several studies and case reports have shown efficacy of duloxetine in adults with OCD. To the best of our knowledge, our patient is the first report in the treatment KEYWORDS Adolescent; duloxetine; obsessive-compulsive disorder; treatment adolescent diagnosed with OCD. Duloxetine may be an alternative drug in adolescents study by Odlaug and colleagues, in 40% of patients with at least one first-degree relatives have a psychiatric disorder, especially depression and substance abuse. The case has also been shown in the literature that SSRIs are effective in studies for skin picking disorder treatment. Considering all this, the case supports the literature in many ways. Abstract Obsessive-compulsive disorder (OCD) in children and adolescents is characterized by intrusive thoughts and compulsions that typically cause distress and functional impairment. Guidelines for the treatment of OCD include Cognitive-Behavioral Therapy (CBT) as first line treatment option along with family counseling and psychoeducation. Selective serotonin Reuptake Inhibitors (SSRI) have long been used in the pharmacological treatment of OCD, with much success. Multidrug choices and augmentation strategies have only been proposed for cases that are resistant to treatment. The term "treatment-resistance" reflect persistent and severe continuum of symptoms even though efficient and suggested line of treatment options have been used with indicated dose ranges and time interval. This might reflect unsuccessful response to at least two SSRI use or use of one SSRI and clomipramine along with enough number of CBT sessions. Many drugs have been tried for augmentation, in the face of treatment-resistance. However, these mainly have been conducted with adults and studies that assess augmentation in children and adolescents have been scarce. Some of these have focused on aripiprazole as an option to be used for augmentation. This series comprises the clinical course and treatment process of six adolescents diagnosed with OCD from three different centers in Turkey. Due to different underlying reasons that were elaborately described within each case presentation, recommended treatment guidelines were in a way distorted, resulting in an earlier onset of low-dose add-on aripiprazole, in turn, causing relief in symptoms and clinical severity as well as functional impairment. We hope this case series shall make a contribution to relevant literature and studies designed to improve treatment options and guidelines. Obsessive-compulsive disorder (OCD) is a neuropsychiatric illness characterized by intrusive, repetitive thoughts and ritualistic behaviors. The obsessions or compulsions are timeconsuming and interfere significantly with the person's normal routine, occupational functioning, usual social activities, or relationships. Most people are diagnosed by about age 18-25. Some studies classify the OCD as "juvenile-onset" (<18 years), "adult-onset" (18-39 years), and "late-onset" (≥40 years)." We report a patient with late-onset OCD who had a cerebrovascular event (CVE) a month before the onset of the obsessive and compulsive symptoms. A 67 year-old female, who did not have any psychiatric complaints before, applied to the emergency service with anxiety, multiple suicide attempts, religious intrusive thoughts and she had compulsive behaviors as avoiding religious routines and repeat other's speeches which she had heard for the last 2 months. In medical history, it has been KEYWORDS Obsessive-compulsive disorder; cerebrovascular event; late-onset understood that she had right internal carotid artery aneurysm 3 months ago. And a stent was placed to her aforementioned artery as treatment. After hospitalization, there wasn't any reported pathology at cranial magnetic resonance imaging (MRI) and routine blood tests. In her examination she described hypnopompic visual hallucinations without any psychotic symptoms and intrusive religious thoughts. Alprazolam and sertraline were given for her obsessive-compulsive symptoms which presenting with anxiety. These symptoms were partially improved in the fourth week of the treatment. Although there is no objective sign on MRI imaging, late onset suggests that the cause of OCD should have been related with an organic pathology due to CVE. In literature, it is reported that late onset OCD especially after 50 years of age is generally related with organic etiopathogenesis. It is aimed to draw attention to the possible association between late onset OCD and organic etiology. It may be useful to investigate organic etiopathogenesis in late-onset OCD cases. Abstract:0443 Complex Childhood Trauma History in a Patient with Obsessive-Compulsive Disorder and Trichotillomania: A Case Report

Ilgaz Kınalı and Münevver Yıldırım Hacıoğlu
Bakırköy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul, Turkey E-mail address: ilgazkinali@hotmail.com ABSTRACT Child sexual abuse is an important subset of all sexual abuse and encompasses all the behaviors that adults do by fooling, convincing, tempting, enforcing, or enforcing the child's sexual satisfaction. The physical, emotional or sexual abuse that an individual is exposed to during his childhood affects his or her future experience and behavior. Compared to non-abusive individuals, abused individuals experience many psychopathological and physical problems. The reason for this is that traumatic events affect the functioning of the body, resulting in more vulnerable and vulnerable to the threats of the body and subsequent stress stimuli. Studies have shown that childhood trauma can have an important role in both neurotic excoriation and accompanying psychiatric problems. Emotional abuse and incest have been shown to be associated with markedly higher ovarian involvement with sexual obsessions. A 22 year-old woman was admitted to the hospital with the complaints of obsessions mainly in sexual and religious settings and decrease in performance. In physical examination alopecia was observed mainly at the occipital region and trichotillomania was identified. After the medical treatment except the sexual obsessions other obsessive-compulsive disorders were decreased and patient`s performance was increased. There is a childhood complex trauma in the patient`s history. After we find out about the childhood trauma due to the sexual abuse of the father her treatment started. We related her sexual obsessions with the abuse that she had experienced. In this case we wanted to show that there is a possibility to change the complex traumas which was started in the childhood who present patients with OCD and trichotillomania can be treated. We wanted to show the treatment process and how the resistance could be altered. vascular reaction on dermis and subcutaneous tissue in the periorbital area. This localized edema which seen rarely, is caused by increased dilatation and permeability of the capillaries because of extravasation of serous fluid. Periorbital edema is rare and non-specific symptom and there is limited reference in the literature. The exact mechanism of mianserin related with periorbital edema is unknown and remains unclear. The formation mechanism of edema was described with immune-mediated processes and autoimmune mechanism. Mianserin has a wide action on the different receptors as described above. Generally, antihistaminergic effect of drugs are used for preventing the great deal of allergic reactions Despite the antihistaminergic receptor activation of mianserin, some kind of allergic reaction might be emerge. This condition shows that different mechanisms can be effective on occurring the periorbital edema. In our case, we discussed a patient with periorbital edema associated with mianserin treatment and possible formation mechanism of this rare side effect and as far as we know, this is the first case that demonstrated the periorbital edema related with mianserin in the literature.

Abstract:0028
Three Cases with Hypomania Occurred with Use of Sertraline he/she has strong attachment and that he/she is unwillingness to school or anywhere else due to separation anxiety. In separation anxiety disorder, the child experiences difficulties in major functionality domains (relations in school, peer relations or social life) for his/herself. Acute urticaria is the most common skin disorder leading emergency visits at childhood. In the literature, association between psychiatric factors and chronic urticaria has been investigated in general and it was reported that 70% of patients with chronic urticaria has predisposition to anxiety, depression and psychosomatic symptoms. In our case, we will discuss urticaria triggered by separation anxiety. The patient was a 6-years old child attending to grade 1 in primary school. The patient was referred to our outpatient clinic due to recurrent acute urticaria episodes requiring emergency department visits. The complaints of the patients began after starting preschool education. Parents reported that the patient experienced difficulty to separate from mother; thus, the patient left preschool education. However, the complaints recurred by beginning grade 1 in elementary school. The patient was prescribed fluoxetine (10 mg/day) and dramatic improvement with recovery of urticaria was observed in the patient. As in all anxiety disorders, somatic symptom can accompany to separation anxiety. Somatic symptoms may include abdominal pain, headache, nausea and vomiting as well as skin lesions. In our case, finding that skin lesions were associated to anxiety and regressed by treatment of anxiety disorders suggests that such cases should be evaluated more comprehensively. Hyponatremia is the most common electrolyte disorder and occurs in 1% of hospitalized patients (1). A 57-year-old male patient was admitted to the hospital with anxiety and depression symptoms citalopram 40 mg / day was recommended. Patient has used for one year. He had the sudden onset of headache, anorexia nausea and vomiting sleepiness and then he applied to emergency and hospitalized to internal medicine hospital. In patients with hyponatremia (Na: 107 mmol/L and Cl:78 mail/L) has been detected. Patients without a history of hypertension were treated with 3% NaCl infusion and daily blood Na values were checked. after another reason could not be determined, It was thought that the cause of low sodium was connected to the SSRI. Drug side effects should be considered when unexplained complaints develop in patients within the first few weeks after the initiation of SSRI drug treatment.
dopaminergic and serotonergic receptor antagonist, is an atypical antipsychotic with efficacy in schizophrenia slightly higher than others. Olanzapine, which is commonly used, are reported several side effects such as weight gain, insulin resistance, including over sedation, extrapyramidal side effects, myocarditis, prolonged QTc interval, toxic megacolon and agranulocytosis. A 32 year-old married military man with a 3-year history of chronic schizophrenia accompanied by paranoid symptoms. He was initiated olanzapine 10 mg/day and titrated up to 30 mg/day in the following 1 mount. In September 2016, while the patient was on olanzapine (30 mg/day) and biperiden (4 mg/day), he developed perioral, lingual and jaw movements of moderate severity. He was hospitalized and olanzapine was tapered off and clozapine (25 mg/day initiated and titrated up 200 mg/day) were administered. One weeks later, there was marked improvement of his involuntary movements and it clearly stopped. Two weeks later, there was no evidence of neurological symptomatology. There are a lot case reports indicating that olanzapine treatment is associated with tardive dyskinesia but in our case tardive dyskinesia ameliorated in one week. Although olanzapine has been claimed to carry a low risk for tardive dyskinesia and other extrapyramidal symptoms, in this case tardive dyskinesia was most likely a result of olanzapine treatment. Early detection of extrapyramidal side effects, in particular tardive dyskinesia, is critical to its management and clinicians should remain vigilant regardless of the type of antipsychotic prescribed.

Abstract:0074
Olanzapine-Induced Hyponatremia: A Case Report Çağlar Soykan, Serdar Süleyman Can, Ali Çayköylü and Ayşegül Taşdelen Kul Department of Psychiatry, Yildirim Beyazit University, Ankara, Turkey E-mail address: aysegul.tsdln04@hotmail.com ABSTRACT Psychotropic drugs have clinically important adverse effects such as hyponatremia. Psychogenic polydipsia occurs in 6% to 20% of psychiatric patients and it is more commonly seen in schizophrenia. We report a case presenting with life threatening severe hyponatremia secondary to olanzapine treatment. A 61 year-old, male diagnosed with schizophrenia for 40 years presented to our outpatient psychiatry clinic in a confusional state. He had a history of generalized muscle aches, lethargy, confusion, irritability, headache, weakness for a week before admission to hospital. CT angiography and magnetic resonance imaging of the brain had shown no abnormalities. Laboratory investigations revealed hyponatremia with sodium value of 108 mmol/l. He was on olanzapine 5 mg and risperidone 2 mg daily for last eight years. He had not used any other medication known to cause hyponatremia. Psychiatric history revealed that he had excessive water intake. He received treatment with hypertonic saline. At discharge his sodium levels were normalized, he had clear consciousness. The patient was recommended to continue treatment with risperidone 2 mg/day, water intake of 1.5 L per day and sodium intake of 4 g. Despite the psychiatrist's recommendation to discontinue olanzapine treatment the patient take 5 mg of olanzapine for 5 days. One week after the discharge the patient was presented to our emergency service with the symptoms of weakness, lethargy, nausea and vomiting. Laboratory data revealed serum sodium level of 111 mmol/L. He received hypertonic saline treatment and his serum sodium levels normalized again. He was discharged on risperidone 2 mg with discontinuation of olanzapine treatment there was no hyponatremia and or signs of water intoxication during 2 months follow up. Olanzapine was incriminated as the causative agent of hyponatremia. In conclusion, clinicians should be aware that patients being treated with olanzapine have a risk of hyponatremia.
Hyperprolactinemia is a frequent consequence of antipsychotic medication. Recent studies and clinical trials have suggested that the antipsychotic aripiprazole, a partial dopamine D2 receptor agonist, can lower prolactin concentrations and potentially reduce prolactin-related effects when given with antipsychotics. We describe a patient who developed hyperprolactinemia while taking haloperidol decanoate treatment which improved on the introduction of aripiprazole. A 45-year-old female was diagnosed with schizophrenia for 22 years and received haloperidol decanoate 200 mg every 4 weeks for 4 years. On admission to hospital, her prolactin level was found to be high (237.0 ng/mL, normal range 4.79-23.3 ng/mL). She also suffered from hypothyroidism. She was consulted to endocrinology department due to hyperprolactinemia and TSH level as 7.84 mIU/L (normal range 0.57-5.6 mIU/L). After the brain magnetic resonance imaging, she was diagnosed as asymptomatic (lack of secondary adrenal insufficiency and growth hormone deficiency with preservation of gonadotrophic function and lack of galactorrhea -amenorrhea) partial empty sella. Thyroid hormone replacement was started. On a stable dose of thyroid hormone additional prolactin levels were drawn 3 and 4 weeks after starting thyroid hormone and were 189.73 and 193.58 ng/ mL, respectively. Hyperprolactinemia of the patient did not improve sufficiently in this period. Next, aripiprazole 5 mg/ day treatment was added to haloperidol decanoate due to hyperprolactinemia. Fourteen days after the beginning of aripiprazole (5 mg/day), the prolactin level firstly decreased to 97.66 ng/mL and after 3 weeks decreased to 53.92 ng/mL. The case we presented in this report suggests that adjunctive treatment with aripiprazole reduces the prolactin concentration that had been increased because of haloperidol decanoate treatment. Adjunctive aripiprazole therapy was generally well tolerated. We experienced any serious adverse effects during the aripiprazole combination treatment in the reported case. Discontinuation of the neuroleptic agent in DIP should relieve the symptoms of parkinsonism. However, differentiating DIP from Parkinson's disease (PD) may be a challenge to clinicians. Timeframe between the neuroleptic withdrawal and resolution of the symptoms of parkinsonism may prolong up to 6-12 months as written in literature. We aimed to present a persistent DIP with PP treatment. A 47-year-old woman with a history of delusional disorder for 2 years was referred to inpatient clinic. She was started on paliperidone palmitate (PP) 150 mg/1,5 ml loading dose and then 100 mg/1,5 ml maintenance dose per month in her first hospital admission. She was discharged from hospital with 100 mg/1,5 ml PP per month. After 6 months PP dosage was reduced 75 mg/1,5 ml per month. After second dose of 75 mg PP she presented to hospital with parkinsonism. PP was ceased and feniramin maleat, diazepam and biperiden treatment was administered intravenously a few times per day. Although one week administration of antiparkinsonian treatment parkinsonism resisted. She had no psychotic symptoms when admitted to hospital with parkinsonism. She was discharged from the hospital and after 4 months she was admitted to hospital with psychotic flare up. Her symptoms of parkinsonism was still existing. She was started on clozapine and the dose was brought to 300 mg daily. Neurology did not evaluate patient as Parkinson disease. Her parkinsonism symptoms fairly alleviated in the first month of clozapine treatment. In conclusion, case presented highlights the slow recovery from DIP, especially in patients having depot antipsychotics. Parkinsonism may persist up to 18 weeks after cessation of responsible drugs. In our case paliperidone palmitate was ceased after severe parkinsonism symptoms. After cessation of drugs parkinsonism signs completely revealed after 24 weeks.

Hande Ayraler Taner and Burcu Akın Sarı
Department of Child and Adolescent Psychiatry, Başkent University School of Medicine, Ankara, Turkey E-mail address: carpediemburcu@yahoo.com ABSTRACT Aripiprazole is an antipsychotic agent with partial agonist dopaminergic effect. The drug used for the treatment of schizophrenia, conduct disorder or augmentation for treatment has also been developed specifically for the resolution of side effects of atypical antipsychotics. Although aripiprazole is used for the treatment of schizophrenia, its partial agonist effect may cause some undesirable side effects. In this case such side effects have been observed and discussed. A 16-year-old male patient presented to the clinic with complaints of not getting used to new school, intense anxiety, head and stomach pain, repetition and cleansing compulsions, feelings of uneasiness and unhappiness. In the mental condition examination; he has repetition and cleansing compulsions. There was no perception disorder. In blood tests; fasting blood sugar, thyroid functions, vitamin B12 level, hemoglobin, folic acid liver and kidney function were normal. Considering the obsessive-compulsive disorder in the patient, sertraline 50 mg was recommended. Dosage was increased to the 75 mg as the obsessions did not pass. During follow up the medication was adjusted to 100 mg for the patient since the obsessions decreased but anxiety symptoms were added. Following a 40% reduction in obsessions, aripiprazole 5 mg was added for augmentation. On the 2nd day of aripiprazole, this medication was reduced to 1.25 mg due to the patient's visual hallucination. At this dose, the patient's aripiprazole was withdrawn, since the patient described insomnia, nightmares and visual hallucinations. The resulting hallucinogenic side effect is thought to be due to the sertraline interaction or partial dopaminergic effect. Wolf-Parkinson-White (WPW) syndrome is a congenital heart disease, an extra electrical pathway between the atria and the ventricles that causes a rapid heartbeat, a reentrant tachycardia circuit. Risperidone is an atypical antipsychotic and its cardiac effects are orthostatic hypotension, QT prolongation, arrhythmias and sudden cardiac death. We present the case of a patient with schizophrenia and WPW syndrome who was treated with risperidone. A 30 year-old woman was admitted to psychiatry inpatient clinic with complaining of aggression, irritability, psychomotor excitement, suspicion, susceptibility, auditory hallucinations, exacerbation of paranoid and persecutory delusions, reduced sleep, decreased appetite, suicide attempts for 5-6 months. No pathology was found in routine laboratory results. Treatment was ordered as an oral risperidone 3 mg/day, lorazepam 3 mg/ day, due to poor compliance with medication long acting injectable risperidone 37.5 mg. Before the start of treatment, ECG was in sinus rhythm, the QTc interval was 458 ms, heart rate (HR): 65 bpm. One week later, QTc: 469 ms, HR:106 bpm. A second injection of risperidone was administered, QTc: 473 ms HR: 72 bpm. A third injection of risperidone, QTc interval was 472 ms, HR: 64 bpm during sinus rhythm. Her psychotic symptoms improved and no side effects worsening arrhythmia was observed. Schizophrenic patients have a shorter life expectancy than many other psychiatric patients and the healthy population. Some antipsychotic drugs may prolong the QTc interval, and whether this may result in torsades de pointes and sudden death. In WPW, wide QRS tachycardias can be caused by multiple mechanisms: sinus or atrial tachycardias, AV nodal reentry, and atrial flutter or fibrillation with anterograde conduction over the accessory pathway; but are not related to prolong the QTc interval and torsades de pointes. Regular ECG and heart rate follow-up are sufficient when treating WPW patients with atypical antipsychotics that the lowest arrhythmogenic side effect should be selected. Fluoxetine is an often prescribed selective serotonin reuptake inhibitor. It is certified as a first resort drug by US Food and Drug Administration for use in major depressive disorder, panic disorder, bulimia nervosa, premenstrual dysphoric disorder and in obsessive-compulsive disorder. The most common side effects include headache, nausea, insomnia, anxiety and nervousness. On the other hand with few major side-effects; changed serotonergic transmissions in hypothalamic pathways might lead to a distressing, and often embarrassing, manifestation of hyperprolactinemia. Hyperprolactinemia is characterized as an elevated level of serum prolactin, in the lack of such conditions as pregnancy or lactation, and is induce by an rise in prolactin secretion from the pituitary gland. It is a common endocrine disorder, with a prevalence of 1-1.5%, and may be caused by a number of pathological and pharmacological conditions. Selective serotonin reuptake inhibitors (SSRIs) commonly cause hyperprolactinemia owing to presynaptic mechanisms indirectly via 5-hydroxytryptamine (5-HT)-mediated inhibition of tuberoinfundibular dopaminergic neurons. However, there is not much insight about the mechanisms by which fluoxetine causes hyperprolactinemia via the postsynaptic pathway. In literature, some studies and case reports describing galactorrhea with SSRIs have reported various degrees of changing in prolactin levels. Prolactin is secreted by the anterior pituitary under hypothalamic calibration through a mixed series of connections. In past individual case reports could be indicate a mighty association of SSRIs with prolactin abnormalities. We report here a young women with major depressive disorder of fluoxetine-induced hyperprolactinemic galactorrhea developing treatment on a stable regimen. Vortioxetine is an antidepressant drug that is certified in the US for the treatment of adults with major depressive disorder (MDD). Its mechanism of action is concerned to its multimodal activity, which combines two pharmacological properties. A multi-modal antidepressant that functions both as serotonin transporter (SERT) inhibitor and as 5-HT3, 5-HT7 and 5-HT1D receptors antagonist, 5-HT1A receptor agonist and 5-HT1B receptor partial agonist. However, we don't know from the how vortioxetine's multimodal mechanism of action contributes to its antidepressant effect. The efficacy and tolerability of vortioxetine in comparison with other antidepressants is not clear. On the other hand, in some studies designed to specify cognition in depression, vortioxetine showed evidence of improving cognitive performance in patients with acute major depressive disorder. According to last studies, vortioxetine appears well-tolerated, with very limited effects on weight gain and sexual functioning. The most commonly side effect (nausea) was generally transitory. We report the case of a female patient with a generalized urticaria because of hypersensitivity to vortioxetine. There were several case reports about generalized urticaria of antidepressants in the literature. But as far as we know, our case is the first showing the possible adverse effect with vortioxetine. Specifically, vortioxetine may have important clinical advantages by virtue of its cognitionincrease effects. Clinicians should be careful when prescribe of this drug, because experience with side effects is limited. Although dermatological reactions such as urticaria is seen secondary to antidepressant drug use, rarely life-threatening dermatological disorders may also be seen. Urticarial lesions alone were present in the in our case here and no lifethreatening clinical picture such as angioedema accompanied the lesions. Lesions regressed after the cessation of the drug.

Vortioxetine; urticaria; side effect
Olanzapine is an atypical antipsychotic which is widely used for the treatment of schizophrenia and bipolar disorders effectively and reliably. Olanzapine is also used to increase the efficiency of the treatment for various psychiatric disorders. Olanzapine's mechanism of action involves antagonism at serotonergic, dopaminergic receptors. It was reported that weight gaining, postural hypotension, constipation, dizziness, akathisia and sedation are the most frequently observed adverse effects due to olanzapine usage. One of the slightly-observed side effects of olanzapine is edema. Local edema is reported as a rare-side effect in 3% of the patients treated with olanzapine. Although there are many factors in the etiology of local edema, intake of food and medicine stand out among these factors. Although medicine-induced edema is often developed particularly depending on calcium channel blocker, beta blockers, non-steroid anti-inflammatory medicine and some hormone medicine, it is rarely developed with the new type antipsychotics. The patient's developing facial edema when olanzapine added on his paroxetine treatment and the edema's going away when olanzapine was stopped led us think that the reason of the facial edema was the side effect of olanzapine. Looking into the literature, we have seen 3 olanzapine-induced facial edema cases, however the case of facial edema when olanzapine added on paroxetine treatment is the first in the literature. A peripheral edema may be observed as the side effect of olanzapine which is among atypical antipsychotics. The etiology and development mechanism of the facial edema hasn't been clear. Patients get scared of the look of the facial edema, which interrupts the treatment harmony of the patient. Here, a case that olanzapine-induced facial edema was discussed. Future research is needed to clarify the mechanism, dose dependence and risk factors for olanzapine-induced facial edema. Little attention has been focused on the antipsychotics potentially fatal adverse drug reaction of venous thromboembolism (VTE), which includes pulmonary embolism and deep-vein thrombosis. Association between antipsychotics and VTE has been strengthened as a result of the published studies and case reports. In this case report, pulmonary thromboembolism was thought to be associated with the use of quetiapine and it was planned to draw attention to this side effect. A 36-year-old man presented to the Emergency Department (ED) complaining of general weakness, mild fever, and dizziness. There was no chest pain, leg edema or swelling, orthopnea, PND, or sweats. The patient has a history of Bipolar disorder and taking 1200 mg/day Lithium. The psychiatrist added Quetiapine 200 mg/day a week before the recourse to ED. The vital signs recorded heart rate 132 beats/min, body temperature 37.9°C and oxygen saturation in room air was 70%. D-dimer was 1773 μg/L. The helical chest CT scan revealed; bilateral superior and inferior lobar branches trunk thrombosis. There were no risk factors such as age, smoking, trauma, immobility, surgery, heart disease and genetic risk factors such as protein C, S and antitrombin III deficiency, dysfibrinogenemia, Factor V Leiden thrombophilia, PT20210 and MTHFR gene mutation, lupus anticoagulant and Homocysteine level was normal. There was no family history of hypercoagulable state. The biological mechanism explaining the relation between antipsychotic drugs and venous thromboembolism is unknown. Several hypotheses have been proposed: antipsychotic drugs enhance aggregation of platelets or increase anticardiolipin antibodies, and venous stasis is exacerbated by sedation. In this case report, pulmonary thromboembolism seen in the patient was associated with the use of quetiapine. We should be more careful about this fatal side effect; pulmonary thromboembolism. Urinary retention is a condition in which impaired emptying of the bladder results in postvoidal residual urine. Data from observational studies suggest that up to 10% of episodes might be attributable to the use of concomitant medication. Urinary retention has been described with the use of drugs with anticholinergic activity, opioids and anesthetics, alpha-adrenoceptor agonists, benzodiazepines, NSAIDs. In this article, a case of urinary retention developed after the use of alprazolam was discussed. A 67-year-old male patient. The patient who underwent prostatectomy operation due to benign prostatic hypertrophy developed complaints such as insomnia and fear of death after surgery. Alprazolam 1 mg/day was started to the patient. After using alprazolam treatment, complaints of drowsiness and inability to urinate in the patient started. There was no pathologic finding to explain the urinary retention in the patient who underwent cystoscopy. The alprazolam treatment was discontinued in the patient who consulted to us about urine retention. It was observed that the patient was able to urinate without urinary catheter after the alprazolam treatment was stopped. Urinary retention following use of benzodiazepines (clonazepam and diazepam) has been reported. But, as far as we know, there has been no report of urine retention after the use of alprazolam in the literature. Also, elderly patients are at higher risk for developing druginduced urinary retention, because of existing co-morbidities such as benign prostatic hyperplasia and the use of other concomitant medication that could reinforce the impairing effect on micturition. This case is remarkable both reporting the development of urinary retention after alprazolam use and in attracting attention to urinary retention that may develop with the use of benzodiazepine in elderly patients with disorders that have impairing effect on micturition. Menometrorrhagia is a condition in which prolonged or excessive uterine bleeding occurs irregularly and more frequently than normal. There are a few consumer reported menometrorrhagia cases while using aripiprazole and one incident was mentioned on an FDA report. A seventeen-year-old girl with moderate mental retardation had been using aripiprazole for one year. In her medical history, she was treated with risperidone for irritability and hyperactivity for one year. Risperidone was discontinued due to weight gain, hypomenorrhea and reduced effectiveness on her symptoms and aripiprazole was initiated.
Within a year of the initiation of aripiprazole, she complained of prolonged and abundant menstrual bleeding and presented to Child and Adolescence Psychiatry Department with the thought of an adverse effect of aripiprazole. Her vital signs were normal and there was no pathological physical examination finding. USG performed by an obstetrician was evaluated as normal. Complete blood count and hemostasis parameters were normal. On account of excluding other causes of menometrrohagia, we speculated that aripiprazole induced this symptom and stopped the treatment. Within 3 months of follow-up, her menstrual cycles have been regular. Although a few patients shared their experiences of menorrhagia and metrorrhagia associated with aripiprazole on patients' health websites, aripiprazole has not been previously reported as a cause of menometrorrhagia. However, Hoşoğlu and friends reported a case presenting with nasal and gingival bleeding during aripiprazole treatment and suggested that aripiprazole's 5-HT2A antagonism might have possibly caused bleeding by its antithrombotic effect on microcirculation. Although it is a rarely reported adverse effect, bleeding might be more frequent than reported. Clinicians should be aware of this adverse effect and further trials should be done to explain this effect. Modafinil is a medication approved by the FDA to treat excessive daytime sleepiness associated with narcolepsy. It is also has been reported as a treatment option in a treatment resistant depression but evidence is sparse. In this case report, we present a patient diagnosed with depression, which had previously failed augmentation with aripiprazole and lamotrigine but achieved remission with the addition of modafinil. A 25 year-old male patient applied to the outpatient clinic. Two years ago, the patient started treatment with paroxetine 20 mg/day with somatic complaints and anxiety. The patient's complaints have declined with this treatment. However, on initial evaluation, he reported a number of depressive symptoms including anhedonia, low energy, lack of motivation and drive. He was postponing his works repetitiously and he wasn't going to school. He was spending all his time playing computer games or sleeping at home. Laboratory studies were all within normal limits. Paroxetine was increased to 40 mg/day gradually but there was no improvement in his symptoms. In the follow-up, aripiprazole and lamotrigine were tried as the strengthening options but the patient did not benefit. Subsequently, paroxetine was reduced and switching to venlafaxine extended release was attempted but continued with paroxetine because the patient was unable to tolerate it. There was a remarkable improvement in the depressive symptoms of the patient after he started paroxetine 40 mg/day and modafinil 100 mg/day. On follow-up, modafinil was increased to 200 mg/day and it resulted in full remission of the patient. Modafinil is not a widely preferred augmentation option by clinicians in the treatment of major depression. In this case report, it is aimed to draw attention to augmentation with modafinil in a patient with treatment resistant depression with continued low energy. Patients with bipolar disorder experience depressive episodes three times more often than they do manic and hypomanic episodes. Depression, having a greater impact on patient's global psychosocial functioning. Despite a wide range of various drugs, a significant proportion of depressed bipolar patients fail to respond to the treatment strategies. Rasagiline secondgeneration, selective, irreversible monoamine oxidase-B inhibitor (MAO-B), is used clinically in treatment of Parkinson's disease. A 58-year-old man with Bipolar I Disorder. The patient admitted to our psychiatry inpatient clinic due to depressed mood, unhappiness, disturbed sleep and appetite, anhedonia, mutism, loss of interest in activities. For the last six months, the patient was receiving sodium valproate (1000 mg/day) and fortnightly 200 mg zuclopenthixol decanoate intramuscular injections. The patient was leaning slightly forward, his arms slightly bent from the elbow and not swinging as he walked. Bradykinesia, rigid and associative movements was noted on examination. Sodium valproate 1000 mg/day, quetiapine 300 mg/day and biperiden 4 mg/day was started. 18 sessions of electroconvulsive therapy was applied. Depressive and parkinsonian symptoms did not improve with this therapy. Antipsychotic medications was stopped because of extrapyramidal side effects and lithium 900 mg/day was started (Lithium level: 0.84 mEq/L). After 3 weeks, rasagiline was added to treatment at the recommendation of neurology. After addition of rasagiline both the patient's depressive and parkinsonian symptoms were improvement. It was demonstrated that protective potential of rasagiline on depressive-like behavior and cognitive impairment in aged mice. The clinical efficacy of rasagiline is well established. In the ADAGIO study (Attenuation of Disease Progression with Azilect Given Once daily), treatment with rasagiline was reported to improve mood symptoms on the non-motor KEYWORDS Bipolar depression; extrapyramidal side effects; rasagiline experiences of daily living. This case report suggests that rasagiline as adjunct-therapy may be an effective and safe medication for treating treatment-resistant bipolar depression.

Abstract:0208
Quetiapine-Induced Autoimmune Hemolytic Anemia in a Child Patient: A Case Report Asiye Arıcı a , Hatice Altun a and Can Acıpayam b a Department of Child and Adolescent Psychiatry, Kahramanmaras Sutcu Imam University, Kahramanmaras, Turkey; b Department of child hematology-oncology, Kahramanmaras Sutcu Imam University, Kahramanmaras, Turkey E-mail address: drhaticealtun@gmail.com ABSTRACT Autoimmune hemolytic anemia (AIHA) can be roughly stratified into two groups according to serological features and secondary causes including drugs induced hemolytic anemia. Drugs induced AIHA is very rare in pediatric patients. Even though hematological side effects such as leukopenia, agranulocytosis, eosinophilia, thrombocytopenic purpura and aplastic anemia might occur due to psychotropic drug use; to the best of our knowledge there is no AIHA case due to quetiapine, an atypical antipsychotics, in literature. We hereby describe the first child case of AIHA during quetiapine treatment. A 12 year-old male patient who have been followed-up with mental retardation and attention deficit hyperactivity disorder in our clinic for 6 years was receiving risperidone for 5 years. Patient experienced risperidone-induced a convulsion. His laboratory test results were normal. After discontinuation of risperidone, quetiapine 12.5 mg/day was initiated for his complaints and four days later the dose was increased to 25 mg/day. Patient presented to pediatric emergency department with weakness and jaundice at the 8th day of treatment. In his laboratory tests these results were observed: Hgb 9.6 g/dL, RBC 3.21 M/uL, reticulocyte (RET) 2.01%, (WBC) 6.81 K/uL, LDH 307 U/ L, total bilirubin 3.8 mg/dl, direct bilirubin 0.8 mg/dl, indirect bilirubin 2.88 mg/dL. In his physical examination general medical condition was moderate, his sclera was icteric and his abdomen was slightly sensitive. Patient was diagnosed as hemolytic anemia and steroid treatment was initiated in hematology department. Vitamin B12 level was normal, folic acid level was low and ferritin level was high. Others all organic tests were normal. Because of his direct Coombs test (++++) result and other laboratory and clinical findings, his AIHA diagnose was related with quetiapine use. It is unclear whether quetiapine or its metabolites cause this clinical picture and whether hemolysis occurred with or without dose-dependent manner. To our knowledge, this case is the first case to report quetiapine-related hemolytic anemia and one should always keep in mind that atypical antipsychotics might cause several hematological side effects including hemolytic anemia.

Pelin Çon Bayhan
Psychiatry Hospital, Samsun, Turkey E-mail address: pelincon_1986@hotmail.com ABSTRACT Atypical antipsychotics (AAPs) can induce emergence and exacerbation of obsessivecompulsive symptoms (OCS) in some patients. Induced OCS may be due to complex neuromodulation involving many serotonin, dopamine and glutamate receptors. Girl patient who is 16 years old applied to outpatient clinic with complaints as feeling very energetic, rising in self-esteem, speaking a lot, decreasing in sleep duration for a week. Risperidone 3 mg/day had been started at another hospital five days before. She had a depressive episode before. She was hospitalized with diagnosis of bipolar disorder and the same medical treatment was continued. Obsessive-compulsive symptoms (OCS) started a week later. She had no history of obsessive-compulsive disorder (OCD). Risperidone was slowly reduced and discontinued. Olanzapine 10 mg/day was started, but manic symptoms KEYWORDS Obsessive-compulsive disorder; bipolar disorder; risperidone; olanzapine continued without decreasing. Lithium 900 mg/day was started instead. The severity of OCSs and manic symptoms decreased after the initiation of lithium treatment. The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score decreased from 16 to 1 after two weeks. AAPs are efficient as augmentation to selective serotonin reuptake inhibitors (SSRI) in treatment resistant OCD, but AAPs cause induced OCS in some patients. It has been suggested that the anti-serotonergic effects of AAPs are responsible for the emergence of OCSs and the dopamine is implicated in the mediation of some obsessive-compulsive behaviors. Reports of atypical antipsychotic drug-related OCSs are linked to clozapine, risperidone, olanzapine and quetiapine. AAPs induced OCSs seem to be dose-related. Treatment-induced OCSs emerged within weeks to months of AAPs therapy or dose increase. The onset of OCSs does not seem to be predictable. Especially when high doses of AAP are used, OCS should be followed closely. Abstract:0211 Tactile Hallucination Developed by Use of Atomoxetine Neslihan Taştepe, Melike Kevser Gül, Sevgi Özmen and Esra Demirci Department of Child and Adolescent Psychiatry, Erciyes University, Kayseri, Turkey E-mail address: ntastepe1@hotmail.com ABSTRACT Tactile hallucination(TH) is defined as cutaneous sensations of crawling, stinging, and biting without evidence of infestation to explain these sensations. Stimulant medications such as methylphenidate and mixed amphetamine salts used for the treatment of ADHD have been reported to be associated with TH in five cases in the literature. In all cases, TH resolved after discontinuation of the associated medication. We were unable to find any case of atomoxetine induced tactile hallucination via PubMed and Google Scholar. A 7 years old girl, who was referred our polyclinic with complaints of inattention, forgetfulness, difficulty doing homework, stubbornness. We diagnosed as ADHD inattentive type. ATX was initiated at a dosage of 10 mg /day and the dosage was increased 18 mg/day after 2 weeks. Since the beginning treatment, she had itching in the head and defined cutaneous sensations crawling and biting. We wanted dermatology consultation and they evaluated dermatologic disorders which cause itching in head and they said it was normal from a dermatologically. We searched disorders which occur tactile hallucinations and distinguished psychotic disorders, organic causes such as neurologic diseases, nutritional deficiencies and dermatologic conditions, central pruritus. We decided it was side effect of ATX, we stopped ATX treatment by reducing the dose. 1 month later we evaluated and there was no symptoms. One commonly reported group of medications causing TH in the literature was dopaminergic agents. Stimulants such as methylphenidate and mixed amphetamine salts. TX, is a selective norepinephrine reuptake inhibitor and the first nonstimulant medication for the treatment of ADHD. In our case, we thought that ATX induced tactile hallucination because of developing after the initiation ATX. We believe that clinicians should be aware of this side effect of ATX and should be searched with the clinical trials. Stroke is second most common cause of death and major cause of disability worldwide. The antipsychotic treatment is associated with increased risk of cerebrovascular events in elderly patients. We present the case of a patient with schizoaffective disorder who was treated with KEYWORDS Antipsychotics; intracranial hemorrhage; schizoaffective disorder antipsychotics and complicated by intracranial hemorrhage after sudden hypertension. A 68year-old woman patient presented to our inpatient clinic with nervousness, irritability, psychomotor agitation, and logorrhea, flights of ideas, decreased need to sleep, grandiose, paranoid, reference delusions, auditory and visual hallucinations. She had a diagnosis of schizoaffective disorder since age 21. There was no prior history of any other medical disease. Her routine laboratory and physical examination were within normal limits. BMI25 kg/m 2 , no smoking. Her blood pressure monitors were all under 140/90 mmHg. Treatment was initiated as Quetiapine 12.5 mg/day. Two days later, followed by Risperidone 0,5 mg/day and Quetiapine 25 mg/day. Risperidone dose 2 mg/day was gradually raised and continued for ten days. Suddenly vomiting and loss of consciousness developed after a headache. That blood pressure was 220/140 mmHg. After the first intervention, intracranial hemorrhage was detected in the cranial CT scan taken by the emergency department. When the consciousness started to open, left hemiplegia, speech impairment was detected. Neurosurgery planned operation. In our case, there was no vascular risk factors, such as history of previous stroke, diabetes, hypertension, hyperlipidemia, obesity, smoking and atrial fibrillation and whether it is by chance or by antipsychotic treatment is unclear. Clinical studies indicated that antipsychotics may increase the risk of stroke. In hypertensive rat studies with risperidone may increase the vulnerability to stroke as endothelium injury. Another one long-term clozapine treatment is associated with increased rates of hypertension. Older adults who take atypical antipsychotics may have a risk of cerebrovascular events. Regular blood pressure should be followed. Hyperprolactinemia is a side effect of antipsychotic medications and may cause amenorrhea, hirsutism and sexual dysfunction. In this case report, we present a female bipolar disorder patient had hyperprolactinemia and benefited switching from long-acting injectable (LAI) risperidone to paliperidone palmitate (PP). A 24 year old single female patient had a history of bipolar disorder for five years referred to our outpatient clinic by the gynecologist with symptoms of four months prolonged amenorrhea, hirsutism in September 2016. She had being treated 50 mg of LAI risperidone and valproic acid (VA) 1000 mg/day, had 16months of euthymia. Her prolactin level was 121.0 ng/ml. On her next injection day LAI risperidone was switched to 100 mg of PP and VA 1000 mg/day was continued. Manic or depressive symptoms were not observed in monthly outpatient clinic controls, euthymic state was continued. Serum prolactin level was 28.3 ng/ml in December 2016 on the third control, after the third PP injection. She had her menstrual period twenty days before the control. Risperidone is one of the most potent drugs for prolactin elevation. Prolactin levels in patients treated with LAI risperidone seem to be generally lower than the oral form. Paliperidone is an active metabolite of risperidone. Paliperidone's mechanism of prolactin elevation is substantially congeneric to risperidone. Nevertheless, according to two studies published in 2013, prolactin levels decreased after switching from risperidone to paliperidone. On the contrary, Pandina (2011) have reported no differences in prolactin levels between risperidone-LAI and PP. However, this study compare two long-acting forms yet don't analyze the shift from risperidone-LAI to PP. As a conclusion clinicians should periodically assess prolactin levels of patients on risperidone and paliperidone palmitate. Switching from risperidone-LAI to PP can be an alternative way to decrease prolactin levels.

Hyperprolactinemia; paliperidone palmitate; longacting injectable(LAI) risperidone
A patient diagnosed with attention-deficit/hyperactivity disorder (ADHD) who experienced visual hallucinations developing in the course of concurrent methylphenidate and indomethacin use is discussed in this paper. A 14-year old girl was admitted to our clinic due to weird images. She stated that she saw strange creatures which had a very short stature like a dwarf but with faces different from humans, these creatures looked at her unfriendly and talked between and laughed at her. Her complaints began 48 hours ago. The patient first presented to our clinic four months ago. She was diagnosed with ADHD and 27 mg/day long acting methylphenidate was started and tapered to 36 mg/day thereafter. She had been using methylphenidate for three months when she presented with psychotic symptoms. Her menarche started 4 days ago and she had been using indomethacin for 3 days due to severe dysmenorrhea. Her mother stated that she sometimes experienced headache or abdominal pain and used indomethacin without problem. Organic examinations did not reveal any disorders. Psychotic findings were suggested to result from indomethacin use. Indomethacin was discontinued and methylphenidate continued. Visual hallucinations completely disappeared after discontinuation of indomethacin. Both molecules were reported to be able to cause psychotic symptoms when used separately. In our patient, methylphenidate use alone did not lead to psychotic symptoms. Visual hallucinations emerged when she began to use indomethacin due to dysmenorrhea suggesting that symptoms were related to indomethacin. This condition suggests that these two medications which did not cause a problem when used alone could increase their effects when used together. Drug-drug interactions may lead to dangerous conditions for the patients. Clinicians should kept this in mind in presence of unexpected psychiatric symptoms.  Drug-induced skin reactions has been reported commonly, which may include a wide range from mild exanthemas to serious systematic reactions. Skin reactions are observed more frequent in women, old people, black people, people using multi drugs and people who have serious medical diseases. Bupropion, a widely-used drug for depression and smoking cessation, may also induce urticaria and rash and less commonly angioedema and serum sickness-like reactions. These reactions are thought to be dose related, more frequent in younger patients and especially angioedema more frequent in women. Here, we report a case of a 28-year-old female who was suffering depression and had angioedema and urticaria induced with bupropion treatment. Main complaints of the patient were unhappiness, unwillingness, heaviness, loss of energy, difficulty in concentration, decreased sleep time. Depressive symptoms were assessed using the Hamilton Depression Rating Scale and her score was 21. Bupropion XL 150 mg/day was administered. After 20 days, the patient was presented with the complaints of urticaria on her face, body and limbs, angioedema in the eyes and lips, tightness in the chest and shortness of breath which were existing for a week. She had no other medical disease or drug use. She was diagnosed with urticaria and angioedema with systematic reactions, and bupropion was discontinued due to recommendation of dermatology consultation. The symptoms had disappeared with antihistaminic treatment. Bupropion's allergic side effects has been reported in previous studies and case reports. Because not only skin reactions but also systemic reactions may be induced, clinicians should be careful against these adverse effects of bupropion. In this paper, duloxetine treatment in an adolescent patient with body dysmorphic disorder (BDD) who did not benefit from selective serotonin reuptake inhibitor (SSRI) was discussed. A 17-year-old male patient presented to our clinic due to checking his face frequently in the mirror, thinking that his right ear is bigger than the left, continuously dealing with a scar tissue in his face, thinking that other people continuously look at this scar, unhappiness, social isolation, distractibility, irritability, harming himself and other people and suicide thoughts. He was diagnosed with BDD and major depression and medication was started at another institution. He was treated with fluoxetine, sertraline, aripiprazole, risperidone and clomipramine alone or in combination in proper doses and durations during his one year follow up. He and his family stated that medications decreased depressive feelings however a significant improvement couldn't be obtained in his beliefs about body dysmorphic disorder. He presented to our clinic as depressive findings increased. He was diagnosed with BDD and major depression. Considering his prior drug therapy and current status, duloxetine was started 30 mg/day and increased to 60 mg/day carefully. BDD symptoms were decreased in follow-up. Thereafter depressive symptoms were significantly improved together with normalization of body image perception. All of his complaints improved at the end of 6 months of therapy. The drug was well tolerated and no drug-related side effects were encountered. Duloxetine is a serotonin norepinephrine reuptake inhibitor (SNRI) group antidepressant which inhibits serotonin and norepinephrine reuptake. Its use is gradually increasing in psycho-pharmacology of children and adolescents. However no reports are available in literature about duloxetine use in adolescent with BDD. Our case significantly benefited from duloxetine treatment. A SNRI drug, duloxetine may be an alternative pharmacologic agent in adolescents with SSRI-resistant BDD.

Hande Yıldırım and Ayşe Ender Altıntoprak
Department of Psychiatry, Ege University School of Medicine, Izmir, Turkey E-mail address: yildirim-hande@hotmail.com ABSTRACT Clozapine is an exceptionally effective antipsychotic which is reserved for treatment-resistant schizophrenia because of its adverse effects. These are predominantly neutropenia and agranulocytosis. Other adverse reactions which also limit its use include sedation, hypotension, seizures, metabolic syndrome and myocarditis. A 39 year-old man with schizoaffective disorder and multiple-substance use disorder, presented to our clinic with suicidal and homicidal thoughts, marijuana and biperidene use. We learned with his psychiatric interview that he used marijuana, biperidene, synthetic cannabinoid, clonazepam, alprazolam. He was diagnosed with schizoaffective disorder in 2013 and for this reason he was hospitalized two times in 2013 and in 2014. In psychiatric examination; auditory, visual and olfactory hallucinations; reference delusion, marijuana and biperidene withdrawal and craving were found. Clozapine was applied to the patient who could not respond to olanzapine 30 mg/day, risperidone long acting injection 50 mg intramuscularly every 2 weeks and venlafaxine 150 mg/day treatment. Clozapine was initiated at a dose of 25 mg per day, and titrated up to 200 mg. At first visit, he was somnolent, febrile and tachycardia. His laboratory results were significant for an elevated CRP, troponin T and leukocytosis. Because of common ST elevation in ECG and elevation of troponin-T, echocardiography was performed by the cardiologist. Pericarditis and myocarditis were coexisted. Clozapine treatment was stopped immediately. Then, fever, chest pain, leukocytosis, elevation of CRP and troponin-T trended down to normal. Several symptoms that are characteristics of clozapine-related myocarditis such as mild fever, tachycardia, and fatigue, are reported to be relatively common while initiating clozapine titration. Once clozapine-related myocarditis has been diagnosed, it is mandatory to immediately stop clozapine treatment. Because myocarditis has a high mortality rate, clinicians should be on high alert when clozapine patients display any symptoms of myocarditis.

KEYWORDS
Clozapine; myocarditis; pericarditis E-mail address: funda-kutuk@hotmail.com ABSTRACT Gelastic cataplexy is a rarely described phenomenon in children presenting with a brief episode of bilateral loss of muscle tone, triggered by laughter. Gelastic cataplexy is a strong predictor of NPC, although it may also be seen in patients with narcolepsy. The aim of this report is to demonstrate the successful treatment of gelastic cataplexy with the use of atomoxetine and to discuss the possible mechanisms of drug action. A nine-year-old female patient with moderate mental retardation was diagnosed as NPC1 at age 4 and was under miglustat treatment since then. She developed gelastic cataplexy at the age of 7. She benefitted from imipramine treatment and was free of cataplexy for 16 months. Later, she developed generalized tonic clonic seizures under imipramine and miglustat treatment. Imipramine was stopped and levetiracetam was started for seizures. In two months she was free of seizures but the cataplexy episodes came back and worsened. Then atomoxetine was started and titrated to 1.2 mg/kg/day. She is again free of cataplexy for the last two months. Current studies consider cataplexy as a complex REM-related phenomenon involving multiple neurotransmitter systems. The REM-On and REM-Off networks work together in regulating REM sleep. It is hypothesized that cataplexy occurs when there is a loss in the excitatory noradrenergic and serotonergic neuron activity of the REM-Off network. We had hypothesized that nonspecific monoamine reuptake inhibitors may be useful in the treatment of cataplexy by increasing the availability of serotonin, noradrenaline and dopamine in the monoaminergic neurons of the REM-Off network, which hold back atonia producing pathways during wakefulness. In this report we further focus our hypothesis on noradrenaline with the successful use of atomoxetine. The positive response to atomoxetine KEYWORDS Atomoxetine; gelastic cataplexy; NPC in our NPC patient supports the idea of the disrupted noradrenergic activity playing a role in the pathophysiology of cataplexy in NPC.

Visual Hallucination Induced by Escitalopram in an Adolescent Patient: A Case Report
Bahar Yeşil a and Behice Han Almış b a Elazig Mental Health and Disorders Hospital, Elazig, Turkey; b Health Sciences University Adiyaman Education and Research Hospital, Adiyaman, Turkey E-mail address: baharyesilege@hotmail.com ABSTRACT Escitalopram is a kind of selective serotonin reuptake inhibitor (SSRI) which used in treatment of depression effectively. In this case we report an adolescent patient with depression, who suffered from visual hallucinations. A 16-year-old girl with depression symptoms, such as depressed mood, lack of interest, anhedonia and weight loss, within the previous two weeks. Developmental story and intelligence capacity were normal limits. No severe medical illness and psychotic symptoms was noted. She started to receive escitalopram 5 mg/ day for the first week, with no side effects, then the dose was titrated to 10 mg/day, however within the second week of the escitalopram treatment the patient defined visual hallucinations. Biochemical tests and neuroimaging were normal. Escitalopram was stopped, visual hallucinations disappeared within 3 days without using antipsychotics. In the following six months no hallucination were seen again. The specific cause of the SSRI-induced hallucinations is unclear. A 70 year-old man with depression was suffered from visual and auditory hallucinations after escitalopram treatment. Sensitive patients including youth and elderly could develop hallucinatory behavior as a general adverse reaction to SSRI. The visual hallucination could be developed because of the serotoninergic hyperactivity and subsequent cholinergic hypoactivity. Additionally SSRIs would cause hallucinations through direct blockade of dopamine reuptake or indirectly via stimulation of postsynaptic 5HT2 and 5HT3 receptors. Although escitalopram has been reported to be one of the safest SSRIs it might induce the visual hallucinations through the modulation of neurotransmitters. Clinicians should be careful in term of its side effects especially in specific age groups. Akathisia is a frequent adverse effect of antipsychotic drugs. Hereby, we report a case of a 59year-old female who developed treatment resistant akathisia with risperidone. A-59-year-old female suffering from major depressive disorder with psychotic features has been admitted to our inpatient clinic. Firstly, risperidone 1 mg/day and biperiden 4 mg/day were ordered. To target the psychomotor agitation and restlessness symptoms, which foreground of her depressive complaints, clonazepam 4 mg/day was started. Risperidone gradually stopped in two days. Other benzodiazepines (lorazepam and diazepam) and propranolol were tried for 3 weeks but failed. Thereafter, escitalopram 2,5 mg/day was started for depressive symptoms and increased 5 mg/day after 5 days. Mirtazapine 15 mg/day was also added to treatment both for sleep problems and akathisia. But akathisia was still as severe as to lead to suicidal thoughts. Because of the suspect that escitalopram may have worsened akathisia, its dose was decreased to 2,5 mg/day but it did not work. Because of the previous history of several adverse events with psychiatric drugs (akathisia with risperidone, pretibial edema with olanzapine, cellulite with quetiapine etc.), possibility of being slow metabolizer was evaluated. The patient was informed about this evaluation and she gave informed consent to CYP 450 enzymes mutation analysis. According to the analyses, she was conversely found as a "rapid metabolizer for CYP 2D6 and 2C19" and the possibility of being slow metabolizer KEYWORDS Treatment-resistant; akathisia; antipsychotic was excluded. Other alternative treatment options including baclofen and hydroxyzine were also tried for additional 3 weeks, but akathisia symptoms did not resolve. After three months, the patient was discharged on her own request. Akathisia not responding to two of the three pharmacological treatments is defined as treatment resistant akathisia. The exact mechanism of this reaction is poorly understood and may involve acetylcholine, serotonin, and GABA systems and CYP 450 polymorphisms.

Milnacipran-Induced Spontaneous Ejaculation
Can Tuncer, Volkan Seneger, Rümeysa Yeni Elbay and Aynur Görmez Department of Psychiatry, Istanbul Medeniyet University, Istanbul, Turkey E-mail address: drctuncer@gmail.com ABSTRACT Milnacipran is an antidepressant of selective serotonergic and noradrenergic reuptake inhibitors (SNRIs). There are reports in the literature about venlafaxine, methylphenidate and amphetamine causing spontaneous ejaculation because of adrenaline and noradrenaline increase. That means noradrenergic reuptake inhibitors lead to decrease ejaculatory latency time and ending up with spontaneous ejaculation through peripheral effects of noradrenaline. A 54 years old, male patient presented with the symptoms of erectile difficulties without loss of libido, premature ejaculation, depressive mood, lack of pleasure, irritability, insomnia, marital problems. He was suffering from depression. His medication included milnacipran capsules 25 mg twice a day and mirtazapine tablets 15 mg one tablet at night. Patient revisited the outpatient clinic 4 days later with complaints of spontaneous ejaculation half an hour later taking milnacipran. This continued for 3 consecutive days. Then milnacipran was stopped and spontaneous ejaculation no longer happened. He continued mirtazapine without spontaneous ejaculation. He was on moclobemide 300 mg per day and then moclobemide was increased 600 mg per day. İn the literature, to our knowledge, there is only one case report about milnacipran-induced spontaneous ejaculation and it happened after defecation without orgasm. One of the interesting things about our case was he even experienced spontaneous ejaculation while he was walking. None of his spontaneous ejaculation involved sexual activities. This shows that there might be peripheral involvement of ejaculation function under adrenergic control. Kleptomania is an impulse-control disorder defined as the recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary value. Kleptomania is a relatively rare condition. A number of case reports found various medications effective in the treatment of the disorder. There are only three different case reports examined the effect of methylphenidate (MPH) in patients with attention-deficit/hyperactivity disorder (ADHD). I describe a child with kleptomania and ADHD, treated with methylphenidate. A 7-year-old boy was brought to our outpatient clinic by his father for his inattention, short attention time, concentration difficulties, hyperactivity, impulsivity, irritability, oppositional defiant behavior, and stealing behavior. He had stolen his friends' school materials, including pencil sharpeners, pen cap, and eraser dust. His parents reported that although he collected the things that he had stolen, he almost never used them. Though his parents were uncertain whether he experienced tension prior to stealing, he typically seemed to be comfortable after the acts. Though the parents had used various punishments to criminate him for his actions, no reduction in his stealing behaviors was observed. In his psychiatric assessment, he met criteria for combined type ADHD, oppositional defiant disorder and kleptomania. An KEYWORDS ADHD; kleptomania; methylphenidate 18 mg OROS-MPH treatment was initiated daily. It resulted in significant improvement in the his ADHD symptoms and the complete resolution of the kleptomania within the first week. In the present case, it seems that the MPH treatment is responsible for the significant improvement in the patient's stealing behavior. Kleptomania is a rare condition and this report observing the complete resolution of kleptomania with a MPH treatment in a school-age child with ADHD. The anti-kleptomaniac effect of the MPH for ADHD patients' needs to be validated through additional studies. Abstract:0390 Risperidone as a Possible Cause of Seizure: A Case Report Gonca Aşut, Elif Tatlıdil Yaylacı, Ömer Asan and Erol Göka Department of Psychiatry, Ankara Numune Training and Research Hospital, Ankara, Turkey E-mail address: goncaasut@hotmail.com ABSTRACT Seizure is a serious adverse effect which can happen with psychopharmacological treatment. Almost all antipsychotics decrease the seizure threshold to varying degrees and have been associated with increased risk of epileptic seizures. Risperidone, fluphenazine, haloperidol seem to be the least likely antipsychotics to induce seizures. In this case, we report a patient who suffered from seizure provoked with risperidone use. A 32 year-old male patient was admitted to our inpatient unit with 6-months history of auditory and visual hallucinations, persecutory delusion and aggressive behavior. He had been diagnosed with Schizophrenia for 4 years and had taken no medication for the last 3 years. On admission, the laboratory tests and EEG were within the normal ranges and no pathology was detected by Cranial MRI. Risperidone 4 mg/day treatment was initiated and the dose was increased to 8 mg/day on the 3rd day of treatment. He had 2 generalized tonic-clonic seizures on the 10th day of Risperidone 8 mg/day treatment. There were no history of epilepsy, febrile convulsions or concomitant diseases. We took blood and urine sample after both seizures and all results were within normal ranges. The result of Neurology consultation suggested that his seizure might be associated with the antipsychotic medication. Risperidone was stopped and valproate sodium 1000 mg/day was administered. 6 day after the cessation of risperidone treatment his delusions and hallucinations recurred. As he had a history of good response to Risperidone treatment, Risperidone 2 mg/day was restarted and increased to 4 mg/day at day 4. After 24 days of close seizure monitoring he was discharged from the hospital. There is no doubt that many different drugs used in psychiatry can elicit seizures. Risperidoneinduced seizures are reported as quiet rare. Due to propensity to provoke seizures seems to be dose related, high dose therapy, rapid upward dose titration and combination with other antipsychotics should be avoided. Hyperprolactinemic Galactorrhea as a Side Effect of Aripiprazole in an Adolescent: A Case Report 4-20 ng/ml). Other biochemical and common blood tests, metabolic parameters, and brain MRI were unremarkable. The increased level of serum prolactin and galactorrhea were thought to be related to aripiprazole and we discontinued the medication. After stopping aripiprazole, galactorrhea had resolved gradually within two weeks and her prolactin level reduced to 8.25 ng/ml. We reported an adolescent female who developed an unexpected adverse effect after initiating aripiprazole and had remission after stopping the medication. The chronological sequence and dramatic response to discontinuation suggested that aripiprazole was probably responsible for hyperprolactinemic galactorrhea in our case. Aripiprazole is known as a partial agonist at dopamine D2 receptors. The functional activity of aripiprazole at D2 receptors depends on the presence or absence of dopamine in the surrounding area. Hence, it is possible that in the presence of dopamine, aripiprazole may act as a functional antagonist at D2 receptors and elevate prolactin levels. In conclusion, aripiprazole related hyperprolactinemia and galactorrhea should be kept in mind when using this medication even at low doses, especially in children and adolescents. Abstract:0398 Switching to Aripiprazole in Olanzapine-Induced Hyperprolactinemia: A Case Report

Bahar Yeşil
Elazig Mental Health and Disorders Hospital, Elazig, Turkey E-mail address: baharyesilege@hotmail.com ABSTRACT Hyperprolactinemia is a side effect associated with antipsychotics. Galactorrhea, gynecomastia, menstrual irregularities, sexual dysfunction, and osteoporosis could be results of hyperprolactinemia. Little is known about the effect of olanzapine on prolactin levels in women. We report a case with olanzapine-induced hyperprolactinemia. A 37years-old woman who had been diagnosed with bipolar disorder for 20 years applied psychiatry clinic with excessive speech, insomnia and nervousness. She has hospitalized for one month and olanzapine 20 mg/day and valproic acid 1000 mg/day added on the treatment. 5 months later after discharge, still on olanzapine 20 mg/day, amenorrhea developed. Medical evaluation revealed an elevated serum prolactin level (53.1 ng/ml), a negative pregnancy test, normal thyroid function tests, and premenopausal levels of follicle-stimulating hormone and luteinizing hormone. Magnetic resonance imaging showed no evidence of pituitary adenoma. Olanzapine decreased to 10 mg/d and aripiprazole was added to prevent the exacerbation of psychotic and affective symptoms. One month later prolactin levels decreased to 31.7 ng/ml and patient's menstruation cycle has returned to normal. Aripiprazole increased to 20 mg/d and olanzapine treatment was discontinued. After one month, prolactin level was found 21.1 ng/ml and the patient was still in remission in terms of bipolar disorder. In this case prolactin levels returned to normal levels when olanzapine was stopped and aripiprazole added. The exact mechanism of olanzapine-induced hyperprolactinemia is not clear. It may occur due to dopamine antagonism, which is a part of the antipsychotic activity. It has been suggested that females are more sensitive to dopamine blockade in the tuberoinfundibular region of the brain. Olanzapine is an effective agent for the treatment of bipolar disorders, schizophrenia and other psychotic disorders with its low side effects. Hyperprolactinemia is an important side effect that should be considered by clinicians in the use of olanzapine.

ABSTRACT
Sexual side effects such as reduced libido, erectile dysfunction, and retrograde ejaculation are becoming increasingly recognized as important potential side effects of the antipsychotics. Retrograde ejaculation due to potent alpha-1 adrenergic antagonism may also occur, and has been reported frequently with certain typical antipsychotics such as thioridazine, but rarely with atypical antipsychotics. Paliperidone palmitate, a palmitate ester of paliperidone, an atypical long-acting injectable antipsychotic. Paliperidone acts on dopamine D2 and serotonin 5HT2A receptors as an antagonist. It also binds and antagonizes the α1and α 2-adrenergic receptors and H1-histaminergic receptors. Mr. A 44 year-old male was on paliperidone palmitate (100 mg eq.) and valproate (1000 mg/day) treatment for schizoaffective disorder. Mr. A reported the absence of ejaculation with normal orgasm and reduced libido. On physical examination, patient showed no signs suggestive of any genitourinary lesions or malformations. He was highly distressed about this symptoms. Aripiprazole long-acting injectable (400 mg/month) was started after stopping paliperidone palmitate. He also continued to take valproate in the same dosage. On follow-up after 3 months, patient did not experience reduced libido, dry orgasms anymore. We report a case of paliperidone palmitate-induced retrograde ejaculation in a male who was being treated for schizoaffective disorder. The retrograde ejaculation following treatment with paliperidone palmitate could be postulated due to the blocking of alpha 1-adrenergic receptor. Sexual side effects could interfere with the drug compliance of patients with schizoaffective disorder but are still frequently overlooked by clinicians. Retrograde ejaculation can be due to medications, health conditions or surgeries affecting the nerves or muscles that control the bladder opening. If retrograde ejaculation is caused by a drug, stopping the drug may be an effective treatment. Clozapine from atypical antipsychotics is more effective in the treatment of schizophrenia resistant to treatment but agranulocytosis is the most important side-effect which limits its use and may be fatal. Until recently, second-generation antipsychotics were not associated with hematologic side-effects. In recent years there have been case reports showing that clozapine is similar to other second-generation antipsychotics in the literature, leading to agranulocytosis. A 68 year old, female. The patient who has been followed with schizophrenia for about 40 years has been recurrent hospitalization. Clozapine therapy was started because the patient had haloperidol, chlorpromazine, fluphenazine decanoate, frequent psychotic exacerbations and hospitalizations at the time of treatment. Approximately 7 years, with the treatment of olanzapine 25 mg/day, risperidone 6 mg/day the patient is stable. According to the information obtained from relatives, the number of leukocytes and neutrophils in hemogram follow-ups continues to decrease in this period. Patient who was stable in psychiatry was admitted to the emergency service with high fever reason. On the examinations, neutropenia and leukopenia were diagnosed and the patient was admitted to internal medicine service. The pathologic findings of the patient during hematological examinations during the hospitalization period and the reason that the hematological chart could be related to olanzapine and rısperidone and the psychiatric drugs were stopped. Amilsulpride gradually increased to 800 mg/day. She was admitted to our hospital due to a psychotic exacerbation under this treatment. The typical antipsychotic started, the amisulpride was stopped. During the follow-up period, the patient was discharged on improvement of the both psychotic symptoms and the improvement in the number of leukocytes and neutrophils in the hemogram. Leukopenia (white globe<3000)and neutropenia (neutrophil count<1500) have the potential to develop against almost all antipsychotics, and life can be threatening. It is recommended to change antipsychotics when severe hematologic changes are detected. In our case, neutropenia developed with the use of clozapine, olanzapine and risperidone. Our case study also supports the literature that more attention should be paid to the hematologic side effects in the use of new generation antipsychotics.

Selma Hilal Avci, Aynur Görmez, Can Tuncer and Volkan Seneger
Department of Psychiatry, Istanbul Medeniyet University, Istanbul, Turkey E-mail address: hilalselma@gmail.com ABSTRACT Sexual dysfunction is common symptom of depression also a frequent adverse effect of treatment with most antidepressants and is one of the predominant reasons for premature drug discontinuation. Selective serotonin reuptake inhibitors are the most widely prescribed antidepressants and have significant effects on arousal and orgasm compared with antidepressants that target norepinephrine, dopamine, and melatonin systems. We present a case of milnacipran-induced erectile dysfunction. A 48 year old male who had been suffering from depression and anxiety, was on paroxetine 20 mg and mirtazapine 15 mg for 4 years. When he consulted us due to ongoing symptoms, he was switched to sertraline, mirtazapine dose was increased but his depressive symptoms persisted. Due to insufficient response to treatment and decrease of his libido, he was switched to milnacipran 25 mg/day. The day after starting milnacipran, he reported he had spontaneous erection all day. He was obviously ashamed of this situation and he was covering his front with a bag when he came to outpatient clinic the following day. Milnacipran was stopped and he was switched to sertraline again and erectile dysfunction resolved within a day. But lack of sexual desire was still a problem and this lead to his disengagement from psychiatric services. Milnacipran is a dual action antidepressant with a balanced inhibition of the reuptake of serotonin and noradrenaline. In the literature there are inconsistent results about sexual dysfunction effect of milnacipran; however in some cases Milnacipran appears to have positive effects on sexual function together with improvement in depression. On the other hand there are cases involving spontaneous ejaculation by milnacipran. In our case it caused long lasting spontaneous erection that wasn't mentioned in the literature before. Individual vulnerabilities to such unwanted effects should be considered and sexual dysfunction should be assessed thoroughly during the treatment. Sialorrhea is a frequent, unbearable, disturbing and persistent adverse effect of antipsychotics, especially related with clozapine, risperidone, olanzapine. This is known dose related adverse effect. This condition may be particularly socially stigmatizing and troubling for patients, resulting in treatment nonadherence or discontinuation. Sialorrhea may emerge all day however its frequency and amount that is inversely proportional with ability to swallow, increases during sleep time. The patients frequently complain of awakening with a "wet pillow". Aripiprazole which is a relatively new atypical antipsychotic used in the treatment of schizophrenia, depression, bipolar disorder, tic disorders, irritability, impulsivity and obsessive-compulsive disorder. This safe and tolerable profile of aripiprazole is not valid for every side effect as sialorrhea and akathisia. We herein present a case of reversible sialorrhea that developed in a male patient with first episode psychotic attack on aripiprazole-induced sialorrhea responsive to amitriptyline. In this report, we presented a case of sialorrhea during aripiprazole treatment and remitted amitriptyline treatment in a patient who suffered from first attack psychosis. Because of the temporal relationship between the onset of sialorrhea and use of aripiprazole, it is thought that the sialorrhea might be associated with aripiprazole. In the literature, there are two reported case, 27 year-old male patient with aripiprazole-induced sialorrhea responsive to diphenhydramine and 14 year-old boy with aripiprazole-induced sialorrhea responsive to trihexyphenidyl. As for as we know, this is the first case of patient with aripiprazole-induced sialorrhea responsive to amitriptyline treatment. In conclusion, it is important to be aware of the possibility of a sialorrhea being induced when starting aripiprazole therapy. Amitriptyline may be a therapeutic option for patients with aripiprazole-induce sialorrhea. We believe that these case reports serve as a base for future research to examine the relationship between using aripiprazole, onset of sialorrhea, and treatment response.

Kevser Altıntaş, Alişan Burak Yaşar and Sencan Sertçelik
Department of Psychiatry, Health Sciences University Haydarpaşa Numune Training and Research Hospital, Istanbul, Turkey E-mail address: kevser-su@hotmail.com ABSTRACT ECT is potent and reliable treatment option on the patients who are acute depression, bipolar disorder, and refractory schizophrenia. CT is a suggested method for acute treatment as well as recurrence and prevention from exacerbation. As a result it is shown by the studies that maintenance ECT can be a treatment method alone or with drugs for the continuity of remission in the treatment. Case1: A 46 years old female patient. In care of schizophrenia with recurrence hospitalization, benefit from acute ECT in exacerbation period. During her hospitalization after acute ECT she was planned maintenance ECT in addition to her medical treatment. Nearly 7 months along 9 sessions had been applied to the patient and she did not have any exacerbation. When she left her maintenance ECT sessions she got exacerbation and hospitalized. Case2: A 37 years old female patient. She has nearly been followed by the disorder of major depression. She has 4in average depressive attacks in a year. She has epicenter depressive episode diagnosis and she has repeating admissions to hospital. During her hospitalization she was planned acute ECT in addition to her medical treatment. Her acute ECT treatment finished at the 7 session. Maintenance ECT was planned in addition to her medical treatment. 7 sessions maintenance ECT applied. During sessions she did not have any exacerbation. Case 3: A 37 years old male patient. He has bipolar disorder nearly 12 years. He has depressive attacks for a month in average in a year. He got admission to hospital with the diagnosis of bipolar disorder-depressive episode. He had 7 sessions acute ECT during hospitalization. Clinical recovery was observed. Therefore maintenance ECT was planned in addition to his medical treatment. Nine sessions maintenance ECT was applied. During sessions she did not have any depressive or manic episodes. Maintenance ECT efficiency is a proven treatment method. However it is not used frequently. Our study and reference studies demonstrated that maintenance ECT is an efficient treatment method. The common result that when maintenance ECT applied, the increase on period of remission of case studies shows the efficiency of maintenance ECT. The concept of separation in early psychological development and its impact in children's mental health and further implications in adult psychiatric clinical area is well known. The role of attachment in child's early life has enormous effects in development of child's trust and confidence. Winnicott's model of 'two mothers' such as 'environment mother' and 'object mother' is very much instrumental shedding light on pathological effects of attachment in psychiatric disorder. In order the illustrate the pathologic effects of attachment in mothers role and the imposed transgenerational effects on the mother and child in separation anxiety, the following case history will be discussed. An eight year old girl, presented with the symptoms of fear, anxiety, reluctant to be alone, not want to sleep by herself, not want to leave her mother, apprehensive about something bad will happen to herself or to her mother. One of the authors has assessed her mother as well. The family dynamics included mother been very protective and the grandmother also being described as protective to the extent of "guardian angels". These dynamics are essential in highlighting their role in separation anxiety. Awareness of these family dynamics including the pathological effects of attachment difficulties caused by mother and child interaction, even the transgenerational ones are essential in providing high quality psychotherapy to these patients.

KEYWORDS
Anxiety; attachment; fear; mother; separation; transgenerational Abstract:0168 Trichotillomania in a Child with Celiac Disease: Irrespective of Iron Deficiency Anemia

Tuğba Kalyoncu and Deniz Argüz Çıldır
Izmir Tepecik Training and Research Hospital, Izmir, Turkey E-mail address: tugbadonuk@gmail.com ABSTRACT Trichotillomania is characterized by recurrent hair pulling behavior and repeated attempts to decrease or stop the behavior. It may result for a trichobezoar in which is a mass of hair found in the stomach, and patients with diagnosed celiac disease may have an urge to swallow their hair due to iron or folate deficiency, which is called pica. We aimed to present a female child referred with an abdominal mass and anemia, diagnosed with trichotillomania and celiac disease and developing trichobezoar irrelevant to iron deficiency and pica. An 11year-old female child, who diagnosed with celiac disease 4 years ago and had symptoms like digestive problems, iron deficiency anemia, and diarrhea. After a while, she applied with complaints of an uncontrollable, irresistible, and repetitive urge to pull and to swallow her scalp hair. However, her hair pulling and swallowing behaviors have been related to iron deficiency and pica. Although supplementary iron and a gluten-free diet have been instituted, her symptoms have not been decreased and she diagnosed with trichobezoar in her stomach after 2 years. During her pre-op assessment, she was consulted to child psychiatry and her trichotillomania symptoms were associated with as a psychiatric disorders secondary to celiac disease. Her course of illness, diagnostic procedure, and post-op treatment history are described. The connection between celiac disease and an trichotillomania has not explained clearly, yet. In this case, trichotillomania was more likely caused by behavioral disorders secondary to celiac disease rather than caused by the iron deficiency. We attempted to emphasize the importance of psychiatric and comprehensive approaches in patients with celiac disease.

Serkan Güneş
Department of Child and Adolescent Psychiatry, Hatay State Hospital, Hatay, Turkey E-mail address: dr_sgunes@hotmail.com ABSTRACT Trichotillomania (TTM) is a disorder characterized by recurrent hair pulling, generally from the scalp. Methylphenidate (MPH) is a well-accepted treatment for attention-deficit/hyperactivity disorder (ADHD) in children and adolescents. In this paper, we report the occurrence of TTM with modified-release MPH use in a boy with autism spectrum disorder (ASD). Our patient was an eight-year-old boy who was referred to our clinic with the complaint of hyperactivity, anger bursts, and irritability. As a result of his psychiatric and psychometric examinations (CARS total score=45), he was diagnosed with ASD and ADHD and initiated modified-release MPH 20 mg/day. One month after, the second examination revealed that his symptoms improved partially, but he started to pull his scalp hair in the left temporoparietal region (Fig.  1). Metabolic parameters, common blood and biochemical tests were normal. So, we ceased MPH and his hair pulling stopped after discontinuation. Two weeks later, we restarted modified-release MPH 10 mg/day to know whether TTM was associated with MPH or not, and we saw that TTM reemerged within the first week of the medication. We reported a case who developed TTM after initiating MPH and had remission after stopping the medication. The chronological sequence and dramatic response to discontinuation of the medication suggested that MPH was probably responsible for TTM, which was seen in our case.
Although not clearly identified, serotonergic, dopaminergic, and noradrenergic dysfunctions are implicated in the pathophysiology of TTM. It is known that stimulants have facilitative effects on serotonin, dopamine, and noradrenaline neurotransmission. Increased serotonergic, dopaminergic, and/or noradrenergic activity with MPH may be related with the emergence of TMM in our case. The use of MPH has become widely common in children and adolescent for treating ADHD. Thus, MPH related TTM should be kept in mind when using this medication. Inappropriate sexual behaviors (ISB) such as public masturbation and impulsive-compulsive sexual behaviors can be seen in ASD and they impair functioning. The purpose of this case study was to research the efficiency of paroxetine for ISB in our patient who had ASD, ADHD and childhood obesity. A 14-year old male patient was first admitted to OMU, Child and Adolescent Psychiatry Polyclinic in June 2006 with a complaint of not being able to talk and he was referred to special education with a diagnosis of autism. Risperidone 0.25 mg/day was started for the patient's stereotype and irritability and it was increased to 1 mg/day in follow-ups. With the continuation of weight gain, risperidone was cut down and stopped and instead aripiprazole was started. The treatment was regulated as methylphenidate 90 mg/ day, aripiprazole 10 mg/day, haloperidol 20 drops/day. The patient's height was 185 cm, while his weight was 120 kg (p>95%). It was learned that during the 6 months, there were complaints as playing with his penis in public and rubbing against objects. Paroxetine 5 mg/ day was started and it was increased up to 10 mg/day a week later. 6 weeks after the treatment was started, it was learned that there was an obvious decrease in ISB and an increase in appetite with no weight gain. ISB can be an important problem that causes impairment in the patient's functionality in psychiatric diseases such as mental retardation and ASD. Case reports about paroxetine have reported paroxetine to be effective in irritability, destructive behaviors and ISB in autistic individuals. Since ISB had decreased and no obvious weight gain was observed within 6 weeks after paroxetine use in our patient, it can be said that paroxetine use can be a good choice of therapy in obese ASD adolescents who have ISB when compared with drugs that cause weight gain.  psychiatric comorbidities such as depression, anxiety disorder, behavior disorder or BAD. Limited verbal skills and the fact that some symptoms can also be observed in the normal course of ASD make it difficult to diagnose and treat a new psychopathology added to ASD. In particular, association of ASD and BAD is not retained by clinicians. In patients with ASD, identifying comorbid conditions is important regarding both quality of life and compliance to education programs. Thus, clinicians should be alert about comorbid diagnosis. Abstract:0399 Evaluation of Shared Psychotic Disorder During Forensic Psychiatric Process: A Case Report

Hasan Mervan Aytaç and Fatih Öncü
Department of Psychiatry, Bakırköy Prof. Dr. Mazhar Osman Mental Health and Neurological Diseases Training and Research Hospital, Istanbul, Turkey E-mail address: mervan176@hotmail.com ABSTRACT Unusual condition has also been called folie a à deux and induced or shared psychotic disorder. It develops in an individual in the context of a close relationship with another person who has an established delusion that he or she also believes, and requires an absence of psychotic disorder prior to the onset of the induced delusion. A 58 year-old man and mechanical engineer. His wife is 44 years old, graduated from high school, two children's mother. Due to crime about "disturbing individuals' peace and harmony" that committed in September 2016, they were brought with the police in order to determine the criminal responsibility with the writing of the chief prosecutor of the republic. Patient. Felt that they had been disturbed by their downstairs neighbor for 5 years. He believed their neighbor wanted to influence themselves with telepathic and hypnotic methods. Patient thought that his neighbor could spread electromagnetic waves that were intelligence-linked and could enter into their subconscious minds, thus changing their decisions. His wife who had been admitted to female inpatient clinic at same time, like her husband she had thought that their neighbors would harass them by affecting them with electric waves and force them to take the house from their hands, their phones are listening too so they had to pay a high price bills. According to their evaluations in health council, they were affected by the illness called "Atypical Psychosis" during the crime and they could not perceive the legal meanings and consequences of acts they committed and their ability to direct their behaviors significantly decreased. A report about failure of their parental duties was also wrote and sent to society for protection of children. Although rare, shared psychotic disorder cases will continue to challenge our understanding of psychiatric phenomenology. In forensic pretrial settings, this challenge is multiplied because psychiatric experts must be able to explain this complex disorder to the judge who are most often non-medically trained people. assessment, he was conscious, oriented and had depressive mood with thoughts about his experience. Based on history and clinical assessment, the patient was diagnosed as posttraumatic stress disorder. Fluoxetine (20 mg/day) and Risperidone (0.5 mg/day) was prescribed to the patient. Since the grandmother was HCV positive, the patient was referred to pediatrics department. Childhood abuse and neglect is an important, frequently seen problem that may recur and results in several physical and psychological disorders or even mortality. A child can be subjected to abuse by caregiver, relatives or unfamiliar persons. Given the family structure and culture in our society, elder individuals with several disorders and children commonly share same environment. Neglect and abuse are important social problems and the most important issue is early recognition and protection. Elder individuals and children comprise two major, featured groups regarding abuse and neglect. In particular, clinicians providing care to these groups should have to assess their patients for abuse and neglect.

Abstract:0045
The Effect of Fluoxetine on Foreign Accent Syndrome Associated with Conversion Disorder in an Adolescent: A Case Report Foreign Accent Syndrome (FAS) is a rare speech disorder which may cause speaking in an accent different from native language. Speech rhythm alterations and deficits in prosody have been reported in most of the cases. Several adult psychogenic FAS cases associated with conversion disorder have been reported. However, treatment of this disorder is not well known. In addition, there is no report on FAS associated with conversion disorder in adolescents in the literature. Herein, we present an adolescent case who admitted to our clinic with symptoms of FAS secondary to conversıon disorder which disappeared with fluoxetine treatment. A 15 year-old girl presented to our clinic with complaint of change in speech accent. A month ago, she had admitted to emergency service due to numbness in her hands and feet which started suddenly. Her family had noticed that she was speaking Turkish with a Syrian accent. Before this event, she had spoken typical Turkish accent. No physical or neurological reason was found which could explain speech disorder and no additional psychiatric disorder was found in her psychiatric evaluation. She was diagnosed as FAS associated with conversion disorder and Fluoxetıne 10 mg/day treatment was started. Two months later, her speech was completely normal. Several FAS cases associated with conversion disorder were reported in adults. Our patient is first reported adolescent case. Some reported cases before our patient were treated with speech therapy and cognitivebehavioral therapy. In the literature, selective mutism, cerebellar mutism and psychogenic aphony cases were reported to be successfully treated with fluoxetine. This is the first report suggesting fluoxetine may be effective for FAS secondary to conversion disorder. Further research is needed on this topic. to our clinic. Patient diagnosed with ALL in 2013, received induction therapy with vincristine, dexamethasone and cyclophosphamide and received maintenance therapy with methotrexate and mercaptopurine, and cured 9 months ago. She has been seeing her relatives' heads, sometimes big or small, for about two months. Neurological examination of the patient and MR, EEG, eye examination revealed no pathology. No psychopathology or psychosocial stress was detected in her. After a month and a half follow-up of, the symptoms of macropsia and micropsia disappeared. Chorioretinopathies may result in micropsia or macropsia. It is known that chorioretinopathies are also observed in ALL. However, no findings have been observed in our case of ophthalmic evaluation suggesting chorioretinopathy. Antineoplastic therapies have also been associated with visuospatial disorders in adults and children. Our previous MR findings are consistent with changes in the use of parietal carcinoma in situ chemotherapy. This finding, which developed after treatment, may be related to cyclophosphamide, methotrexate from the chemotherapy agents used. There is no information on micropsia and macropsia that arise during the treatment of ALL in the literature. And data on visual problems related to chemotherapy agents are limited. This case suggests that micropsia and macropsia should be evaluated both during and after treatment. Neuroleptic malignant syndrome (NMS) is a life-threatening idiosyncratic reaction that occurs after the administration of neuroleptic drugs. Dementia with Lewy bodies (DLB)'s thought to be the second most common subtype of the dementia. DLB presents with cognitive, motor and psychiatric symptoms. Cognitive impairment, visual hallucinations, parkinsonism and fluctuating confusion are the most common presenting symptoms of DLB. In this paper, it's aimed to report a case with DLB presenting with psychotic symptoms, parkinsonism and autonomic instability like neuroleptic malignant syndrome. After a follow-up of 10 years with a diagnosis of recurrent major depressive disorder, 50 year-old male patient presented to the hospital with lability of blood pressure, insomnia, parkinsonism, visual hallucinations, cognitive impairment, fecal and urinary incontinence. He was using escitalopram 20 mg/day for a year and olanzapine 2.5 mg/day was added to his treatment for visual hallucinations and insomnia by a psychiatrist 15 days ago. The symptoms worsened after the addition of olanzapine to the treatment. In psychiatric examination; orientation was limited, the association of ideas were disorganized. He had fluctuation of consciousness and affective lability. The content of thought was disorganized by persecutory and reference delusions. He had auditory and visual hallucinations at perception examination. He had psychomotor retardation. Upon suspicion of DLP, the patient was immediately assessed by the consultant neurologist. Ultimately, the neurologist recommended the discontinuation of all treatment. He had a loss of hippocampal volume on MRI. Background activity had slowed down in the EEG. This constellation of symptoms was indicative of the DSM-5 criteria for DLB. The most common NMS symptoms include fever, muscle rigidity, altered mental status and evidence of autonomic instability. Fluctuating cognition, recurrent visual hallucinations, spontaneous parkinsonism and autonomic instability are also the most common symptoms in DLB. About half of patients with dementia with Lewy bodies react adversely to antipsychotics. The diagnosis and the clinical management of DLB must be recognized by the psychiatrists because of the fact that the clinical presentation routinely includes psychiatric symptoms. Auditory hallucinations are described as auditory experiences without the presence of out stimuli. They are most strongly linked to schizophrenia but are also characterized in patients with Alzheimer disease and patients with epilepsy. Persistent auditory hallucinations (AHs) are a general problem in patients with schizophrenia and contribute to going on disability and morbidity. Repetitive transcranial magnetic stimulation (rTMS) has recently been developed and trialed as a possible, novel treatment for patients with treatment resistant AHs. rTMS has been subjected to a few small randomized controlled trials. On the other hand, little is known about the long-term impact of rTMS on the clinical outcome of patients with persistent auditory hallucinations. We used PSYRATS scale and Positive and Negative Syndrome Scale (PANSS) for auditory hallucinations. PSYRATS scale provides an assessment of 11 dimensions of hallucination severity and character and has established validity and reliability. The PANSS was also used to measure general psychotic symptoms and psychopathology. A 35-year-old right handed man, suffering from auditory hallucinations presented to the psychiatry clinic. He had been treated over this time with multiple typical and atypical antipsychotic medications at full therapeutic doses. These had resulted in a recovery in his general clinical state but had little impact on the existence or severity of his hallucinations. At the time of first rTMS he had been admission treatment with a combination of quetiapine (400 mg/day) and aripiprazole (20 mg/day) for over 12 months. He was enrolled of treatment and received 10 days of rTMS. This was provided for 15 minutes per day, at 1 Hz, left temporoparietal cortex at 90% of the resting motor threshold. This resulted in a dramatic reduction of his auditory hallucinations from PPSRS and from PANSS AH item. His total PANSS score decreased from 67 at baseline to 42 at study end. Serotonin syndrome is a condition that could present as a complication of treatment with serotonergic drugs, with both central and peripheral symptoms. Symptoms could be prolonged due to delayed diagnosis, comorbidities of the patient and the agents that triggered the serotonergic toxicity. A 62 year-old woman with psychotic depression had a fluoxetine dose increase at her routine visit as she complained of drowsiness. The patient was admitted to our psychiatry ward with serotonin syndrome, which presented with fever, diarrhea, pupillary dilatation, motor agitation, apathic confusion and unsteady gait. Fluoxetine was discontinued and benzodiazepines with chlorpromazine were started. By the third day of follow-up, fever, diaphoresis and diarrhea ceased. The patient was discharged from the hospital with her relatives' demand and consent about the potential risks. About two weeks later, with no obvious improvement in the debilitating symptoms and after her hospitalization in another center for acute renal failure; the patient applied to the emergency service with persisting confusion and motor agitation. She was first admitted to neurology suspecting encephalitis. After the tests proved negative, admitted again to the psychiatry ward. We started electroconvulsive therapy (ECT) with family consent and she had 9 consecutive doses (3 per week) with gradual but satisfactory improvement. Here we present a case of serotonin syndrome triggered with fluoxetine dose increment that could have overlapping catatonic symptoms of accompanying psychotic depression. The patient was eventually decided to be treated with ECT to accelerate the course of recovery and to prevent further complications. As the symptoms persisted, although the few case reports of ECT triggered serotonin syndrome made us cautious, we decided to give the patient ECT. This report suggests that ECT without serotonergic drugs, could be used in serotonin syndrome patients with residual cognitive and motor symptoms.

KEYWORDS
Serotonin syndrome; electroconvulsive therapy; treatment; fluoxetine; psychomotor agitation; confusion mechanisms of these symptoms are not elusive yet. A misdiagnosis of a neurologic disorder as a conversion disorder will be discussed in this paper. A 44 year-old female patient admitted to our psychiatry outpatient clinic with complaints of vertigo, dizziness, speech problems, sleep disorders and postural instability. Nearly one year ago she was hospitalized to two different neurology clinics because of the same symptoms. She was diagnosed as conversion disorder. She told about her marital problems and dizziness at psychiatric examination. But she was unconcerned about her neurologic problems. Escitalopram treatment changed with fluoxetine and quetiapine was stopped. Because of vertigo and dizziness she fell at home and injured her chin. After this event she hospitalized to our psychiatry clinic to check conversion disorder diagnosis. Routine biochemical, hemogram, infectious, and hormonal tests were normal. Radiologic examinations were at normal limits. She was evaluated by neurology department of our hospital. After discharging psychiatry clinic her depressive and anxiety symptoms increased. Nearly six months later her cerebral magnetic resonance imaging showed diffuse atrophy at both two cerebral and cerebellar hemispheres. Modern psychiatric diagnostic systems classify neurological symptoms that cannot be explained by a physical disease or another psychiatric disorder as conversion disorder. The most common presenting symptoms of misdiagnosed patients are gait and movement disturbances. The aim of this case report is to draw attention to the psychiatric presentations of neurologic diseases. Encopresis is defined as passage of stool in inappropriate places in children older than 4 years old. Encopresis may be together with or without constipation. Comorbidity with psychiatric disorder occurs in approximately 30-50% of children with encopresis. Epilepsy, common disease in childhood may accompany with encopresis. A 12 years old boy, has been complaining enuresis and soiling for two years. He was not constipated. He was soiling one or two times a month, he was soiling when he watch TV and he doesn't aware of that. There was no organic pathology obtained in pediatric examination. For further examination electroencephalogram was planned. In the right frontotemporal region of brain spike-wave paroxysmal activity was reported. Patient was diagnosed as epilepsy and valproic acid 500 mg/day treatment was started. Second case was 12 years old boy again. His complaint was soiling for 5 years. His problem started 4 years after toilet training. According to both parent's anamnesis and observation of doctor during the interview, the conflict between the patient and his mother was evident. No organic pathology was found that cause encopresis. Patient was not constipated. Parents expressed that the child had periods of loss of consciousness. EEG was planned for evaluation of epilepsy. Generalized 3 Hz 3-10s spikewave discharge was reported which was considered as absence epilepsy. The comorbidity of elimination disorders and emotional disorders such as ADHD, conduct disorder is well known in clinical and research practice. However the comorbidity of other medical diseases and elimination disorders such as epilepsy is a strong candidate to be investigated. EEG can be used more frequently in psychiatric patient evaluations. We emphasized that minimal neurological findings should not be ignored in cases with encopresis. It is a condition with an urge to move which is caused by inner restlessness. Akathisia can be an adverse effect of treatment with several drugs, particularly, antipsychotic, antidepressant or antiemetics. Akathisia is the most escaping sign among acute movement disorders. Patients with this condition are unable to feel comfortable in any position, such as sitting or standing for more than a few minutes. Individuals with this condition have a compulsion to move and feeling of inner restlessness. It may be cause of discontinuation of a drug, violence and suicides. Thus; it is important to differentiate akathisia from the psychotic agitation. Our current case are presented in order to enhance awareness on akathisia, a component of many syndrome and confusing with many clinical situations. A 20 year-old man has distress, unhappiness and sleep disorder, after the army recruitment, his complaints became more evident. The patient was hospitalized to psychiatry service on account of acute onset psychomotor agitation, visual and auditory hallucinations at night. He administered escitalopram 10 mg/day, risperidone 4 mg/day, quetiapine 200 mg/day. After 14 day of treatment period, there were no regresses on complaints. The patient was given 10 days of rest and discharged from hospital voluntarily. Patient discontinued his medications on 5th day of his rest due to exacerbation of complaints. On account of increased activity and aggressiveness, the patient was admitted to emergency department. In the Emergency Room treatment with haloperidol 10 mg, chlorpromazine 25 mg, biperiden 5 mg, and metoclopramide 10 mg intramuscular have been administered. Motor movements, anxiety and agitation exacerbation has occurred after the medicament administration. Following our examination, it could be associated with drug-induced extrapyramidal side effects. There was no pathology detected on image or biochemical tests. Patient started to be treated by Lorazepam and biperiden. His complaints became less evident. Lorazepam and biperiden were given up gradually and continued with escitalopram treatment.  Swedo et al. in 1998 to describe a subset of childhood obsessivecompulsive disorders (OCD) and tic disorders, which is triggered by group-A beta-hemolytic Streptococcus infection. The treatments of OCD and tic disorders are being researched by scientists intensely. Some reports suggest that OCD symptoms or tics in patients diagnosed with PANDAS may be treated with serotonergic and antipsychotic drugs, or combined behavioral and pharmacological treatments. When the standard treatments of PANDAS failed, and the symptoms were still existing, Swedo and colleagues suggested using immunomodulatory interventions. The patient was a 15 year-old boy, who had a treatment history with Amoxicillin/clavulanic acid after his febrile illness, applied to child psychiatry with choreiform movements, as well as motor and phonic tics (including shrugging, knocking and coughing). His course of illness, diagnostic procedure and treatment history are described. The etiology of post-streptococcal inflammation shows that it has an opportunity for treatment and even prevention by applying the immunomodulatory therapies like intravenous immunoglobulin. Recent studies revealed that intravenous immunoglobulin had positive effects to reduce the neuropsychiatric symptoms of severely ill patients diagnosed with PANDAS. However, there were some other reports in which the treatment with immunomodulatory therapy did not effect on symptoms of PANDAS. In this case, we aimed to discuss the effectiveness of this treatment in the context of the literature. According to the PANDAS Physicians Network (PPN) to be able to control all of the symptoms, it is necessary to use a combination of treatments including immunomodulatory therapy, antibiotic prophylaxis, and drugs for target symptoms. These suggestions need to further research in this area. Insomnia is one of the most common mental disorders and the prevalence is about 10%. Assessment of insomnia should include structured clinical interview, prospective sleep log, and actigraphy. Pharmacological drugs are used in the treatment of insomnia. Apart from these treatments, cognitive behavioral therapy, sleep restriction, sleep hygiene recommendation, relaxation exercises are also used. The use of alcohol for the treatment of some patients is clinically known. Here we will discuss the alternative method used by the insomnia patient referring to our clinic. A 45 year-old male patient, retired, living alone admitted to our outpatient psychiatry clinic. For 10 years, he has been followed with the diagnosis of primer insomnia. The patient previously used trazodone 50 mg/day, mirtazapine 15 mg/day and agomelatin 25 mg/day treatments, and these treatments did not benefit. The patient started quetiapine 25 mg/day 6 months ago and went up to 50 mg/day 2 months later. The patient said that, he cannot sleep well if he doesn't take two different branded drug with the same molecule. Despite the detailed explanation that the two drugs with different names had the same substance, the patient insisted on this issue. The patient says that he can sleep by doing train travel these days. An average of 190 hours of travel by train per month on a journey of 900 km has been detected. Although there are many options in the treatment of insomnia, some patients do not receive the desired treatment response. Many patients, as we describe in our case, refer to alternative medicine and treatment KEYWORDS Insomnia; travel by train; unusual treatment methods. In conclusion, consideration of insomnia as a multidisciplinary approach, investigation of comorbid conditions, detailed information of the patient in treatment and sleep hygiene suggestions should be supported.

Ebru Sağlam and Ömer Faruk Akça
Department of Child and Adolescent Psychiatry, Necmettin Erbakan University Meram School of Medicine, Konya E-mail address: e-saglam-55@hotmail.com ABSTRACT Sleep bruxism (SB) is a temporo-mandibular joint dysfunction with grinding or clenching of teeth in the sleep leading to masseter muscle hypertrophy, headache and periodontal problems. It is a common problem (the prevalence of SB in children ranges from 3.5% to 40.6%), however, no specific treatment has been reported for this disorder. Buspirone is an anxiolytic drug with its partial agonistic activity at the serotonin 5-HT1A receptors in addition to its various activities on dopamine and 5-HT2 receptors. In this study, we present a 7-yearold child whose sleep bruxism disappeared with daily single dose buspirone treatment. A 7 year-old boy was referred to our outpatient clinic with complaints of carelessness, hyperactivity, fear of darkness, anxiety about losing his mother, sleeping with mother and tooth grinding about 2 hours every night. After psychiatric evaluation and gathering information from teacher and parent, he was diagnosed with ADHD combined presentation and separation anxiety disorder according to criteria of the DSM-5. His mother did not want medication for ADHD, she only wanted to medication for sleep bruxism. He was treated with daily single dose buspirone (5 mg per night). His bruxism symptoms significantly declined after a week of treatment. By the end of 6 weeks of buspirone treatment, his family reported no bruxism symptoms. On the disappearance of bruxism, his mother stopped the medication. However, SB started again a week after stopping the medication. The treatment was not restarted because his family refused to take treatment again. This report suggests that daily single dose buspirone 5 mg can be useful in bruxism childhood. This may be related to its effects on serotoninergic and dopaminergic receptors. Further systematic studies are required in order to establish the relationship between buspirone and bruxism. Narcolepsy is a chronic disorder that might cause severe morbidity and functional deterioration with a wide range of complicated symptoms and no clear identified etiology. The condition is even more difficult to be recognized in children as clinical picture and symptoms vary and interchange even further. With this report, we aimed to present an 11 year-old case diagnosed with narcolepsy in a child psychiatry unit along with relevant literature. Psychiatric assessment of the case that applied to our child psychiatry unit was carried out by using Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5) criteria. Detailed clinical examination, neurological tests and imaging as well as polysomnography were made. The case was diagnosed with Narcolepsy. She clinically improved with a combined treatment regimen of methylphenydate-OROS and behavioral therapy for sleep pattern and hygiene. As narcolepsy is a less common condition encountered in child psychiatry settings and symptoms might mimic other neurological and psychiatric conditions, in turn, lessening the odds to recognize early on, we believe that we, as child psychiatrists, need to bear this disorder in our minds for differential diagnosis. Since current treatment options mainly target visible symptoms, developing novel treatment strategies directed towards underlying etiology would be important. In that sense, we believe that increasing the number of case studies and researches in this understudied field of child psychiatry shall contribute greatly to have a better understanding of the disorder. Kleine-Levin syndrome (KLS) is a rare and frequently misdiagnosed disorder with typical onset at adolescence and a male dominance that is presented with hypersomnia, hyperphagia, disinhibited behavior and perceptive abnormalities. Even though increasing number of researches have been conducted to shed a light on its etiology, no clear underlying mechanism have yet been identified. Similar to relatively small information about etiology of the disorder, no specific treatment technique has been identified to successfully eliminate the phenomenon; however treatment options that target symptom relief and decline in frequency of episodes have been present. This case report aimed to present the clinical course of a 12 year-old adolescent with KLS who was successfully treated with a combination of Carbamazepine (CBZ) and short-acting methylphenydate (MPH) that was used during episodes, along with discussion of relevant literature. Montelukast is a selective leukotriene receptor antagonist which is prevalently used for the treatment of asthma in both children and adults. It is preferred as an add-on therapy to inhaled corticosteroids. Although a number of clinical trials suggested that montelukast is a safe drug in terms of adverse drug reactions (ADRs), several cases have been reported with nightmares and sleep abnormalities. With this case report, we aimed to present a female adolescent patient who had severe and long-termed nightmares after treated with montelukast. A 14 year-old female, who diagnosed with allergic asthma for 3 years ago, had some severe attacks in the certain time of the year. Her physicians took the disease under control with corticosteroids and they attempted to prescribe leukotriene receptor antagonist as an add-on therapy. During the therapy's second week, patient applied with severe nightmares. Her treatment was ceased. One-month after, she applied our child psychiatry unit. Her follow-up process was measured by "Children's Sleep Habits Questionnaire" and "Global Assessment Scale". Sleep disturbances including nightmares due to montelukast have not been described sufficiently, while several cases have been reported. Previous research showed that both adults and children developed psychiatric symptoms after the intake of the medication. However, the symptoms of the reported cases disappeared within 48 h after the cessation of drug intake. We aimed to discuss the management of longtermed nightmares despite of the discontinuation of the montelukast therapy. The use of montelukast can cause several ADRs, especially in children, of which physicians should be aware in their clinical practice. Human Immunodeficiency Virus (HIV) is a retrovirus. It affects CD4 lymphocytes and inflammation and neoplasms occur as a consequence of destruction of the cellular origin of immunity and disruption of the general immunity regulation. Many psychiatric syndromes can be observed in HIV-infected individuals, such as depressive disorders, anxiety disorders, personality disorders, bipolar disorder, alcohol-substance abuse disorders, delirium, dementia and psychosis. Our aim in this case report is to discuss the case of hypomania that develops in an HIV positive patient. A 41 year-old male patient was diagnosed with acquired immunodeficiency before 6-month and followed up at infection clinic, and the last three days of sudden onset of increased insomnia, more spending money, nervousness complaints. He was consulted to psychiatric polyclinic and at psychological examination of the patient, increased psychomotor activity was detected. Haloperidol 10 mg/day and biperiden ampule 5 mg/day for 3 days were applied. The diagnosis of the psychiatric illness was evaluated as hypomania due to acquired immunodeficiency. 1000 mg/day of valproic acid was started to patient whose symptoms were regressed by discussing the infectious diseases clinic. The patient has been followed in remission for the last three months. The prevalence of mania in HIV disease is 9%. Premorbid bipolar disorder in acute mania HIV disease; may be associated with opportunistic infections or AIDS-related neoplasms or treatments or HIV-based brain lesions. Self or family history of mood disorders were found in those who developed manic syndrome İn the early stages of HIV disease, but there was no family story in our case. Finally It is important that patients with acquired immunodeficiency can have various psychiatric disorders and the hypomanic attack should be kept in mind. Herbal supplements are used widely in alternative medicine. These supplements are mostly used for various health problems. There are reports for manic episodes caused by hypericum perforatum, physalis peruviana, arginine-ortinitine-lysine containing supplements. This case report illustrates a supplement containing wild berry as a cause of manic episode. The patient was 34 year-old man who has been working as a security officer. He was referred to our with manic symptoms. This symptoms were visible after starting an herbal supplement. Patient's Young Mania Rating Scale (YMRS) score was 32. When he did not accept to be hospitalized, he was prescribed antipsychotic. After patient was recommended on often visits. The last exam showed that the patient was recovered from the manic symptoms. When evaluated with Young scale again, he scored 6 on YMRS. In the patient giving the fact that working in shifts made it easier to onset of mania in genetically prone people. But the lack of family history and having no attacks in earlier ages as well as lacking the seasonal changes has driven away this diagnosis. The fact that manic episode has an abnormal onset age led us to think of an organic reason. Using an herbal supplement as well as the symptoms onset led to belief that this condition was caused by supplement. Diagnosis was supported by patient getting better after stopping the supplement. There were no case reporting that blueberry can be caused of manic episode. If there is no other stimulants in the after mentioned supplement, this case may be important for the effects of blueberry. The herbal supplements like this one causing our patient to have a manic episode, should be tested extensively. While questioning the patient about substances, we believe psychiatrists should question herbal supplements also. Corticosteroid use could cause psychiatric symptoms such as mania/hypomania or depression 1 . Also it is known that cannabis use increases the risk of developing mania 2 . We present two cases having first time manic episodes induced by cannabis or corticosteroid use and both were treated with quetiapine. Case 1: Our first case was a 37 year-old, married, female patient. One month ago she was diagnosed of solitary plasmacytoma. She was treated with dexamethasone 16 mg/day (approximately 106.6 mg/day prednisolone equivalent). On the tenth day of the steroid use she had insomnia, increase in her speech amount and speed, grandiosity and irritability. She was transferred to psychiatry clinic for having manic episode. She was treated with quetiapine 600 mg/day and corticosteroid was discontinued. The manic symptoms improved rapidly in two weeks and quetiapine was stopped a month later. During her follow-ups for two years she did not show recurrence. Case 2: Our second case is a 42 year-old, single, female patient. She had symptoms such as insomnia, grandiosity and increase in her speech amount and speed for a month. She was using cannabis every day for the last two months. The patient was hospitalized with the diagnose of manic episode and quetiapine 900 mg/day was started. After one month she was discharged and quetiapine doses were decreased to 300 mg/day. During her follow-ups for one year, she also did not show recurrence. Using corticosteroids for short term and high doses (>40 mg/day prednisolone equivalent) by intravenous administration causes more likely manic symptoms than depressive symptoms 3 . There are also other risk factors for our first case such as being female, having a first degree relative with psychiatric disorders and having hypoalbuminemia. For the both of our cases, the rapid improvement and not having any recurrence during long-term follow-ups showed that using quetiapine was an effective choice to consider. Psychotic and manic disorders are more common in patients with multiple sclerosis compared to the general population. Interferon-β1a treatment is commonly used for patients with multiple sclerosis and have several psychiatric adverse effects. These side effects are described as depression, delusion and acute delirium in studies and case reports. We will discuss the manifestation of manic symptoms after the interferon β 1a treatment has been started for the patient who has been followed up for ten years with diagnosis of multiple sclerosis. A 25 years-old male, working as security officer and diagnosed with multiple sclerosis for ten years presented with depressive mood, suicidal ideas, anhedonia, impaired sleep, and loss of appetite for 4 months was referred to psychiatry outpatient clinic from neurology. The patient gave no family history of bipolar disorder in a sibling. There was no history of substance abuse and psychiatric illnesses. It was learned that the patient had started IFN beta 1a treatment 6 months ago. Afterwards he began to exhibit euphoric mood, hyper sexuality, psychomotor acceleration, decreased need for sleep, excessive talkativeness for a month. In this period, it was learned that there was no psychiatric outpatient admission and that the functioning was not significantly affected. Because the patient don't have any mood episode story before and complaints emerged after the interferon B1a treatment, hypomanic episode is attributed to drug. Psychiatric side effects, particularly mood disorders, KEYWORDS Hypomania; interferon; multiple sclerosis have been reported with IFN-α treatment before but IFN-β-induced hypomania or mania is not yet fully established. Considering the link between IFN-β and psychiatric symptoms, physicians should closely monitor the patients who takes multiple sclerosis treatment. Marfan Syndrome (MFS) is mainly characterized by pathological connective tissue in various organ systems. The mutant fibrillin-1 (FBN1) gene misleads the constitutive pathways of various tissues through inappropriate transforming growth factor beta (TGF-β) signaling. Bipolar disorder (BPD) is believed to arise as results of impaired synaptic modulation and neural plasticity in crucial pathways those mediate cognition and affection. In the literature, Marfan Syndrome and BPD comorbidity has not been sufficiently figured out. This report aimed to present a Marfan Syndrome case with BPD with arguing probable impaired neuroprotective mechanisms. A 26 years-old male, was diagnosed MFS when he was found to have aortic root dilatation requiring surgical repair, in his 23, with confirmed lens dislocation and shown mutation in chromosome 15. The patient was diagnosed with BPD in his 18, with the first episode of mania. The patient was hospitalized with suicidal thoughts, anhedonia and sleeplessness, with the diagnosis of BPD depressive episode. He had been under per oral medication with olanzapine 10 mg/day and lithium carbonate 900 mg/day. We raised olanzapine up to 20 mg/day and lithium carbonate up to 1200 mg/day per oral and depressive symptoms improved. Defects on the microfibrillar-proteins may predispose for neurodevelopmental abnormalities. TGF-β was found to be affiliated with neurogenesis and developmental neural remodeling in animal studies. Altered TGF-β functions with pleiotropic effects to the brain could increase susceptibility to psychiatric disorders. Disrupted circuits of molecular signaling chains cause improper synapse formation, synaptic transmission and synaptic plasticity those ultimately end up with BPD. The mutant FBN1 gene in MFS misleads the TGF-β signaling and may disrupt its roles in neuroprotection and neurodevelopmental processes. Our report could pave the way for latter studies on possible shared etiopathogenesis via defective microfibril proteins, of both disorders.  Bipolar disorder, also known as manic depression, is a mental disorder with periods of depression and periods of elevated mood. The causes are not clearly understood, but both environmental and genetic factors play a role. Mania can be easily diagnosed generally. Early diagnose and suitable treatment provides some advantages like short duration of manic episode, decrease the possibility of new manic episode and protection of cognitive functions. In this report we presented case about first episode mania and conversion disorder like epileptic seizure differential diagnosis and treatment. The patient was a 31 year-old married woman. She complained sleeplessness, suspiciousness, irritability, self-mutilation, inappropriate crying and laughing attacks in the past 3 days. Because of these complaints she applied emergency service and after first treatment she consulted with psychiatrist. After first examination; initial diagnosis is manic episode so that olanzapine 5 mg/day was ordered. 2 days later she fainted like epileptic seizure or conversion disorder. After analyzing EEG and KEYWORDS Mania; conversion disorder; epilepsy Brain MRI by neurologist for differential diagnosis of manic episode or temporal lobe epilepsy. In MRI there is no major pathology but in EEG there is slow wave activity. Neurologist ordered carbamazepine 400 mg/day to the patient. Her seizure frequency increased after medication of carbamazepine so carbamazepine stopped. ECT has been applied 10 session and olanzapine dose potentiate to 20 mg/day. After this treatment her complaints seizures regressed obviously. Valproic acid was ordered to patient as mood stabilizer. Conversion disorder is now contained under the umbrella term functional neurological symptom disorder. In cases of conversion disorder, there is a psychological stressor. Conversion symptoms typically do not conform to known anatomical pathways and physiological mechanisms. Mania must be differentiated from conversion symptoms and disorder. So psychiatrist must be aware of this situation because early diagnose is important for treatment and prognosis of mania. Abstract The role of psychological and social factors in depression is important. Particularly major economic problems, loss of love object, experience of injurious events and more physical and psychological events cause to initiate and become chronic mood disorder. In this case report, it was aimed that negative life events could initiate to Major Depressive Disorder in vulnerable individuals to depression. A 62 year-old, uneducated, illiterate woman who was married 41 years ago and lost her husband from myocardial infarction 5 years ago, has 8 children and not working female patient. The patient has been seeing evil images and talking to them for the last 1.5 months. She thought that others have injured her. After the patient had lived in her hometown for 60 years, she migrated to her children a year ago due to economic problems. She was an unsocial, helpful, self-giving, benevolent, meticulous person. When she was a child, she experienced physical violence from her mother, her father and then her husband in marriage. When the patient was child her mother and father and then in marriage her husband may have been exposed to physical violence, loss of partner, migration from their home country for a long period of time, problems in their new environment, financial problems; they may have induced her unpleasantness, inferiority, imperfection, failure and inadequacy ideation and they may have led her to believe that she was a worthless and unloved person, that her future would dark and empty, and that she may has perceived it. The patient with personality traits that were susceptible to depression may has been exposed to adverse events many times during her life, has been unable to escape from them in the face of painful events, has been unable to cope them may have caused to depression. ABSTRACT Treatment-resistant depression (TRD) is a term used to describe case of major depressive disorder (MDD) that do not respond adequately to appropriate courses of at least two antidepressants. Bipolar disorder, also known as manic depression, is a mental disorder with periods of depression and periods of elevated mood. According to DSM-5, patients must be experiencing their first manic episode to meet the diagnostic criteria for bipolar I disorder, single manic episode. This requirement rests on the fact that patients who are having their KEYWORDS Treatment-resistant depression; bipolar disorder; predictive Mood disorders, depression and bipolar disorders, are the most common psychiatric comorbidities among patients with substance use disorders (SUD). Comorbid mood and SUD often have more severe illness that is difficult to manage compared with either a mood or a SUD alone. A 61 year-old man presented to emergency department with superficial wrist incisions. He is suffering unhappiness, misery, hopelessness, desperation, thoughts of death, insomnia, nasal discharge, sneezing, tearing, fatigue, trembling in hands and feet and not wanting to talk. Approximately 6 months of daily use of 2 gr heroin. The examination revealed that the patient's speech was vivid, elaborate, the amount and speed of the conversation increased, accompanied by mimics-gestures. The use of heroin is good for his own confusion, sleepiness, taking care of his work, doing his job, ensuring calmness in his movements. Despite the irritability of the mood, there were hopelessness, regret, sinful thoughts. The past history of the patient was detailed and diagnosed as bipolar disorder (YMRS score:17; HAM-D score:39) and treatment were given 100 mg of quetiapine. Findings of abstinence were not detected. Buprenorphine + naloxone were not needed. Follow-up treatment was regulated as lithium 600 mg/day and quetiapine 600 mg/day. Why are these comorbidities so common? Mood disorders may motivate individuals to resort to drugs and alcohol to cope with their negative affective states. Individuals will tend to select drugs that reduce their specific psychiatric symptoms. An underlying neurobiological tendency to sensitization may promote both drug dependence and mood disorders. Some evidence indicates that treating a comorbid mood disorder can decrease substance abuse and craving. Mood disorders and SUD comorbidity are common. Therefore, patients with SUD should be carefully questioned in other psychiatric disorders in their anamnesis. Successful treatment of one condition can be helpful recovery from the other. We report here a case of antibiotic-induced mania that developed in a 32 year old woman treated with ciprofloxacin for urinary tract infections (UTIs) and which resolved spontaneously after discontinuation. A 32 year-old housewife presents to the emergency department with her husband. She seems very restless, pacing up and down the emergency room. She is intermittently starts singing rather loudly. She is wearing bright and colorful clothes. The patient was started on 500 mg of oral ciprofloxacin twice daily for 7 days by the family physician. According to her husband, at the fourth days of treatment, the manic symptoms began. For the past 5 days she has had a broken sleep, but she feels increase of energy. She displays irritable mood, grandiosity, and excessive spending reflecting poor judgement for 5 days. Her speech was mildly pressured and tangential. Physical examination is unremarkable. There is no family history of any mental illness. Results of serum electrolytes, liver and renal function, and blood glucose tests; hemogram; brain magnetic resonance imaging; and electroencephalogram were within normal limits. She smokes 15-20 cigarettes a day, for 6 years. Antibiotic-induced mania, a rare but significant adverse-effect of many drugs, is mostly under-recognized. Our case is presenting with a manic episode. Her ciprofloxacin was stopped at admission. The patient improved as spontaneously several days after stopping the ciprofloxacin therapy. It means that, starting of treatment with mood stabilizing and antipsychotic drugs. Most cases of drug-induced mania are frequently resolved if the etiology is treated. Mania that has drug causes generally does not require protective mood-stabilizing treatment. Indeed, new-onset mania in older adults is most commonly secondary. The KEYWORDS Antibiotic; case; ciprofloxacin; side effect; mania started reducing within a week. Two months later YMRS score decreased to 6 and we stopped both valproate and risperidone. Therapeutic doses of stimulants can cause psychosis and/or mania symptoms in a small proportion of treated children. Presenting symptoms generally resolve within a week after discontinuation. However, the symptoms did not resolve with stoppage of MPH and we had to initiate valproate and risperidone in our case. Although not clearly understood, psychotic/manic symptoms may be associated with the mechanism of action of MPH. MPH inhibits the reuptake of dopamine and noradrenaline in the striatal, frontal, and temporal regions. Increased dopaminergic and/or noradrenergic activity in these regions may be related with the emergence of the symptoms. Eventually, this case highlights the fact that therapeutic dose of modified-release MPH may cause mania-like symptoms in children and adolescents with ID and psychopharmacological interventions may require to control these symptoms.

ABSTRACT
The role of stimulants in Bipolar Disorder has been an area of interest. 3,4methylenedioxymethamphetamine (MDMA) is an amphetamine derivative stimulant, and is typically the active component of ecstasy, a popular illicit drug. The pharmacological action of MDMA leads to a rapid and substantial increase in serotonin levels in the intrasynaptic space but it also boost dopamine, norepinephrine and acetylcholine in multiple brain regions. It may have antidepressant-like effects. MC is a 21 year-old man. In 2016, MC had used one ecstasy tablet and directly afterwards he was brought to the emergency service by his mother for increased level of energy, decreased need for sleep, increased verbal output with a disorganized thought process and auditory and visual hallucinations. The patient was hospitalized. Valproate (1000 mg/day) and olanzapine (10 mg/day) was started. He improved clinically and was discharged on day 35. At 12 weeks after discharge his mood was normal on assessments. After he had used one ecstasy tablet his symptoms relapsed. When he presented the second time, his behavior was more exaggerated than the first hospitalization. Olanzapine's dose was increased by 20 mg. At 4 weeks after increasing olanzapine, he improved clinically and was discharged. Our patient developed a manic episode with single dose use of MDMA. The case presented here is unusual because in most reported cases, the authors described manic episode in individuals who were heavy stimulant abusers and who also chronically misused other illicit drugs. It is documented that ecstasy may induce manic episode associated with psychosis among adults and it would be prudent for clinicians to routinely ask patients about ecstasy use and to include MDMA in toxicology screens. KEYWORDS Bipolar disorder; manic episode; ecstasy; 3,4methylenedioxy methamphetamine (MDMA) diagnosed with bipolar depression and hospitalized. He was taking lithium 900 mg, clozapine 400 mg, and quetiapine 400 mg as maintenance treatment. An add-on therapy of buspirone 15 mg/day was titrated to 30 mg/day for his anxiety. Neither antidepressants nor benzodiazepines were prescribed because of switch risk and cognitive impairment. In 2 weeks all complaints were improved and the patient was discharged. One week later, he presented with increased energy, elevated mood, improperly spending money, increase in sexual desire, decrease in need for sleep, flight of ideas, and boost in goal-directed activity. The patient was hospitalized with hypomanic episode. Buspirone treatment was discontinued and 300 mg quetiapine was prescribed. After 3 weeks the patient was discharged with partial remission. Buspirone, which the patient never used before, reduces depressive anxiety; however, manic shift can be interpreted as mania/hypomania induced by buspirone. Possible mechanism is that buspirone may enhance dopaminergic and catecholaminergic activity while inhibiting serotonergic activity in the central nervous system. In our case there is also a known bipolar disorder, it may be a hypomanic episode unrelated to the buspirone. Nevertheless, given the facts in the literature, hypomania may be developed after the onset of buspirone, and this case report may be an example for buspirone-induced mania/hypomania. Parkinson's disease (PD) is a chronic and progressive neurodegenerative disease co-occurring degeneration in dopaminergic neurons. It is recognized by the presence of a variety of neurological symptoms such as rigidity, bradykinesia, postural imbalance, and usually unilateral resting tremor. Although Parkinson 's Disease is mainly a movement disorder, it defined as a neuropsychiatric disorder due to often accompanied by affective, cognitive and psychotic disorders. The incidence of depression is around 30-40%, which the most common psychiatric disorder in Parkinson's disease. We aimed to share a case to contribute to the literature, which major depressive disorder was diagnosed in the outpatient clinic and understood to be Parkinson's disease causing depression as a result of detailed anamnesis and examination in the clinic. At the age of 55, he had Parkinson's disease for 6 years and did not receive any treatment. He applied to our clinic with reluctance, malaise, lack of enjoyment of life, decreased self-care, insomnia and decreased appetite. There were tremor, mask face, bradykinesia and parkinsonian walk depending on the Parkinson. The blood count, routine biochemistry, complete urine analysis, thyroid function tests were within normal limits. Cerebral magnetic resonance imaging was within normal limits. Patient's history was obtained from the family and this was not supportive of dementia diagnosis. Patient was counseled with neurological examination with MR results, and then Parkinson was diagnosed and Parkinson therapy was added to the depression treatment. In this case report, it was emphasized that depressive disorder may occur during Parkinson's disease monitoring, that patients should be watched carefully and the treatment should be regulated.