2025 Residency Symposium Poster Abstracts
Residents
First Author : Justin Adam, M.D.
Psychiatric Residency Program: Atrium
Additional Author(s): Layla Soliman, M.D.
Abstract Title:
Clozapine-Induced Myocarditis: A Case Report and Review of Risk, Monitoring, and Presentation
Introduction:
A 29-year-old male with severe treatment refractory schizoaffective disorder developed myocarditis after 14 days on first-time Clozapine therapy. This case report is intended to contribute to the growing body of evidence regarding the potential of clozapine to induce myocarditis.
Methods:
Data pertaining to the history, evaluation, and treatment plans from attending psychiatrist Layla Soliman, the medical team at Carolina’s Medical Center, and nursing/ancillary staff was gathered retrospectively by way of EMR (Epic) from 07/31/2024-12/31/2024. Objective data including lab values, vital signs, and study results was also done by retrospective review of the EMR from 07/31/2024-12/31/2024. Literature review was conducted via PubMed, UpToDate, and GoogleScholar (Elsevier).
Results:
Lack of abnormalities on routine laboratory monitoring just 48 hours prior to symptom onset rendered high clinical suspicion necessary to expedite further work-up (including patient transfer to a medical hospital) and treatment. Elevated troponin, EKG changes, and patient symptomatology were consistent with the diagnosis of clozapine-induced myocarditis which was then confirmed with cMRI. Symptoms presented 14 days into treatment, earlier than the median time to diagnosis of “Probable Myocarditis”. There was no observable evidence that our patient progressed to the point of cardiomyopathy. Our patient was ultimately discharged to a group home on Dual Antipsychotic Therapy (Zyprexa and Invega Sustenna).
Conclusions:
Our patient suffered from a case of clozapine-induced myocarditis which luckily was caught soon enough not to progress to further complications. High clinical suspicion played a role in a timely diagnosis for our patient as routine lab monitoring and preliminary diagnostics did not reveal his diagnosis. While the potential of clozapine to cause myocarditis is well-documented, the current risk is thought to be between 1 in 500- 1 in 10,000. A higher volume of documented cases is required to narrow down this window and aid in risk vs. benefit stratification when considering clozapine.
First Author: Liliana Gonzalez Cabrales M.D.
Psychiatric Residency Program: Atrium
Additional Authors: Yongyue Chen M.D.
Abstract Title:
Navigating the Thin Line: Conspiracy Theories and Delusions, A Case Report on a Healthcare Professional
Introduction:
Delusional beliefs are false convictions held despite evidence to the contrary, often stemming from abnormal personal experiences. Conspiracy theories are overvalued beliefs about the causes of social and political events involving secret plots by powerful actors shared by a group. These have increased with the internet, enabling faster exchange of ideas and amplifying beliefs through reinforcing content. Delusions are individual, implausible, and tied to personal experiences, while conspiracy theories can be more plausible, based on real events, and usually don’t impair daily functioning. The "paranoia spectrum" describes a continuum of mistrust, from skepticism to conspiracy beliefs and, at its extreme, persecutory delusions. Although distinct, the clinical difference between conspiracy beliefs and delusions is often unclear. Some suggest that non-delusional conspiracy beliefs can evolve into persecutory delusions, highlighting a fluid boundary between non-psychosis and psychosis.
Methods:
Case report
Results:
The patient is a 53-year-old male physician with a history of depression managed with SSRIs. He became intensely preoccupied with conspiracy theories, researching them on social media. Beliefs included Los Angeles wildfires caused by eco-terrorism and the U.S. being under undetectable drone attacks. His beliefs were reinforced by online information. Later, he developed persecutory delusions, believing his phone was hacked by linking app updates to an orchestrated attack. The patient’s spouse revealed erratic actions like driving for hours after seeing a firetruck believing an eco-terrorist fire was nearby. The patient reported racing thoughts, increased energy, sleep deprivation, self-neglect and memory lapses. He was diagnosed with a manic episode and was started on Quetiapine 200 mg. He reported reduced thought intensity and acknowledged his excessive preoccupation with conspiracy theories. However, despite improvement in manic symptoms, he continued to endorse persecutory delusions.
Conclusions:
Conspiracy theories and psychosis are distinct but linked by mistrust, forming a clinically hard-to-differentiate continuum. In this case, the patient’s conspiracy beliefs, reinforced by social media and events like Los Angeles wildfires, evolved into persecutory delusions, impairing his functioning in the context of bipolar disorder. His workload and sleep deprivation likely contributed. As a healthcare worker with high health literacy and insight, he recognized the harm of his conspiracy beliefs on his mental health, but his delusions remained fixed. This case highlights the spectrum from conspiracy thinking to delusions, with external reinforcement playing a role, and calls for further exploration of social media’s influence on conspiracy beliefs.
First Author: Margely Carrion Carrero, M.D.
Psychiatric Residency Program: Cone
Additional Author(s): Margaret Cinderella, M.D.
Abstract Title:
Somatic Symptom Disorder or Delusional Convictions? A Case of Functional Decline and Health Preoccupation
Introduction:
A 36-year-old female with a history of major depressive disorder with psychotic features and benzodiazepine dependency who was medically admitted following a suicide attempt on alprazolam and acetaminophen. Previously healthy until age 34, she developed an escalating pattern of obsessive illness concerns, abandoning one diagnosis after another following negative workups; her index suicide attempt leading to psychiatric diagnosis was approximately 6 months prior to presentation. Despite extensive reassurance and an unremarkable (though exhaustive) workup, she adopted progressively restrictive dietary patterns and limited her activity to 23+ hours daily in a dark room.
Methods:
She presented with a BMI of 15.44 on admission and there was significant concern for refeeding syndrome. She somehow enrolled in hospice despite no clear life-limiting diagnosis, reinforcing her belief in a severe, life-limiting illness. Following enrollment, she engaged in a three-week trial of voluntarily stopping eating and drinking (VSED). She spent significant time in online illness communities, where she originally encountered mast cell activation syndrome (MCAS) and myalgic encephalomyelitis/long COVID and became convinced she had a terminal illness, culminating in her suicide attempts and admissions. Notably, neither of these diagnoses is considered disprovable by their online communities.
Results:
She spent 20 days on the medical unit prior to transfer to psychiatric floor and was trialed on duloxetine, bupropion, mirtazapine, and olanzapine, often discontinuing medications due to nebulous side effects despite outward appearance of improvement. She routinely discussed a desire for medical aid in dying or travelling to Switzerland for assisted suicide. She was discharged from the inpatient psychiatric unit on 2.5 mg of olanzapine, 15 mg of mirtazapine, and 0.25 mg twice daily of clonazepam. Her conviction in undiagnosed medical pathology raised concern for delusional disorder, while her repetitive, compulsive research behaviors suggested OCD.
Conclusions:
This case underscores the blurred boundaries between SSD, DD, and OCD in patients with rigid health-related beliefs and functional impairment. While SSD is characterized by excessive distress regarding actual symptoms, DD involves fixed false beliefs resistant to contradiction, and OCD may manifest as intrusive illness fears with compulsive reassurance-seeking. The patient’s preoccupation with having a terminal diagnosis despite medical reassurance, extreme functional impairment, and suicidal ideation suggested SSD with possible delusional features versus obsessive-compulsive pathology. Understanding the phenomenology of somatic distress versus delusional conviction and compulsive behaviors is essential for diagnosis and management. Addressing the impact of online illness communities and cognitive distortions may be key in preventing further psychiatric and medical deterioration.
First Author: Stephanie Chien, M.D.
Psychiatric Residency Program: Cone
Additional Author(s): Nick Gabrielle M.D. and Molly Cinderella M.D.
Abstract Title:
“A Pinch of Spice, A Rift in Mind”: A case report of synthetic cannabinoid-induced psychosis in an adolescent
Introduction:
Synthetic cannabinoids, commonly known as “Spice” or “K2” are designed to mimic THC but evade FDA regulation by being labeled “not for human consumption.” Despite their classification as Schedule I substances by the Synthetic Drug Abuse Prevention Act in 2012, these drugs remain accessible and are associated with prolonged psychotic symptoms. This case report discusses the course of an adolescent male who developed persistent psychosis following synthetic cannabinoid ingestion.
Methods:
A 17-year-old male with no past psychiatric history was medically admitted for paranoia, emotional lability, insomnia, and decreased appetite two days after ingesting a spice gummy. His mom denied prior abnormal eye or limb movements, fever, headache, viral illness, or prodromal period. His neurologic exam was non-focal. Urine toxicology was positive for cannabis, but other labs and head CT were normal. The differential included synthetic cannabinoid-induced psychosis, autoimmune encephalitis, and catatonia. Given the temporal relationship with synthetic cannabinoid use, further encephalitis work-up was deferred. Catatonia was considered less likely with his increased engagement. He improved with olanzapine. After discharge, he showed symptom resolution at one month, prompting a dose reduction. Paranoia and ideas of reference emerged the next month despite abstinence from substances. Due to medication side effects, he was switched to aripiprazole, leading to resolution of paranoia.
Results:
Adolescents are vulnerable to synthetic cannabinoid-induced psychosis. Our case highlights that consistent, regular outpatient follow-up is a feasible alternative to inpatient psychiatry for patients with strong social support and minimal psychomotor agitation. This case is also unique in that the patient experienced several months of psychotic symptoms following a brief, initial exposure to synthetic cannabinoids. Synthetic cannabinoids may precipitate prolonged periods of psychosis, warranting further investigation into their long-term psychiatric impact.
Conclusions:
Synthetic cannabinoids can induce psychotic symptoms with durations ranging from 24 hours to several months after the ingestion of these substances. Outpatient management with close follow-up is appropriate for patients without immediate safety concerns. However, substance use confounds psychiatric diagnoses and necessitates careful evaluation. Antipsychotic treatment effectively mitigates symptoms, though medication side effects involve ongoing adjustments.
First Author: Katelyn Einloth, M.D.
Psychiatric Residency Program: UNC
Abstract Title:
Psychiatric decompensation and self-inflicted injury while incarcerated: a case report
Introduction:
Individuals with mental illness are overrepresented in carceral settings. Although incarcerated people have a legal right to healthcare, jails and prisons are ill-equipped to diagnose and treat mental illness. This case describes one patient’s clinical presentation after months of presumed psychiatric decompensation while in prison.
Methods:
Mr. H, a 38-year-old incarcerated male with a psychiatric history of attention deficit hyperactivity disorder (ADHD), major depressive disorder (MDD), antisocial personality disorder (ASPD), alcohol use disorder (AUD), and cannabis use disorder (CUD), was urgently transported via air ambulance to a level one trauma facility after a self-inflicted open globe eye injury. Despite being escorted to the hospital by prison staff, his identity and medical history were unknown at the time of his admission. Psychiatry was consulted after a behavioral response was called on the patient because of verbal and physical aggression toward staff.
Results:
Upon initial psychiatric evaluation, Mr. H was floridly psychotic and perseverated on a somatic delusion that he had a parasite in his brain. He repeatedly told staff that the parasite had entered his brain after he was stabbed in the jaw during a prison fight several months prior. Mr. H detailed his repeated pleas for help and attempts to seek medical attention, which was later corroborated by prison staff. In an act of desperation, he had attempted to use a chicken bone to remove his eye so that the parasite could be removed. Upon review of prison medical records, chief complaints listed for his multiple prison clinic visits included “substance user” and “malingering.” Mr. H underwent urgent ophthalmological surgery, but sight in his injured eye could not be restored. His anxiety and psychosis improved modestly with antipsychotics, though he continued to experience somatic delusions until the time he was discharged to another prison with a psychiatric unit for further stabilization.
Conclusions:
This case illustrates one patient’s psychiatric decompensation while incarcerated and exemplifies how the carceral system has failed mentally ill patients. The unfortunate reality is that many justice-involved individuals have unmet physical and mental healthcare needs due to a myriad of factors including, but not limited to, rapidly growing incarceration rates, budget cuts, staffing shortages, facility conditions, and limitations on drug formularies. Addressing these barriers to care is essential not only for the treatment of existing mental illness in prison settings, but also to reduce sentence lengths and reincarceration rates.
First Author: Mary Margaret Fessler, M.D
Psychiatric Residency Program: Duke
Abstract Title:
Ballots for the Behavioral Health Inpatient Unit (aka Ballots for BHIP)
Introduction:
Purpose: While voting is a right inherent to citizens of a democracy, many individuals with psychiatric disabilities lack access or face barriers on the way to the ballot box. Inpatient voting rights have been discussed in the literature from a civil rights, ethics, and self determination perspective, though care providers infrequently consider the suffrage of their patients (Rees, 2010). Patients are often unaware of their voting rights, may lack the knowledge on how to register or vote, or face barriers to participation in the same (Siddique & Lee, 2014; Graziane et al, 2024), with the low turnout among psychiatric inpatients raising concerns that accessibility is poor within a psychiatric inpatient setting (Melamed et al, 2007). This service effort sought to clarify and expand enfranchisement opportunities for psychiatric inpatients on a single inpatient ward ahead of the 2024 general election.
Methods:
Work conducted: Between the period of July- October 2024, a resident physician identified rules related to voting that pertained to psychiatric inpatients in North Carolina, attempted numerous times to get in touch with local board of elections, sent a number of unanswered emails, met with stakeholders, and, in concert with local experts and hospital administrators, developed a plan to legally support inpatient voting. The process of getting answers to questions related to inpatient enfranchisement was prolonged and difficult; but ultimately, a team of multi partisan volunteers was arranged to register staff and patients on the inpatient ward, ahead of the 2024 election.
Results:
Clinical Implications: As a result of this intervention, 2 patients were able to request absentee ballots, 1 new voter registered, and 3 people (2 staff, 1 patient) made voting plans. Voting has been determined to be a social determinant of health (Firth, 2022), and evidence suggests a positive correlation between voting and improvements in mental health and recovery from mental illness (Bazargan et al.,1991; Ballard et al., 2019; Bergstresser et al., 2013). Voting can, and should, be part of connecting patients to their community and fostering meaningful connections as they recover to return to society. Knowing the steps, potential pitfalls, and appreciating the tenacity required to introduce such an intervention may be illustrative to residents who wish to facilitate provision of similar services to their patients.
Conclusions:
Conclusions Reached: Increasing suffrage for psychiatric inpatients can be a complicated process; by sharing legal information, resources, methods, and expectations, more residents can feel equipped to support their patients in casting their vote ahead of elections. Creating healthy democracies is part of creating healthy communities and should be part of our advocacy work as psychiatrists.
First Author: Alexandra Grzybowski, D.O.
Psychiatric Residency Program: Cape Fear Valley
Additional Author(s): Brody Montoya, D.O. and Geoffrey Green, D.O.
Abstract Title:
AI as an Instrument in Trainee Research: Enhancing Research Efficiency in Psychiatry Residency
Introduction:
Research participation is an essential component of psychiatric residency training, yet significant barriers persist, including time constraints and inefficiencies in research execution. Recent academic discussions highlight the potential for artificial intelligence (AI) to enhance research efficiency and effectiveness. This quality improvement project, conducted within the Adult Psychiatry Residency Program at Cape Fear Valley Health (CFVH), sought to introduce AI as a research tool and assess its impact on residents' understanding, confidence, and willingness to integrate AI into their research practices.
Methods:
A curriculum-based intervention was developed in the form of an in-person presentation titled “AI as an Instrument in Trainee Research: Turning a Rock into a Toolkit.” The curriculum covered fundamental AI concepts, specific AI tools applicable to research, ethical considerations (including bias and HIPAA compliance), and academic journal policies on AI use. Participants completed a ten-question pre- and post-presentation survey, where questions six through ten used a 10-point Likert scale to assess their knowledge, confidence, and attitudes toward AI in research. Statistical analysis was performed using paired t-tests (significance level: two-tailed p< 0.05) and Hedges’ g to measure the effect size.
Results:
Seven residents participated in the intervention. Statistically significant improvements were observed across all survey questions assessing AI knowledge, familiarity with tools, confidence in addressing ethical concerns, likelihood of AI utilization, and awareness of journal policies (ranging from 71% to 116% above baseline scores). The overall survey mean score increased from 20.71 (SD = 8.34) pre-intervention to 36.43 (SD = 9.50) post-intervention. Effect size calculations (Hedges’ g) confirmed moderate to strong improvements across all individual and overall areas, with values ranging from 0.962 to 1.577.
Conclusions:
The educational intervention successfully enhanced residents’ understanding of AI applications in research and increased their confidence in using AI tools while addressing ethical concerns. Future iterations should expand participation and focus more on journal-specific AI policies to further refine AI integration in psychiatric research training. Next steps for this project include resident feedback regarding their experiences with AI introduced in the presentation, and specific education to improve on intermediate/advanced user experience.
First Author: Daniela Hoang, M.D.
Psychiatric Residency Program: Cone
Abstract Title:
Clozapine and Cholinergic Rebound: A Case Report
Introduction:
Clozapine is an antipsychotic known for treatment-resistant schizophrenia. While its effectiveness is high, it does not come without caution. Adverse effects that are commonly discussed include sialorrhea, constipation, myocarditis, seizures, and neutropenia. Some of these adverse effects are due to the anticholinergic and cholinergic properties of the medication. In this case report, we will discuss a patient who experienced an episode that was likely due to the management of clozapine.
Methods:
The patient is a 57 male with past psychiatric history of schizoaffective disorder, depressive type, seizure disorder, developmental delay, and alcohol use disorder who presented the inpatient psychiatric hospital for further psychiatric stabilization. At home he was on clozapine, fluoxetine, and lorazepam. During the first day of hospitalization, there was concern for catatonia so he received intramuscular lorazepam and he showed a positive response. His home clozapine and fluoxetine was continued this same morning. With the patient having dizziness, weakness, and overall blunting prior to hospitalization along with the first few days while the patient was hospitalized, there was a concern that the patient was intolerant to his clozapine dose so this was gradually decreased. The next day, the patient's clozapine level that was drawn six days ago resulted and was found to be 1,723 ng/mL.
Results:
The patient’s mother visited the next morning, after which staff reported the patient became preoccupied with exposure to germs and was given an oral agitation protocol. Within a few minutes, the patient began sweating profusely, became hypertensive and restless along with cogwheeling and truncal rigidity on physical exam. During the episode, the patient was noted to be preoccupied about germs and exhibited stereotypic movements. He was noted to be conscious of what was happening and reported loss of control of movements. Patient was given benztropine 3 mg, lorazepam 1 mg and a dose of clozapine 150 mg. Patient was later re-evaluated and he was more alert, calm, cooperative, and vitals were stabilized. The patient's clozapine dose was increased to 500 mg that day. The next day, the patient's clozapine dose was reduced to 450 mg total as his obsessive-compulsive symptoms were much improved.
Conclusions:
Differential diagnosis includes cholinergic rebound (from decreasing clozapine dose + giving as needed haloperidol) only, hyperactive catatonia (excitement, stereotypy, and autonomic abnormalities) secondary to OCD, NMS (physical exam + unstable vitals), malignant catatonia (VS abnormalities + rigidity, but no temp elevation, no CK elevation). Most likely cholinergic rebound as patient’s symptoms resolved with benztropine (and did not need IM lorazepam (if catatonia) or dopamine agonist medication (if NMS)). Conclusion: Look at time of drawing the clozapine level (not trough), balancing the clozapine decrease rate with psychotic symptoms and cholinergic rebound risk (should we have added another antipsychotic to offset the risk), changing the agitation protocol antipsychotic drug of choice (haloperidol vs. chlorpromazine vs zyprexa?)
First Author: Katherine Kessler, D.O.
Psychiatric Residency Program: Campbell
Additional Author(s): Janki Shah, D.O.; Aidan Tirpack, B.A. (MS4); and Kenneth Fleishman, M.D.
Abstract Title:
Picturing Psychosis: Insights into Mental State Through Art
Introduction:
Although medication therapy is the standard approach for managing psychotic symptoms, developing a therapeutic alliance that allows providers to empathize with a patient’s personal experience is crucial. At times, it can be challenging for providers to fully sympathize with the delusions and hallucinations of a psychotic episode. Patients may offer detailed accounts through talk therapy sessions, but often this is obfuscated through disorganized thought process or speech. Studies among patients with significant trauma history have shown artistic expression can provide an avenue to process and discuss difficult experiences. We observed patients experiencing psychotic symptoms may similarly benefit from art therapy as a means to process and relay their perceptions.
Methods:
We hereby present a series of cases from our inpatient psychiatric unit where art therapy played a fundamental role in the care of patients diagnosed with a primary mood disorder with psychotic features. In all cases, patients were encouraged to express their feelings and emotions through creation of artwork. Interestingly, these patients elected to depict their psychotic symptoms through art. The patients found this process therapeutic, and continued to use artwork to communicate their internal feelings, hallucinations, and delusions. Patients were eager to share creations with provider team and discuss how the contents related to their current symptoms. This allowed provider team to track improvement in psychotic symptoms and gave patients a unique avenue to discuss distressing hallucinations.
Results:
The attached pictures are the compilation of our patients’ artwork throughout their stay on the inpatient psychiatric unit. Pictures from earlier in the stay display more distressing themes such as death, purgatory, and malicious figures. We found the artwork was consistent with the patients’ internal feelings and provided detailed depictions of their delusions and hallucinations. As shown, the subjects of the artwork progressively begin to incorporate more positive scenery and themes. The change observed through the artwork was directly correlated with resolution of the psychotic symptoms. All patients described having the opportunity to explore creative outlets was therapeutic and helped their recovery.
Conclusions:
Often while hospitalized, patients are encouraged to find positive coping strategies for managing negative emotions. The described patients all chose artistic expression as their main method of coping with negative emotions and psychotic symptoms. The initial goal of art therapy was to serve as a recreational activity, but we discovered artwork allowed patients to better voice their psychotic symptoms to the provider team. Having a visual representation of the psychotic symptoms showed providers the individual experiences of the patients and helped monitor improvement in symptoms. Allowing patients to express their pathology in a creative way can benefit the patient’s experience and provider’s understanding, and we believe this should become common practice on an inpatient setting.
First Author: Asif Khan, M.D.
Psychiatric Residency Program: UNC
Abstract Title:
Improving access to language interpreters and accessibility assistance across UNC Psychiatry
Introduction:
Language in-access threatens the well-being of more than 27 million US residents with limited English proficiency. Long documented as a primary driver of health inequities for refugee and migrant communities, it blocks their interactions with critical health care providers at every step. We have identified some of the key barriers which includes a) lack of awareness at the top of institutions, driven by an overwhelming absence of quality control or data collection on use and quality of interpretation services; b) widespread reliance on “interpreter volunteerism” - where English-speaking relatives or friends are relied upon to interpret medical information; c) No channels for patients to provide feedback on availability or quality of interpretation services.
Methods:
We have created an interdisciplinary and diverse committee comprised of several members of the outpatient clinic leadership, administrative staff, care coordinators, clinicians, residents, and interpreters. The committee established clear short- and long-term goals with the goals to:1.Start a dialogue to identify the most common challenges associated with language & communication barriers for our vulnerable patient populations. 2.Create awareness and design education/training materials for clinicians and staff. 3.Improve clinical workflow and ensure adequate language access across outpatient psychiatry clinics.
Results:
1.Closely collaborated with in-house interpreter services to enhance their mental health interpreting skills via in-house consultation and providing external evidence-based resources2.Created and disseminated practical and effective educational materials for clinicians and staff members including but not limited to: best practice guidelines when working with interpreters, how to request interpreters depending on specific clinic settings, ADA-specific workflows embedded via EPIC EMR in registration and check-in processes. 3.Obtained ID badges with contact info of language service vendors and created "Language Identification Card" for front desk
Conclusions:
As next steps to this first of a kind initiative to critically assess and practically improve language interpreters and accessibility assistance to improve patient care who those who speaks limited English, we plan to focus on sustaining this resident-led effort by creating opportunities to pursue quality improvement projects based on continuous data collection and informatics. We hope to identify preliminary relevant data, metrics, and outcome measures that should be tracked to make this process successful. Long term, we hope to share our model and the lessons learned with other medical/mental health clinics to improve communication for some of the most disadvantaged refugee and migrant patient populations with limited English-speaking proficiency.
First Author: Artie McCarty, M.D.
Psychiatric Residency Program: Cone
Additional Author(s): Margaret Cinderella, M.D.
Abstract Title:
When Cancer Treatment Cannot Wait: Ethical Justifications for Treatment Over Objection
Introduction:
Psychiatrists are frequently asked to weigh in on a patient’s capacity to refuse treatment, most commonly using the four-pillars model popularized by Applebaum and Grisso. While this approach standardizes common ethical dilemmas seen on the consultation-liaison service, it leaves out the vital question: what do we do next?
Methods:
A 68-year-old male with long-standing schizophrenia, COPD secondary to tobacco use, and chronic homelessness was medically admitted for acute COPD exacerbation while experiencing acute psychosis. When seen by the consult psychiatry team he was noted to exhibit bizarre behavior including cleaning walls with poop, disorganized thoughts, and hyperreligious preoccupations, for which was started on previously effective paliperidone. An incidental lung mass, highly suspicious for cancer, was identified, with radiographic features favoring responsiveness to radiation monotherapy. The patient, experiencing delusions (most notably that “nicotine patches cure cancer” and “you cannot kill cancer because RJ Reynolds created the cigarette”), initially refused diagnostic workup, prompting the decision to proceed with biopsy and MRI (for brain metastases) over patient objection. Given patient's inability psychosocially to follow-up, urgent in-hospital treatment was necessary to prevent missed intervention and disease progression. After biopsy confirmed cancer, the patient intermittently assented to treatment but lacked full capacity for consent. The hospital ethics committee recommended proceeding with single-dose radiation therapy. The patient received the radiation, which he tolerated well, and was discharged in a more stable psychiatric condition with a follow-up plan.
Results:
This poster will illustrate the application of the Rubin-Prager framework in evaluating and addressing treatment refusal in patients with serious mental illness. Using this case as an example, we will demonstrate how ethical and clinical principles guide decision-making when a patient lacks the capacity to refuse treatment throughout hospitalization and will discuss alternate scenarios in which treatment over objection would not have been pursued.
Conclusions:
Capacity evaluations are an important launching point when determining next steps after patients refuse treatment, and the decision to proceed with treatment over objection necessitates a holistic, case-specific approach.
First Author: Brody Montoya, D.O.
Psychiatric Residency Program: Campbell
Additional Author(s): Godwin Dogbey, M.A., MPhil, Ph.D.; Hayley Lazar, M.D.; Brianna Becker, D.O.; Elizabeth Davoli, D.O.; Hannah Contreras, M.D.; and Aidan Tirpack, B.A.
Abstract Title:
The Association Between ACEs and ENDS Use in Adults: A Retrospective Analysis
Introduction:
Adverse childhood experiences (ACEs) have a well-known association with the use of tobacco products. While tobacco products and Electronic Nicotine Delivery Systems (ENDS), also called e-cigarettes, both contain nicotine and have similarities with use, they are separate substances with potentially different factors associated with use. Previous literature regarding ACEs as a risk factor for ENDS use focuses on specific populations while current literature for adults overall is limited. This study evaluates whether elevated ACE scores (≥ 4) are associated with current ENDS use in the general adult population. The aim is to improve the understanding of possible risk factors for ENDS use, with the purpose of guiding current ENDS prevention and treatment efforts.
Methods:
This study analyzes 7,275 responses from the 2021 New York State Behavioral Risk Factor Surveillance System dataset. All responses were from individuals 18 years and older. An adjusted odds ratio (OR) and 95% confidence interval (CI) were obtained from a logistic regression model that assessed the associations between adverse childhood experiences and current ENDS use. Covariates in the model included age (reported in 5-year increments), gender (self-identified), race/ethnicity, LGBTQIA+ status, and smoking history. Adjusted ORs with CIs were also obtained for the associations of listed covariates with ENDS use using logistic regression. Statistical analyses were performed by a biostatistician using a well-known statistical program, SPSS.
Results:
Individuals who reported an ACE Score ≥ 4 were 1.844 times more likely (95% CI 1.392 to 2.443) to report current ENDS use compared to those who reported an ACE< 4. Individuals who identified as LGBTQIA+ were 2.516 times more likely (95% CI 1.693 to 3.737) to report current ENDS use compared to those who did not. Individuals who reported a history of cigarette smoking were 6.524 times more likely (95% CI 4.689 to 9.078) to report current ENDS use compared to those with no reported history of smoking cigarettes. There was no significant difference in the odds of ENDS use when comparing gender or race/ethnicity. Though the prevalence of ENDS use generally decreased with age, there was also no significant difference in the odds of ENDS use when comparing age groups.
Conclusions:
Similar to the literature regarding tobacco use, these findings suggest that ENDS use prevention and treatment should be trauma-informed, consider factors of use in special populations, and navigate the spectrum of use as harm reduction versus as a primary substance. In addition to medications, health organizations, e.g. U.S. Centers for Disease Control and Prevention, publish non-pharmacologic strategies that consider trauma, special populations, and pathway to use for tobacco cessation. Clinicians may consider adapting those strategies to assist with ENDS use treatment in their adult patients. The broad application of these findings is limited. Prospective research from a nationwide sample that considers other potential risk factors, such as socioeconomic factors, should be performed.
First Author: Lindsey Szakasits, M.D.
Psychiatric Residency Program: Campbell
Additional Author(s): Gualberto Morco VI, D.O. and Nicholas Tito, M.D.
Abstract Title:
Routine Assessment of Waist Circumference in relation to Metabolic Monitoring of Antipsychotic Use in the Outpatient Setting
Introduction:
Being on an antipsychotic medication is a known risk factor for metabolic syndrome which can lead to or contribute to heart disease, diabetes, stroke, and other health problems. Because of this, the American Psychiatric Association (APA) has laid out practice guidelines regarding monitoring for physical conditions and side effects for patients on an antipsychotic. The APA specifies routine assessment of waist circumference, blood pressure, triglycerides, lipids, and fasting glucose. It is also important to consider the difficulties that patients with mental health problems face in having the medical side of their health managed. Therefore, it is key for the psychiatrist to lead the way in following up with these routine assessments. In this project, we undertake a quality improvement initiative with a focus on patients on an antipsychotic who are seen at the Cape Fear Valley Community Mental Health Clinic (CFV CMHC).
Methods:
Epic's slicer dicer was used to pull data of all patients on an antipsychotic that were seen in the CFV CMHC resident clinic in the month of October 2024. Concurrent use of other psychotropics were not criteria for exclusion. Indication for antipsychotic use was also not a determining factor on whether a patient was included or not. Chart review was focused on age, BMI, antipsychotic medication, sex, who ordered the lab work, waist circumference, fasting glucose, and blood pressure. Additionally, history of DM, HTN, HLD, and their associated medication treatments as well as lab work were noted. Our quality improvement project also entailed providing provider education, measuring tapes, and an EMR dot phrase to be incorporated into the outpatient documentation template. Third year psychiatry residents, who were the key clinical staff in the outpatient clinic, were oriented regarding the intervention by late December 2024.
Results:
Preliminary data from the month of October 2024 showed poor adherence to the APA practice guidelines of routine assessments at CFV CMHC. In particular, only 2 out of 103 patients on an antipsychotic had their waist circumference measurement offered. One deferred while the other consented to waist measurement. Pending data include an assessment of a four-week period of patient encounters at CFV CMHC starting January 2025. This will determine the rate of care gaps in metabolic monitoring post intervention with specific focus on waist circumference. Rates of assessment compliance pre and post intervention will be compared.
Conclusions:
Providers are generally inconsistent with measuring waist circumference in patients taking antipsychotic medications. Based on our preliminary data, this is true in our psychiatric residency clinic as well. Post implementation data will provide insight to the influence of provider education, access to resources, and reminders for routine assessments on adherence to practice guidelines. APA compliance is important not only in patient safety and standard of care, but also vital in medical training.
First Author: Tyler James Thompson M.D.
Psychiatric Residency Program: WFU
Additional Author(s): Samantha Ongchuan Martin M.D., Brandon Chen M.D., and Sebastian Kaplan Ph.D.
Abstract Title:
Assessing the Impact of Resident Led Group Therapy in Patient Care: A Quality Improvement Project
Introduction:
In NC, there are limited treatment options for people with early episode psychosis living in the Piedmont Triad region. To address these disparities, we introduced a resident led, group therapy program targeted towards patients with a recent diagnosis of psychosis. Group psychotherapy is widely recognized in mental health treatment, yet it remains underprioritized in residency education. By establishing this opportunity, we not only improve patient outcomes but also improve the quality of resident psychotherapy education in a cost-effective and sustainable manner. Acceptance and Commitment therapy (ACT) has proven clinically effective for individuals with psychosis. As a transdiagnostic model, it focuses on shared human experiences, which makes it ideal for group programming.
Methods:
We recruited patients ages 18-30 with a recent diagnosis of a psychosis disorder from a behavioral health outpatient clinic in April 2024. The curriculum consisted of 7 weekly, 1-hour in-person sessions of group therapy based on feasible standardized ACT curriculum for psychosis3 and in collaboration with other ACT practitioners. Each session was led by 2 residents and supervised by an attending psychiatrist and psychotherapist. Demographics characteristics were 60% male and 40% female; 60% Black/minority and 40% non-minority (N=5). Most sessions include an icebreaker, a mindfulness exercise, and activities focusing on ACT principles. We elicited informal qualitative and quantitative feedback each week and with more formalized feedback halfway through and after programming.
Results:
Based on the mid and post-session feedback measuring the helpfulness of ACT concepts, participants overall found increasing benefits in applying ACT concepts in their lives. They rated ACT theoretical processes as helpful to them on the Likert scale midsession as 83.75% to 100% by the post session. We saw an increase in helpfulness in the more complex theoretical processes, such as Defining Valued Directions (75% to 100%), Mindfulness (75% to 100%), and Acceptance/Willingness (85% to 100%). Regarding comfortability within the group and its impact on their lives using the Likert scale, participants generally felt welcome and safe to express their viewpoints (92.5% to 100%). Use of ACT skills learned in the group and overall feeling of the importance of the group increased from mid-session to post-session feedback (87.5% to 100%).
Conclusions:
In conclusion, 100% of our participants found benefit to initial pilot resident led group psychotherapy program, with generally positive feedback from participants regarding positive group atmosphere and opportunities to practice mindfulness/willingness. Not only was the formation of the pilot session streamlined and cost-effective, but this program is sustainable due to high patient demand and resident interest. It serves as an opportunity to improve graduate medical education for psychiatric residents while improving local patient outcomes, possibly as a scaffold for other group-based psychotherapies, such as DBT in a psychiatric residency program. More data is needed to measure patient outcomes with future directions to precisely measure psychological flexibility and functionality and resident outcomes in satisfaction and group therapy knowledge.
First Author: Malcolm Vaught, M.D.
Psychiatric Residency Program: Campbell
Additional Author(s): Meera Patel, M.D.; Antonios Anagnostopoulos, D.O.; Elizabeth Shaffer, M.D.; Daniel Van Rooyen, OMS4; and Kenneth Fleishman, M.D.
Abstract Title:
The Need for More Local SAIOPs: A Retrospective Study Highlighting the Extreme Prevalence of Substance Use Disorders and Comorbid Associations Among Inpatient Adolescents in a Community-based Sample
Introduction:
A decline was reported in adolescent substance use in 2019 prior to the onset of Covid-19, but studies showed mixed results with maintenance of this decline between 2020-2022. Nationwide data were poorly correlated with perceived substance use rates among adolescents within our local psychiatric inpatient population. Substance use disorders (SUDs) frequently co-occur with psychiatric disorders, but few studies have addressed these correlations in an inpatient adolescent psychiatry setting. Adolescent substance abuse treatment is limited in our community. Thus, the purpose of this study was to identify adolescent inpatients with SUDs, relationships between SUDs and psychiatric factors, and if there is more need for local adolescent SUD treatment resources.
Methods:
With IRB approval, a retrospective chart review was conducted of 367 patients from 06/01/2022 to 07/01/2023. Subjects were aged 13-17 years old, in-state residents, admitted to the local adolescent inpatient psychiatric unit with any primary psychiatric diagnosis, and had specific SUD data recorded during admission. Variables included age, sex, gender identity, sexual orientation, substance(s) abused with frequency and age of first use, psychiatric diagnoses, trauma history, family living arrangement, and current and past outpatient psychiatric, psychotherapy, and SUD treatment. Data was analyzed using multiple regression analysis and ANOVA testing, with significance level of p<0.05.
Results:
Of the sample, 34.3% had Cannabis use Disorder (CUD) and 9.54% had Alcohol use Disorder (AUD) [both higher than national data 10.1%/2.9% respectively]. PTSD diagnosis had significant relationships with any substance “tried” (p<0.001), SUD (p=0.004), Poly-SUD (p=0.021), and CUD (p=0.003). DMDD diagnosis correlated with any SUD (p=0.045) and CUD (p=0.023). No significant correlation was found with ADHD/MDD diagnosis. Significant reduction in SUD were shown with age 13 years (p<0.001), non-binary gender (p=0.040), transgender male (p=0.0242); while Poly-SUD and severe AUD were correlated with emotional (p=0.001/0.017) and sexual (p=0.009/0.034) traumas respectively. The sample showed 1.53% of patients with a SUD had prior SUD treatment compared to the national report of 16.81%.
Conclusions:
The results suggest a significant SUD burden among the local inpatient adolescent population in our community compared to national SUD reports. DMDD and PTSD diagnoses were correlated with any SUD, poly-SUD, and CUD. However, this was not seen in MDD or ADHD, suggesting treatment could be targeted toward response to trauma or managing irritability rather than impulsivity alone. Of the sample, only 1.53% of patients with a SUD received specific outpatient SUD treatment, compared to national reports of 16.81%. These results support the need for greater outpatient resources such as SAIOP treatment for adolescent patients in our community and may be utilized to advocate for such development efforts at local and state levels.
First Author: Austin Weld, M.D.
Psychiatric Residency Program: Campbell
Additional Author(s): Malcolm Vaught, M.D. and John Lesica, M.D.
Abstract Title:
It’s Always Complicated: The Relationship Between Autoimmune Disease and Psychosis – A Case Report
Introduction:
Psychotic illness has a lifetime prevalence of approximately 1.5-3.5% in the general population. Causes of psychotic symptoms are vast, but the relationship between autoimmune disorders and psychotic symptoms has been increasingly recognized. Recent literature has coined the term autoimmune psychosis (AP) to describe this relationship. A myriad of antibodies have been found in association with AP, including those involved in systemic lupus erythematosus and Hashimoto thyroiditis. Although causes of psychosis vary, medical professionals are often quick to assume that a primary psychopathology is at play, which can inadvertently lead to misdiagnosis and delays in treatment. To help reduce this bias, we present a case of first episode psychosis in the context of suspected autoimmune disease.
Methods:
A 42-year-old female with a psychiatric history of major depressive disorder, generalized anxiety disorder, and attention deficit hyperactivity disorder presented to the outpatient clinic with complaints of new onset auditory hallucinations and paranoia for 2-3 months. She reported acute worsening of symptoms for two days prior to evaluation, including decreased need for sleep, racing thoughts, irritability, and pressured speech. She described her auditory hallucinations as consisting of various "characters" in her head, some of which were encouraging her to attempt suicide. Her Young Mania Rating Scale was >20 on presentation. She was referred to the emergency department and subsequently hospitalized for psychiatric stabilization. At time of admission, a comprehensive laboratory workup was performed.
Results:
Laboratory studies were significant for an elevated ESR, CRP, RF, and strongly positive ANA (1:320 ratio). Extended antibody testing was positive for anti-Ro (SSA) antibodies, suggestive of an active autoimmune process. During hospitalization the patient was started on risperidone for continued psychotic/mood symptoms, which partially improved affect stability and delusional content. However, fixed paranoid delusions remained for many weeks after patient had been discharged from the hospital. Patient has continued treatment with antipsychotic therapy but has also been established with rheumatology for additional evaluation.
Conclusions:
This is a case of a 42-year-old female with new onset psychosis in the context of a positive ANA and anti-Ro (SSA) antibodies. Although a primary psychotic disorder is possible, this patient’s findings are more suggestive of an underlying autoimmune induced psychosis. Psychosis and other psychiatric symptoms may be the first or only manifestation of autoimmune disease (AD). In particular, isolated psychosis is increasingly found to be associated with AD and illustrates the importance of maintaining a medical cause of psychosis as part of the differential diagnosis until proven otherwise. Secondary causes of psychosis require alternative interventions/treatment modalities to maximize patient care outcomes.
First Author: Benjamin Wise, M.D.
Psychiatric Residency Program: Cone
Additional Author(s): Margaret Cinderella M.D.
Abstract Title:
Imperfect Handoff: Misapplication of Interview Techniques in the Paranoid Patient
Introduction:
Patient was a 40-year-old male with PPH of schizoaffective disorder, MDD, GAD, social anxiety disorder, and insomnia and with a past medical history of HTN and tardive dyskinesia who presented to the hospital accompanied by sheriffs after he chewed through both of his wrists attempting to escape from restraints. He severed one median nerve and severely damaged the other with his teeth. The initial prognosis was the total loss of function in both wrists. Psychiatry was consulted for his acute psychosis and remained onboard during his lengthy recovery and subsequent surgeries. During his 1.5-month stay, complicated by infections and multiple surgeries, the patient was initially followed by a psychiatry intern and the attending psychiatrist. He started on multiple antipsychotics after monotherapy medication trials failed (risperidone, aripiprazole, olanzapine, thorazine, haloperidol) failed. Patient developed worsening akathisia, and the patient was slowly cross titrated on Clozaril.
Methods:
Despite the patient’s paranoia, the initial team gradually built a therapeutic alliance. The patient began to share the details of his hallucinations, paranoia, delusions of reference (e.g., the entire movie "The Hateful Eight" is Tarantino's "Legacy Film" about his life, the Dr Scholl's shoe advertisements about "I'm gelling" are a reference to how he's doing well in life, a random plastic gum wrapper on his mother’s lawn was a message that the individually-wrapped food items were poisoned by the hospital staff), and the violent fears that had led him to self-injury (believing that the police were planning to vivisect and then eventually murder him.
Results:
The intern, building on a Rogerian framework of supportive psychotherapy, tried to conduct a warm hand-off with the patient’s subsequent resident psychiatrist. The introduction of a new provider, mentioned as the “good friend” of the intern who would “take excellent care of him”, caused the patient’s paranoia to worsen – the oncoming resident’s casual comment about going to the gym with the intern led to worsening paranoia that the hospital would put the patient into a “gay prostitution ring.” The patient stopped sharing details of his delusions and paranoia with the treatment team, masking any progress of the Clozaril titration. During this phase, collateral from the patient’s mother and nursing staff were essential in gauging clinical improvement. The attempt to hand-off this patient’s therapeutic alliance with one physician effectively amputated the patient’s trust in the team. He was ultimately transferred to a state psychiatric hospital with significant ongoing psychosis.
Conclusions:
Clinical Relevance: Fledgling psychiatrists should read “Clinical Interviewing: The Principles Behind the Art.” The PGY1’s high valence empathy statements and efforts backfired due to the patient’s paranoid interpersonal stance. A more effective, engagement-building approach for this patient would have been a more matter of fact or “low empathetic valence” handoff. Attempting to foster second-hand therapeutic alliance, while tempting, can be harmful in the case of the paranoid patient. Presentation poster will include the conceptual framework of Shawn Christopher Shea, MD from his book, “Psychiatric Interviewing: The Art of Understanding” and put it into an approachable set of didactic resources for users to apply for paranoid patient interview management.
Medical Students
First Author: Madeline Brown, B.S.
Medical School: Duke
Additional Author(s): Nicole Schramm-Sapyta Ph.D.; Jessica Sperling Ph.D.
Abstract Title:
Using Community-Engaged Qualitative Methods to Assess Efficacy of County Jail Programming for Individuals with Serious Mental Illness and/or Substance Use Disorder
Introduction:
The United States criminalizes social ills and behavioral health conditions. As a result, the criminal-legal system has become a de facto mental health treatment system. Los Angeles County and Cook County Jails each hold more individuals with mental illness than any psychiatric hospital in the US. In 2019, 68% of individuals in jail met the criteria for a substance use disorder, while only approximately 8% of the general population did. Decreasing the population of inmates with behavioral health conditions and strengthening community treatment services should remain the goal. However, improvement of jail services, which are mandated bylaw and have far-reaching benefits for the individual’s health and stability, public safety, and cost, should be pursued in the interim.
Methods:
In a county in North Carolina, the government’s Justice Services Department (JSD) administers programs toward this goal. This research project is a partnership with JSD to evaluate their programs. Through community organizations serving people who are formerly incarcerated with serious mental illness and/or substance use disorders, we recruited participants for 7 focus groups. Broad discussion topics included the experiences of JSD program participants, their perceptions of program effectiveness, and how programs could be improved. Audio files were transcribed, qualitatively coded, and thematically analyzed. Principles of community-engaged research were followed such as soliciting feedback from relevant community organizations during the development of the focus group question guide, co-facilitating focus groups alongside people with lived experience of incarceration and behavioral health conditions, and utilizing individuals with lived expertise as partners in transcript analysis.
Results:
Although only preliminary analysis has been conducted, emerging themes include the need for more effective screening and intake processes, the crucial role of peer support, and the importance of structured discharge/reentry coordination for connection to community resources.
Conclusions:
While community-engaged research can be financially burdensome and time-consuming, it is of paramount importance in this field. A brief published by the Council of State Government’s Justice Center highlighted the lack of participant feedback in behavioral health programs for people who have been incarcerated. An overview of existing literature completed by the US Department of Justice Office of Justice Programs found that there is a large body of literature on “what works” in these programs, however, it notes a paucity of literature that identifies the best policies and procedures to guide implementation of effective evidence-based practices. This project addressed both of these gaps. Participants also expressed that the focus groups themselves were therapeutic and provided a valuable opportunity to hear from peers about community resources they hadn't heard about previously.
First Author: Emily Carletto
Medical School: Campbell
Additional Author(s): Todd Anderson, Mark Bushhouse, Camden Powers, David Schutzer M.D.
Abstract Title:
Maternal Mental Health Affecting Delivery Method in Southern America: A Retrospective Cohort Study
Introduction:
Various medical, obstetric, and psychosocial factors, including maternal mental health, can influence delivery method selection. Emerging evidence suggests that psychiatric conditions such as depression, anxiety, bipolar disorder, and substance use disorders may impact the likelihood of vaginal delivery versus cesarean section. This retrospective cohort study examines the association between mental health diagnoses and delivery methods to identify potential disparities in obstetric outcomes.
Methods:
Data was collected using SlicerDicer on EPIC at Cape Fear Valley Health from January 1, 2020, to December 31, 2024, covering 23,047 singleton births. A two-proportion Z-test (p<0.05) compared delivery methods among mothers with and without mental health conditions, including depression, anxiety, bipolar disorder, and substance use disorder.
Results:
When evaluating the association of mental health disorders to vaginal delivery, there was a significant decrease in rates for depression, bipolar, and substance use disorder, but no significant change was noted for mothers with anxiety. When evaluating the association with c-section rates, there was a significant increase in rates for depression, bipolar, and substance use disorder, but no significant change was noted for mothers with anxiety. When evaluating operative vaginal deliveries, the only significant decrease was with mothers experiencing substance use disorders.
Conclusions:
This study highlights the impact of maternal mental health on delivery methods, showing decreased vaginal delivery rates and increased cesarean sections for mothers with depression, bipolar disorder, and substance use disorder. Anxiety was not significantly associated. Psychiatric conditions may influence obstetric decisions due to comorbidities, pain perception, or provider concerns about maternal coping. Higher cesarean rates in mothers with depression and bipolar disorder align with research linking mental health conditions to increased obstetric interventions. Substance use disorder showed the lowest vaginal delivery rates and a significant decrease in operative vaginal deliveries, possibly due to inadequate prenatal care or provider concerns about fetal distress. These findings emphasize integrating psychiatric care into obstetric management. Further research should explore targeted perinatal mental health interventions to improve outcomes.
First Author: Aren Forster, B.A.
Medical School: WFU
Additional Author(s): Nicholas McDuffee, M.A., B.S.
Abstract Title:
Importance of Identifying Bell’s Mania in Adolescents: Highlighting the Role of ECT and Timely Diagnosis and Management
Introduction:
Bell’s Mania, or delirious mania, is a rare but severe neuropsychiatric syndrome characterized by the rapid onset of mania, delirium, and psychosis, often without the classic motor symptoms of catatonia. Despite being recognized in clinical literature, it remains absent from the DSM-5 and ICD-10, leading to diagnostic and therapeutic challenges. Electroconvulsive therapy (ECT) has demonstrated efficacy in treating Bell’s Mania but remains underutilized. This case report examines the complexities of diagnosing and managing Bell’s Mania in an adolescent, highlighting the necessity of early recognition, a multidisciplinary approach, and the critical role of ECT.
Methods:
A previously healthy 17-year-old male developed progressive neuropsychiatric symptoms after a stressful academic period. He initially presented with insomnia, slowed speech, and abnormal gait, which progressed to severe catatonia with mutism, posturing, and weight loss due to reduced oral intake. Initially misdiagnosed with schizophreniform disorder, he received lorazepam with only transient relief. He later developed Bell’s Mania, exhibiting acute psychosis, paranoia, hyper-religiosity, and emotional lability, necessitating hospitalization. He was treated with IV lorazepam, clonidine, and quetiapine, leading to partial improvement. Due to persistent catatonia and psychosis, ECT was initiated alongside amantadine and memantine. Despite multiple pharmacologic trials, substantial improvement—including stabilized speech, mood regulation, and functional independence—was achieved only after introducing clozapine.
Results:
This case underscores the importance of recognizing Bell’s Mania in adolescents presenting with rapidly evolving psychiatric symptoms, particularly when features of both catatonia and mania are present. Delayed diagnosis prolonged morbidity and necessitated an extensive treatment course, including 24 ECT sessions and multiple pharmacological trials. The case highlights the critical need for increased awareness and timely intervention to prevent long-term disability.
Conclusions:
Bell’s Mania remains an underdiagnosed and poorly understood condition in adolescent populations, presenting significant diagnostic and management challenges. This case reinforces the necessity of early identification, the importance of aggressive intervention, and the efficacy of ECT and clozapine in severe presentations. A multidisciplinary treatment strategy is essential for optimizing outcomes, and further research is needed to refine diagnostic criteria and therapeutic protocols for this complex neuropsychiatric syndrome.
First Author: Lara Maher, OSM-IV
Medical School:Campbell
Additional Author(s): Dr. Pankaj Lamba, M.D.
Abstract Title:
Case Report on OCD: Using Religious Tenets as Defense Mechanisms
Introduction:
Obsessive compulsive disorder (OCD) is a debilitating and time consuming disorder characterized by intrusive thoughts and compulsive behaviors aiming to suppress them. Patients with OCD may use defense mechanisms by channeling their compulsions into socially acceptable behaviors. Defense mechanisms are unconscious psychological strategies that an individual uses to cope with unwanted emotions.
Methods:
A 25 year-old male with a history of OCD who converted to Islam 5 months before presenting to the unit with depression and suicidal ideation. While he may have believed he was adhering to Islamic tenets, his excessive washing, repeated prayers to ensure correctness, and frequent showering appeared more indicative of compulsive behaviors than religious devotion. He employed sublimation – a mature defense mechanism – by channeling his obsessions into religious rituals. The extent of his compulsions became maladaptive, consuming time and energy and ultimately interfering with his daily functioning. This patient used rationalization to justify the compulsions as necessary and beneficial, which allowed the behavior to persist under the guise of being healthy or productive. The patient, who previously had a fear of germs, exhibited reaction formation by transforming this fear into a preoccupation with religious impurity, thereby justifying his compulsion to “stay pure” by showering.
Results:
The case highlights how defense mechanisms shape the presentation of OCD, particularly in the context of religion conversion. One subtype of OCD, scrupulosity, involves excessive concern with religious or moral purity, often leading individuals to perceive impurity or sin where there is none. Given the patient’s compulsive rituals surrounding cleanliness and prayer, his symptoms may align with scrupulosity if this continues to intensify. While sublimation initially provided a socially acceptable outlet for his compulsions, the excessive nature of these rituals ultimately rendered them maladaptive. Recognizing the role of defense mechanisms in OCD is crucial in distinguishing pathological behaviors from sincere religious practice, guiding more effective therapeutic intervention.
Conclusions:
The case presented shows the complex interplay between OCD, defense mechanisms, and religious conversion, particularly in the development of scrupulosity. Understanding these dynamics is essential for accurate diagnosis and targeted interventions that address both OCD symptoms and religious concerns in a balanced manner.
First Author: Nicholas S. McDuffee, M.A., B.S.
Medical School: WFU
Additional Author(s): Aren A. Forster, B.A.; Kaushal Shah, M.D., M.P.H., M.B.A.; and Preston Easterday, M.D.
Abstract Title:
Factitious Disorder in Context of Abuse in Adolescent: Highlighting the Role Screening, Therapist, and Social Worker in Psychiatric Settings with Low Suspicion
Introduction:
*This case report was accepted on 12/2/24 for publication in The Primary Care Companion for CNS Disorders (PCC.24-03832R1)Factitious disorder, a challenging psychiatric condition characterized by intentional production or exaggeration of symptoms for internal psychological motives, poses unique diagnostic and therapeutic challenges in adolescents. This case report discusses an adolescent male with recurrent hospital admissions for unexplained symptoms, which were eventually identified as self-induced, driven by a need to escape a verbally abusive home environment. The case underscores the critical role of multidisciplinary care in identifying and addressing factitious disorder, especially when abuse is a contributing factor.
Methods:
The patient, a 14-year-old male, was hospitalized eight times over three months for intractable nausea and reduced food intake. Initial diagnoses included avoidant-restrictive food intake disorder and obsessive-compulsive disorder. Despite thorough medical and psychiatric interventions, no organic cause for his symptoms was identified. Observations of manipulative behavior during hospitalizations and a detailed psychiatric evaluation revealed significant psychosocial stressors, including verbal abuse at home. The patient admitted to fabricating symptoms to prolong his hospital stays, which he perceived as a refuge from his home environment.
Results:
After the patient's abusive father moved out of the home, his symptoms resolved entirely, with no recurrence noted in subsequent follow-ups. Treatment included medication for anxiety and outpatient psychiatric referrals, though the patient declined intensive therapy. A report to Child Protective Services facilitated an evaluation of the home environment. This case highlights the diagnostic complexity of factitious disorder and the profound impact of addressing underlying environmental stressors.
Conclusions:
This case underscores the importance of a comprehensive, multidisciplinary approach in adolescents presenting with recurrent, unexplained medical symptoms. It highlights the interplay between psychosocial factors, such as abuse, and psychiatric conditions like factitious disorder. Early recognition, thorough psychosocial evaluation, and the removal of environmental stressors are critical for symptom resolution and patient well-being. The insights gained from this case emphasize the need for integrated medical, psychiatric, and social work collaboration in addressing complex adolescent mental health cases.
First Author: Jared D. Smith, OMS-2
Medical School: Campbell
Additional Author(s): Alexis C. Wardell M.S.; Allison M. Deal M.S.; Kirsten A. Nyrop Ph.D.; Hyman B. Muss MD; and Zev M. Nakamura, M.D.
Abstract Title:
Neurobehavioral Toxicities during Chemotherapy for Early Breast Cancer and Associations with Patient-Reported Cognitive Impairment at Long-term Follow up
Introduction:
Cancer-related cognitive impairment (CRCI) is reported by approximately one-third of breast cancer survivors (BCS). The objectives of this study were to describe the prevalence of patient-reported CRCI at long-term follow-up post-primary treatment and its potential risk factors.
Methods:
This study was a secondary analysis of women with stage I-III BCS who had enrolled in trials promoting self-directed walking during chemotherapy (2010-2020). Patients were re-consented for the current project 3 or more years post-primary treatment. CRCI was assessed using the FACT-Cog PCI (cut point for impairment<54). Multivariable log-binomial regression models, adjusting for age and race, examined associations between CRCI and baseline sociodemographic characteristics, cancer diagnosis and treatment, and patient-reported toxicities during chemotherapy.
Results:
Among 108 BCS, 39% met the criterion for CRCI at an average of 6 years post-treatment. Participants who reported at least moderate depression (RR 1.78, 95% CI 1.12- 2.83, p=0.01), anxiety (RR 2.04, 95% CI 1.30-3.21, p<0.001), or fatigue (RR 1.94, 95% CI 1.09-3.45, p =0.02) during chemotherapy were at increased risk for CRCI. In sensitivity analyses limited to BCS with none or mild symptoms prior to chemotherapy, depression (RR 1.87, 95% CI 1.33-3.11, p=0.01), sleep disturbance (RR 1.72, 95% CI 1.01-2.93, p= 0.05) and peripheral neuropathy (RR 2.00, 95% CI 1.06-3.77, p= 0.03) during chemotherapy were associated with CRCI at follow-up.
Conclusions:
Treatment toxicities, including depression, sleep disturbance, and peripheral neuropathy, that were pre-existing at baseline and/or emergent during treatment, were associated with patient-reported CRCI years after primary treatment and should be monitored for timely intervention opportunities.
First Author: Neusha Zadeh, OMS-III
Medical School: Campbell
Additional Author(s): Megan Basco, Campbell OMS-III (additional first author); and Pankaj Lamba M.D.
Abstract Title:
Recognizing Autism Spectrum Disorder (ASD) - Asperger Syndrome: A Case-Based Perspective
Introduction:
In patients presenting with atypical psychosis, identifying the underlying etiology can be challenging. Here we discuss the case-based perspective of our patient whose presentation offered valuable insights during our rotation. Autism Spectrum Disorder (ASD) without intellectual or language impairment, previously known as Asperger Syndrome or High-Functioning Autism, presents a unique diagnostic challenge. This challenge is further amplified in adults who were never assessed or diagnosed in childhood given the milder nature of symptomatology.
Methods:
A 30-year-old, single, college-educated male (dropped out while pursuing Masters), who lived with his parents was hospitalized for the second time. He had no history of substance abuse. About 4 years prior, after leaving school, he sought outpatient psychiatric help and was diagnosed with anxiety, depression, and later bipolar disorder. During his first hospitalization, 9 months earlier, his presentation was initially considered schizoaffective disorder, bipolar type. However, additional information suggested an alternative diagnosis. He demonstrated immense musical knowledge despite a lack of formal training and had a strong preference for order and routines. Despite his talents, his social interactions were limited, and while he had dated in college, he struggled to form meaningful connections. His intelligence and ability to acquire new skills did not align with a psychotic disorder but instead suggested ASD.
Results:
The patient was assessed using the Autism-Spectrum Quotient (AQ), a 50-question self-administered questionnaire evaluating "autistic traits" in adults through five key areas: social skills, communication, attention to detail, attention switching, and imagination (Baron-Cohen et al., 2001; DOI: 10.1023/a:1005653411471). Based on the AQ score, his diagnosis was updated to ASD without intellectual or language impairment. Maximum efforts were made to optimize care in the inpatient setting and he was advised to continue outpatient psychiatric follow-up. Unfortunately, it was later revealed that the patient had committed suicide.
Conclusions:
Patients with ASD without intellectual or language impairment are often misdiagnosed with atypical psychosis or mood disorder before receiving an accurate diagnosis. While the AQ has shown success in identifying autistic traits in adults, its validity is limited in cases with comorbid conditions. Our case suggests the need for additional screening tools or a novel standardized instrument for the adult patients. Literature indicates that treatment regimens primarily focus on managing overlapping symptoms in children, but no pharmacologic interventions have been developed for ASD. An important consideration is post-diagnosis support for adult patients and their families, along with the development of targeted therapeutic interventions. Further research is needed to refine screening and treatment guidelines for the growing population of adults with ASD to reduce the risk of misdiagnosis.
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