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Thought it was psychosis
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Thought it was psychosis

I am a nurse practitioner working in psychiatry. I have been seeing a patient for approximately 3 mos. whose inital and persisting symptoms have included the sensation of her brain melting, dripping and her neurotransmitters leaking. She has also reported her head splitting and reassembling. She has never had head pain. I did some research and found these are called censethetic hallucinations and the web often affiliates them with migraines. I am unable to find much research on this type of migraine and I have not fully confirmed the diagnosis. However, the symptoms have responded positively to verapamil, topamax, and imitrex prn. She has been on all common atypical and typical antipsychotics which all cause a specific side effect. Lamictal caused her brain to pop, risperdal caused burning, etc. Is there any resource you recommend for further information and have you seen similar patients?
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368886_tn?1278962315
Hello.

This is indeed a rare case.

I would like to consider if she has any other symptoms apart from those you have described. If she has other symptoms and signs of psychosis, it will be a case of 'cenesthopathic schizophrenia' (ICD-10). This term may not be in circulation if you are in the US, where DSM IV TR is used.

Since she is on anti-psychotic medication already, I believe she had sign of schizophrenia, but it remains to be confirmed.

I have seen Schizophrenic persons with similar hallucinations about other body parts which are deeper inside, e.g. liver burning, intestines twisting, etc. And topiramate has been used, and found to be useful, in some cases.

This does not rule out migraine though. I really appreciate your efforts and thinking.

Regards

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Avatar_n_tn
Thank you so much for you comments. She has no other psychotic symptoms but has been treated for 2 years by several other providers, myself included, for either schizophrenia, schizoaffective, or BPD with psychotic features. Interestingly, when she was initially on the verapamil she had a wetness behind her right eye that resolved with an imitrex. I found the comparison of a headache behind one or the other eye in comparison with this wetness behind an eye too close to be coincidence. She has had symptoms recently of head buzzing since starting the verapamil and topamax and this is a new symptom. It is not as distressing as the others. Yesterday she was pretty much symptom free all day and she went out and had 3 cokes. She spent time in a smoky bar and that mixed with the caffeine created a feeling of head spinning. This is also new. Her neurologic symptoms onset 2 years ago and prior to that she had smoked marijuana daily. The neurologist I spoke with stated that could have abated any symptoms. Any other thoughts you have is well appreciated as I can not find any comparison literature.
Donna
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Avatar_n_tn
I'm not a doctor but if Imitrex relieved the pain, then unless it was placebo effect - doesn't that mean it really points to Migraine?  And yes, I was never a marijuana user but it has been shown to relieve all sorts of pain.  Also, smokey bar and three cokes - serious migraine trigger.

Also, since she has intolerance to psych meds, it would be conceivable that Migraine is side effect of meds.  Feeling leaking of transmitters could mean she is feeling fluid in her head which could be an important neurological symptom.  Can you tell what her formal diagnosis is - does she say her head actually split open and reassembled or that it felt like her head split open and reassembled.  One more question, DSM widely used in US but HIPAA transaction and code set regulation now governs transactions for precerts, claims etc..  It did make room for DSM's but are you billing with ICD's with DSM's, haven't looked lately.  Would appreciate your guidance in learning.
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Avatar_n_tn
This approach is still new to me and the patient but she has not had two good days in a row for two years and we are now on day 5. She stated that "my head splits and reassembles". I have done a lot of research on the net and in books and the lit. is little to none. I initially had a formal dx of psychosis or BPD with psychotic features. She is definitely stating her brain is leaking and dripping and thus feeling fluid in her head but I don't believe it is an organic cause. Prior CT and MRI's have been ok. I can tell the difference in her jmental clarity when these sx are not present. She has not had any "pain" whatsoever so this dx approach is very nontraditional but there must be others with the same thing.
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Avatar_n_tn
OK - I get what you are doing.  You can have an abdominal migraine with absolutely no head pain.  Children often have this and they only have nausea.  This is difficult because she is on migraine preventatives. Good MRI's and CT's are common with Migraine.  But your best diagnostic tool I can see is that you can tell when she is having symptoms - And you say that Imitrex works for her.  Imitrex isn't going to work on a psychotic episode unless there is something about it that I don't know of - I only have 1 undergrad psych degree so take this with a grain of salt but - if you have her in the office and you can tell she is having symptoms, you could have her take Imitrex (injection would be quickest) but is she on pills?  She could take the Imitrex, have her wait in the office and then re interview her to see if clarity returns.  Also, if you are seeing her symptoms - ask her to touch her toes with her head pointed straight down.  If she has a migraine, that will hurt or she will get dizzy etc... Ask her if she normally eats chocolate, red wiine, really aged cheese, salami, lunch meat.  Does she have any illnesses that have psychotic symptoms as secondary like systemic lupus, does she have even arthritis or anything.  Just guessing but how did she get a script for Imitrex w/o Migraine diagnosis.
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Avatar_n_tn
I did give a dx of migraine based on the efficacy of the meds I had tried and her history. She has been seeking treatment for two years which is miserable considering the type of sx she is having. It is not the imitrex working that has clarified the diagnosis but rather the whole package. Don't forget she is also on Topamax, verapamil, has a hx of BPD (statisticallty high correlation with migraines), atypicals have not worked, etc. Prior to her arrival here, she has had the typical array of medical problems ruled out. It is also important to recall that the sx onset after she stopped marijuana use which can abate sx. I spoke with a neurologist last week who stated this is rare but certainly possible. The final dx will only come the longer she is sx free. In medicine, there is often not a 100% clear dx but rather a process of ruling in and out. Thanks again and I am really hoping for some good resources to glean more info from.
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Avatar_n_tn
Please don't misunderstand - as a rare case patient myself - I completely applaud your willingness to try a non-traditional approach.  And wish some other providers would take the type of time and effort I have seen you take just on this one post for one patient.  I'm sorry, I too have looked quite a bit for research on migraines effect on psychological disorders.  I have only found correlational material.  I am proud just to have the opportunity to talk to you this little bit.  By BPD, I'm guessing - Bi Polar Disorder.  I didn't know it specifically had high correlation with migraines but did know psychological disorders in general did.  My mother was diagnosed with Bi Polar about 40 years ago but I personally think its Personality Disorder, its classic.  I too have severe anxiety and severe migraines.  My daughter, severe Migraines, pretty strong anxiety.  And I hid my anxiety very well from her - I didn't want her learning it.  At two years old, she had horrible clausterphobia (I never did).  My entire family, maternal and paternal, have severe Migraines.  I meet tons of people with Migraines, I always ask if they have depression, anxiety etc..  Almost everyone says yes.  I do know from my own body that when the pain gets unbearable and I go to the ER, I always cry.  But I have no desire to - I cry for no good reason.  I assume the serotonin level just drops quickly.  So, my opinion is yes, you have a plausable hypothesis, just proving it is difficult.  Of the medicine regimen for your patient, Imitrex is the only one that only works on Migraines.  I know Topamax will work on psych issues so its hard for clear dx.  However, speaking as that rare patient - I don't care is you ever get final, final proof - if you can make me symptom free I'm happy.  Let me say again, I applaud your hard work - I just have a special fear of the use of Imitrex because I think many doctors have been led to believe it is relatively safe.  It is for some but the contraindications are deadly for others.  I truly hope you inspire others to investigate the connection between these two maladies.  It is important work you do.
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Avatar_n_tn
I had a similar experience with horrible migraines that were getting progressively worse and lots of psych symptoms. In my case, it turned out that I was having subclinical seizures (even though my EEG was normal) and I feel a million times better on seizure medication and pain free! I'm sorry that your patient has needed to deal with these awful symptoms for two years already and I hope that you are able to help her. Thank you for caring so much about her case.
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