In April 2014, Mr. WF (now aged 73) was admitted to the Department of Neurology of Marburg University because of dizziness. After the physical causes excluded, and because Mr. WF complained of imperative and commentating voices of two witches, who:as he thought:were responsible for the dizziness, a second psychiatric in-patient admission took place. At the admission to the Department of Psychiatry and Psychotherapy of Marburg University, he experienced AVH, paranoid delusions, and perceived the control by witchcraft. In his physical examination, we saw a right-dominated tremor of the hands. Comprehensive technical examinations (including blood tests, structural MRI, cerebrospinal fluid diagnostics, FP-CIT, and 18F-FDG-brain-PET) depicted a moderate subcortical arteriosclerotic encephalopathy, which might be the cause of the vascular parkinsonism. Considering moderately elevated tau protein levels in the CSF, a mesial temporal reduced 18F-FDG utilization [NIA-AA Biomarker profile A-T+N+ ], as well as the impaired short-term verbal and figurative memory, attention, and psychomotor speed, without incapacity for independence in everyday activities, we suggested a minor non-Alzheimer neurocognitive disorder, besides the VLOSLP. For the neurocognitive assessment, the standardized Consortium to Establish a Registry for Alzheimer's Disease (CERAD)-test battery was applied; scores are listed in the  Supplemental Material ,  Tables S1  and  S2 . A monotherapy with olanzapine (up to 20 mg/d) led to a remission of perception of control by witchcraft and dizziness. However, the AVH remitted only partially. Since no complete remission could also be achieved during the 12 weeks of further treatment, Mr. WF was re-admitted to our in-patient unit for an add-on inhibitory TBS trial (July 2014). After the first five sessions, the patient reported a significant reduction of the AVH; after ten sessions, a stable remission was achieved.
After the discharge, Mr. WF resigned the out-patient psychiatric treatment and chose to discontinue his antipsychotic medication in November 2014, mostly due to the absence of any subjective complaints. In January 2015, he was again admitted to a neurologic hospital because of dizziness. Due to low body rigidity and tremor, a treatment trial with levodopa was initiated by colleagues. This medication was well tolerated but did not lead to any significant clinical effects. In June 2015, Mr. WF reported a sudden re-occurrence of AVH and paranoid delusions (evaluated by a face-to-face interview using simple YES/NO questioning, see  Supplementary Material Box S1 ); thus, a psychiatric re-admission was again required. Since no remission could be achieved after dopamine-agonistic medication and an 123I-N-omega-fluoropropyl-2beta-carbomethoxy-3beta-(4-iodophenyl)nortropane) (FIT-CT)/single photon emission computed tomography (SPECT) revealed the non-altered density of dopamine transporter, levodopa was tapered out. Next, TBS monotherapy was carried out in July 2015, however, without significant improvement (evaluated by targeted questioning).
Later, we prescribed clozapine (up to 150 mg/d, July 2015), however, failing to reduce the AVH sufficiently (evaluated by targeted questioning), and leading to a psychomotor retardation and further cognitive decline. Thus, clozapine was then tapered out. In August 2015, olanzapine was prescribed again due to prior positive experience with it during the first psychotic episode. The olanzapine monotherapy (4 weeks, 15 mg /d) led again to a merely partial response (evaluated by targeted questioning). Considering the positive experience during the previous in-patient treatment, the TBS augmentation (September 2015) was then repeated and led to a complete remission of AVH (evaluated by targeted questioning) as during the last episode. Later, the remission remained stable in combination with the maintenance medication olanzapine (5 mg/d). An overview of the full treatment course can be seen in the  Supplementary Material . All essential milestones related to the diagnoses and interventions are presented there as a timeline.