First described as a case series by Pryse-Phillips in 1971, Olfactory Reference Syndrome (ORS) has been increasingly reported in the scientific literature. Although current classifications do not consider ORS as a unique clinical entity, its existence is widely acknowledged. Different approaches to treatment have been described.

1) Portray the clinical features and treatment response of a patient with ORS. 2) Summarize knowledge on different treatment options for ORS.

We present the case of a teenager with major depressive disorder who developed the delusional belief of emitting a foul smell (without any other psychotic symptoms), and report his response to antidepressants and cognitive-behavioral therapy. Subsequently, we embark on a literature review on pharmacological and non-pharmacological options for patients with ORS.

We conducted a literature review in different databases using the keyword 'olfactory reference syndrome'. Papers published from 1971 to 2014 were selected on the basis of availability, relevant information in the title/abstract, and language (English, Spanish or Portuguese).

A brief summary is presented on the treatment options found in selected papers.

Different treatment approaches have proven beneficial for patients with ORS. This may reflect, however, a diversity of mechanisms by which this ailment is generated. More research on the physiopathology of ORS might result in better treatment outcomes.

Fibromyalgia is a disorder characterized by chronic widespread pain and tenderness at palpation of specific points or associated symptoms of fatigue, un-refreshing sleep or cognitive dysfunction. Although his prevalence ranges from 2% to 6,4%, it remains a controversial and an exclusion diagnosis which causes are incompletely understood.

Patients have been reported as being perfectionist, introspective, demanding and exhausting to manage. While such personality traits may appear to contribute to fibromyalgia symptoms, the links between them remain unclear.

The author’s goal is to understand the complex role of personality traits in clinical presentation and management of patients with fibromyalgia. Additionally we present an illustrative clinical case.

A literature search was performed using the key words fibromyalgia, personality, trait psychology and retrieved papers were selected according to their relevance. The patient clinical record was reviewed.

We discuss whether the personality traits result from or cause fibromyalgia symptoms and present a case of a 47 years old woman with fibromyalgia who presents to psychiatrist with a depression syndrome. The personality assessment revealed anxiety, immaturity and impulsivity. A multidisciplinary approach was made with rheumatology, psychiatry and psychology. The patient was treated with antidepressants, mood stabilizers, muscle relaxant and opioid analgesics, as well as psychoeducation. Eighteen months later, the patient remains with pain and concentration complaints, having improved sleep and functional capacity.

Personality might be involved in various aspects of chronic pain, as seen in fibromyalgia, and be involved in triggering, maintaining and exacerbation of the fibromyalgia’s process.

Psychiatric manifestations and disorders involve interactions between psychological, biological and environmental factors and mechanisms. Hence, culture is also expressed in psychiatric symptoms, and while its characteristics have been relatively stable and invariable throughout the centuries and civilizations, their content are often influenced by societies’ history, values and beliefs, leading to the plasticity of clinical features, as variable as culture itself.

In this paper we try to establish a relationship between the pathoplasticity of some paradigmatic psychiatric disorders and beliefs in our society, with special focus on religious and mystical beliefs.

For this review, electronic searches were conducted using PubMed or Science Direct. The search terms used were religion, religiosity, spirituality, mysticism, psychiatry and psychopathology. These terms were used in different combinations and all the relevant articles were identified. Also, the authors present a few clinical cases regarding different psychiatric disorders, illustrating this issue.

Among the various aspects of culture, the influence of religion and spirituality on psychopathology has been one of the most explored areas of research. When merged with cultural aspects, psychopathological aspects acquire complex and rich features that sometimes challenge clinical practice, as demonstrated with the presented clinical cases.

This work highlights the role of culture in shaping psychopathology and that patients' cultural background needs to be taken into account when assessing and treating psychiatric disorders, in order to achieve better outcomes.

There are only a few studies focusing on the religious delusion in relation to Schneider’s first rank symptoms, compared to the presence of these symptoms in paranoid delusions.

This study aims to explore the particularities of Schneider’s first rank symptoms in relation to religious delusion.

The study included 40 subjects with religious delusions. The cases were chosen from the Case Register of Psychoses of the Psychiatric Clinic in Timisoara and they have been followed longitudinally during a 15 year period. All of them had a stable 5 year ICD-10 diagnosis of Schizophrenia, Schizo-affective disorder or Persistent delusional disorder. The following variables were considered: demographic parameters (at onset and at present), clinical and evolutional aspects (including the number of relapses and the diagnostic stability) and psychopathological parameters regarding the variety of psychotic symptoms and the patient’s interpretation of Schneider’s first rank symptoms. The symptomatology was assessed using a method derived from the SCAN instrument and the data were analyzed qualitatively.

Differences between the subjects’ experiences of first rank symptoms in relation to paranoid delusions and religious delusions were observed. The subjects experiencing religious delusions often interpreted the first rank symptoms as being common, normal experiences.

In religious delusion, Schneider’s first rank symptoms are accepted and interpreted by the patient as common actions of supernatural beings, especially in schizo-affective episodes, being different from the interpretation of these symptoms when in relation to paranoid delusions.

The delusional misidentification syndromes (DMSs) are psychopathologic phenomena in which a patient misidentifies persons, places, objects or events. The most common form of misidentification is the Capgras Syndrome (Capgras and Reboul-Lachaux, 1923), other types are Frégoli Syndrome (Courbon and Fail, 1927), Intermetamorphosis Syndrome (Courbon and Tusques, 1932) and Syndrome of Subjective Doubles (Christodoulou, 1978).

There are other syndromes, generally not included in DMSs, which share some common characteristics, like Mirrored Self, Reduplicative Paramnesia, Delusional Companions and Clonal Pluralization of the Self.

These delusions can be the greater part of the presentation or secondary to several psychiatric and neurological disorders.

The authors intend to describe the DMSs, including its definition, epidemiology, etiology, presentation and some considerations about treatment, prognosis and forensic psychiatry. Some of the hypotheses that have been suggested to explain these syndromes will be also addressed.

The authors conducted a literature review about delusional misidentification syndromes.

It’s important to physicians to be able to recognize these syndromes and be aware of the need to investigate the existence of possible organic diseases.

The patients with more structured delusions, as seen in DMSs, are more frequently involved in acts of violence. It’s imperative to assess the risk of aggression, mainly, against the 'impostor”, in order to prevent violent behavior.

There have been few systematic studies in broad samples about this theme. More research is needed.

The conceptual revisión of paraphrenia and the defenceof its clinical distinctive features with respect to other psychotic disorders(Schizofrenia or Delusional disorder

A case report: The patient is a 52 years old male who is referred to the Acute Mental Health Unit, by his primary care physician, regarding an infection caused by the Devil, who takes the form of a micro-organism.

The patient shows a long term psychotic psychopathology, based on a chronic delusion of Mystical and Esoteric nature. He describes the origins of the Universe, and explains the formation of different Civilizations throughout History, originated by the interaction of Gravity forces, Alien intelligence and the Elder Gods, in the end creating what he calls ‘The Pangea” All these powers converge in Morocco, leading the patient to believe himself to be the epicenter of the eternal fight between good and evil. He also has coenesthetic hallucinations which are secondary to those delusionas and, therefore, reinforce them.

The patient speaks with an affective indifference towards this matter, and had a superior tone of voice. He shows no awareness of the disease. He has always been socially well-adjusted, with a normal family and workinf life. He shows no processual impairment.

In this clinical case it is difficult to make an accurate diagnosis, according to the current guides for psychotic disorders. Nor does it fit the paranoid Schizophrenic disorder criteria neither the Delusional disorder criteria.

We consider that, in this case, the diagnosis does not suit he criteria for a Paranoid Schizophrenia or a delusional disorder. Even though some guides, such as the CIE 10, include the paraphrenia as part of the Delusional Disorder Spectrum, we believe it should be considered as a distinct disorder with possible intermediate traits from both. While it is true that the new diagnostic guides have given us an advantageous classification of all the mental disorders, we should not dismiss the current uselfulness of the classical studies of psychopathology regarding diagnosis.

Delusional misidentification syndromes are a group of phenomena in which patients

incorrectly identify people or objects, or parts of the own body, with the delusional belief that these were replaced or changed.

There are different subtypes, however, most authors distinguish them in Capgras Syndrome, Fregoli intermetamorphosis and Double Subjective Syndrome.

Review these syndromes, addressing some of the neuropsychiatric syndromes related, the various etiological theories of these syndromes, as well as recent neuroanatomical/ neurophysiological data.

Literature review on the subject

Delusional misidentification syndromes have been described in association with other psychiatric disorders in about 60-75% of cases; 25-40% of cases identifies an organic etiology.

Neurophysiological and neuroanatomical data support the hypothesis that these syndromes are related to damage or dysfunction of the right hemisphere level.

Neuropsychological theories have emerged over time: changes at the level offacial recognition, neuronal damage interrupting circuits which mediate information among the face recognition areas located in the temporal cortex and amygdala, and more recently, changes on the neuropsychological evaluation of the belief system.

Several etiological theories have been proposed and the evolution of models has followed the functional / organic dichotomy, with particular focus on the Capgras syndrome. Possibly they have been undiagnosed over time. Emphasis should be given to the central importance of neuroanatomical and neuroimaging data to the growing understanding of these syndromes. Despite the current knowledge, they remain real challenges, both from a clinical perspective, whether for research.

To analyse the side effects experienced by patients who are on clozapine for a period of more than one year and to analyse the impact of the side effects.

A descriptive cross sectional study carried out in University Psychiatry unit, National Hospital of Sri Lanka, Colombo. All patients attending the clozapine clinic within one month and who are on clozapine for a period of more than one year and who are in remission were selected. Interviewer administered questionnaire was used to assess the presence of side effects and their impact. Data was analyzed using SPSS software.

Sample was 63. Mean age was 34.9 years (range 18-60). Mean duration of usage of clozapine is 7.0 years (range 1-20). Fifty seven (71.4%) had hyper-salivation and constipation and 12 (19.0%) had nocturnal enuresis. Majority of patients who had hyper-salivation (86.6%) and nocturnal enuresis (100%) were not receiving any medical intervention. Fifteen (23.8%) reported the side effects have caused distress for them and 19% (n=12) revealed they have affected their activities of daily living.

Most common long term side effects were hyper-salivation and constipation. Majority of patients with hyper-salivation were not receiving medical intervention. Majority of patients did not report that the side effects affect their activities of daily living or they cause personal distress.

Approximately 50% of patients diagnosed with Delusional Disorder-Persecutory type show an insufficient response to antipsychotic therapy. This was the case in a 43-year old male patient, single, high education level, current symptom severity 2 (delusions and negative symptoms). The onset of the disorder was at the age of 27, followed with chronic course, on permanent antipsychotic therapy with inadequate clinical response, side effects and poor psychosocial functioning.

As previous treatments with various antipsychotics (flufenazine, haloperidole, risperidone and clozapine) gave inadequate clinical response and produced side effects, we decided to switch to a weight neutral agent, which does not appear to cause metabolic syndrome.

To switch to ziprasidone to enhance clinical response and improve tolerability.

The switching strategy was a gradual cross-titration and tapering of clozapine (300mg/d) over a 6-week period. Ziprasidone was started at 80 mg/d and was then raised to the maximum dose of 160 mg/d, as the patient developed EPS and activation. The patient’s mental state and metabolic parameters (BMI, total cholesterol level, triglycerides) were compared before, and 6 weeks after therapy switching.

Mental state and metabolic parameters before therapy switching: symptom severity 2 (delusion and negative symptoms); Metabolic parameters: BMI=38.7, total cholesterol 6.38mmol/l, triglycerides 2,32mmol/l. Parameters status after switching to ziprasidone: symptom severity 1 (delusions); BMI=37.1, total cholesterol 4.72mmol/l (in range), triglycerides 2.41mmol/l. The patient was ‘awakened”, with reduced body weight, sedation and negative symptoms.

Despite the persistence of central delusion themes, switching to ziprasidone improved negative symptoms and metabolic state.

We describe a case of a man of 39 years, treated with paliperidone palmitate after treatment failure with other antipsychotics, including those of (conventional and atypical) oral and injectable, and developed secudary hyperprolactinemia.

Evaluate the effectiveness of the method for management of hyperprolactinemia secondary to the use of second generation long-acting antipsychotic.

Follow-up during 18 months in outpatient mental health.

In the period the patient remained stable with the use of paliperidone palmitate. Serum prolactin levels were obtained at baseline, and every two months.

The patient had sexual dysfunction as the main complaint.

Initially adopted the gradual reduction in dosage of antipsychotic 150 mg / month to 75 mg / month, however, the patient had psychotic relapse.

So, we decided to keep the dose of paliperidone palmitate and associate the drug cabergoline at a dose of 0.5 mg per week, and serum prolactin levels were normalized.

There was a decrease in serum prolactin levels as well as the related sexual sphere, with the addition of cabergoline to treatment with paliperidone palmitate symptoms.

The long-acting antipsychotic paliperidone palmitate is a safe and effective medicine to control the symptoms of schizophrenia. Hyperprolactinemia is a rare side effect associated with this psychotropic drug, which can be handled without difficulty with antidotes. The cabergoline proved to be an effective and free from adverse side efects alternative to reduce the levels of hyperprolactinemia secondary to use of paliperidone palmitate effects, including sexual dysfunction relieving.

Mania induced by initiation of antidepressants is well documented, as is a withdrawal syndrome following sudden discontinuation of antidepressants. Mania occurring after withdrawal of antidepressants, however, has only been reported infrequently.

We describe antidepressant-discontinuation mania in two older patients initially diagnosed with unipolar depression.

Case 1: Madam P is a 66-year-old Chinese housewife diagnosed with major depressive disorder (MDD) in 2012. She was started on Escitalopram 10mg nocte but discontinued it within 3 weeks without any adverse effects. Escitalopram was re-started in December 2013 when she became depressed again, but she stopped taking it again after three months. Two weeks later, she presented in a manic state. Her mood stabilized with Risperidone 1mg nocte.

Case 2: Mr W is a 76-year-old Chinese retiree diagnosed with MDD in 2009. He was stable on Venlafaxine 75mg nocte and Fluvoxamine 150mg nocte until November 2013, when he requested to stop Venlafaxine. It was tapered off over one month, leaving him on Fluvoxamine alone. Three weeks after stopping Venlafaxine completely, he was admitted for mania with psychotic features. He was stabilized on Sodium Valproate 1000mg nocte and Olanzapine 10mg nocte.

Most antidepressant classes, including SSRIs, TCAs and SNRIs, have been reported to cause antidepressant-withdrawal mania, but this is the first report of Escitalopram being implicated. It is unclear whether antidepressant-withdrawal mania indicates a latent bipolar disorder, with attendant implications on treatment. Cholinergic overdrive is postulated to be the underlying mechanism but more research is needed to understand this rare phenomena.

To assess the monitoring of antipsychotic medication in secondary care services in accordance with The National Institute for Health and Care Excellence (NICE) guidelines1.

Recent NICE guidelines on Psychosis and schizophrenia in adults1state that the secondary care team should monitor patients' physical health and the effects of antipsychotic medication for at least 12 months or until the person's condition has stabilised, and thereafter consider shared care with Primary care.

The electronic database generated a sample of 30 new service users attending a local community team in Solihull, UK who were initiated on antipsychotics between January 2012 and March 2013. We analysed electronic documentation according to an audit tool developed by our Trust Clinical Pharmacist, based on NICE guidelines.

Results showed that 83% of patients were monitored for over 12 months or until stabilised. Other documentations included response to treatment and side effects of treatment (96.7%), emergence of movement disorders (36.7%), adherence to treatment (86.7%) and physical health (90%).

Most patients were followed up for their mental health. Documentation and/or specific monitoring of physical health parameters as detailed in the guidelines remained less than 30%. Similarly, the emergence of movement disorders was infrequently recorded. Training is required to improve the understanding of the importance of monitoring of physical health in individuals with psychosis or schizophrenia, especially those taking antipsychotics. Re-audit to follow.

[1] NICE. NICE guideline on Psychosis and schizophrenia in adults: treatment and management, CG178: February 2014. http://www.nice.org.uk/guidance/CG178/chapter/1-Recommendations.

Contrary to phenothiazines, butyrophenones are very seldom associated with hepatitis. In particular, the incidence of hepatitis on haloperidol is about 0.002%. Almost all these cases consisted of cholestatic hepatitis. Cytolytic hepatitis induced by haloperidol seems to be exceptional.

To outline the occurrence of haloperidol-induced cytolytic hepatitis.

Case report and review

We report the case of a male patient aged 22, with a family history of schizophrenia in two cousins and with a personal history of generalized epilepsy on carbamazepine. The patient was admitted to our department for behavioral disturbances. Psychiatric interview found mystical and grandiosity delusions as well as auditory and visual hallucinations. The patient was started on haloperidol 5mg bid. Routine liver enzymes obtained on day-10 revealed eight-fold elevated transaminases with no associated biological signs of cholestasis. The patient did not report any symptoms suggestive of hepatitis.

Serology for viral hepatitis (A, B, and C), EBV and CMV was negative. Hepatic ultrasound examination was normal. Antinuclear, anti-LMK and anti-mitochondrial antibodies were negative. Serum and urine copper levels were normal.

The diagnosis of a drug-induced hepatitis was made. Haloperidol was withdrawn and switched to olanzapine. Transaminase levels slowly dropped then normalized within two months, thus consolidating our diagnosis.

Cytolytic hepatitis induced by haloperidol is very rare and can be asymptomatic. Routine liver tests when starting antipsychotics are crucially important to diagnose this possibly hazardous side effect.