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The Human Immunodificiency Virus infects primarily the immune system. However, the infection may also affect the central nervous system, materialising itself, in this particular case, in neurological and neuropsychiatric disturbances.
The authors describe the case of a 48 year-old female patient with bipolar affective disease, identified since she was 21. She has a long history of regular examination in speciality consultations, including several psychiatric hospital stays. More recently, she is conducted to the psychiatric emergency department, being admitted for a maniform state. During the stay her general condition deteriorates progressively, being often taken to the regular emergency department. The serious weight-loss associates itself to altered states of consciousness, ataxia and disartry, as well as diahrrea, fever syndromes and breathing difficulty. As a consequence, the patient stays in bed. Despite several diagnosed infections and the histologic result of the cervical cancer biopsy, requested in an ambulatory regime (“lymphoproliferative disease involving the cervix”), she is always conducted to the psychiatric ward. She is admitted in the medicine ward only a month later and is, afterwards, transferred to the infectious diseases ward, with the aim of studying the neuropsychiatric condition in connection with the HIV/AIDS infection.
The authors come to the conclusion that, it is rather important that the anti-HIV antibodies research is included in the routines of complementary diagnosis examinations requested by psychiatrists.
They also reflect about the little relevance that other medicine areas give to the physical diseases of the psychiatric patients, weakening them even more.
Corticobasal degeneration is a rare neurodegenerative disorder affecting both cortex and basal ganglia with clinical and underlying pathological heterogeneity. Although motor features of CBD were emphasized in earlier descriptions psychiatric symptoms, including cognitive impairment and mood disorders, have been consistently reported during the course of the disease. Clinical diagnosis of CBD is challenging and can be difficult to differentiate from other neuropsychiatric disorders with overlapping features. This can lead to significant underdiagnosis of CBD particularly during its early stages.
We report a case of a 48 year-old female patient presenting with insidious orofacial dystonia co-occurring with depression which remained controlled for five years. Later, while experiencing major psycho-social stress factors, she presented with a rapidly progressive clinical syndrome compatible with the diagnosis of cortico-basal degeneration with severe motor, cognitive and behavioural symptoms, including alien limb phenomenon, nonfluent aphasia and personality changes. Neuropsychological assessment revealed significant frontal lobe dysfunction and SPECT imaging showed asymetrical fronto-parietal hypoperfusion.
This case illustrates the difficulties in the clinical diagnosis of CBD both in early and late stages due to its clinical overlap with mood and movement disorders as well as with Fronto-Temporal Dementia. At the same time, it highlights the influence of psycho-social stress factors in the manifestation of degenerative disorders.
Trichobezoar was first described by Baudomant in 1779. This rare entity consists of a compact mass of hair occupying the gastric cavity to a various extent. When the trichobezoar extends past the duodenum it is better referred to as Rapunzel Syndrome.
It is only reliably diagnosed by CT scan and its size may require removal by open surgery.
Albeit trichobezoars are well described in terms of surgical diagnostic and procedure, there are only but scarce reports on psychiatric literature. It is estimated that 30% of cases of trichotillophagia are of patients suffering from tricotillomania, and that 1% of those will eventually require surgical treatment.
The authors report a clinical case of trichobezoar without known trichotillomania, and revise the existing relevant literature, focusing on psychiatric evaluation and management.
The goal of the authors is to stimulate reflection on the distribution in continuum of compulsive and impulsive behaviours and highlight how important it is to constantly question psychiatric diagnoses, to avoid running the risk of dangerous categorisations.
They describe the case of a 31 year-old patient who attended the Emergency department of Coimbra University Hospitals complaining of depression and obsessive-compulsive symptoms that interfered with his daily life and with his sleep. He said that he used to attend psychiatry appointments and that he was “antisocial”, but added: “I'm as impulsive as much as I'm emotional”.
The patient's records show that he was always diagnosed with antisocial personality disorder, established by the first consultant he saw,specifically mentioning: “problems obeying rules”, “impulsiveness”, “getting into fights and brawls entailing legal action” with the obsessive-compulsive symptoms being secondary. However, the follow-up of the patient conduced by me revealed obsessive-compulsive symptoms in special compulsive checking rituals (which began in childhood), excessive concern with the size of his nose (and other parts of the body) that started in adolescence, as well as a personality marked by impulsiveness and a poor frustration tolerance, leading to highly aggressive episodes triggered by events/circumstances that he himself did not regard as particularly relevant. The results of the studies on the relationship between impulsiveness and compulsiveness could have a strong impact on reformulating the psychiatric nosology. Whenever we come across a new patient, as complete a clinical history as possible should be taken and easy diagnoses should be avoided.
In Portugal, Recognition, Validation and Certification of Competences (RVCC) allows adults to achieve recognition of competences acquired by formal and informal learning using a Competences Reference System. By creating a portfolio describing their life story, adults may explore and question their own living experiences.
This communication aims at promoting deep consideration on the importance of an RVCC process in promoting adult mental health. It analyses the relation between mental health and the RVCC process, and its benefits to prevention and rehabilitation. Methods include my experience as a psychologist at a Centra de Novas Oportunidades (New Opportunities Centre) and scientific literature on the subject. Adults are involved in activities which contribute to developing their social competences. They increase self-confidence and self-esteem, control over life choices and accountability for their actions. In Portugal, this process also involves patients with mental disorders and offers appropriate Key Competences Reference Systems. Adults suffering from mental disorder and undergoing a RVCC process re-establish their self-confidence, self-esteem, self-efficacy and gain a positive hope for the future. Empowerment leads them to cooperate more actively with mental health professionals in their own treatment and rehabilitation plan.
Despite being highly criticized as a system which only validates competences, such criticisms to this process are clearly reductive.
The results of an investigation conducted on the Formulario Especial dos Medicamentos para o Hospital de alienados em Rilhafoles (1901), a mental disease drug formulary for the oldest Portuguese psychiatric hospital, are presented. The study considered the Portuguese situation within the European setting.
This study quantifies the number of drugs and pharmaceutical forms and establishes a comparison with the most commonly used international psychiatric medication at the time. The present study aims at contributing to the history of psychiatric drug therapy before the advent of psychoactive drugs. The most commonly used pharmaceutical forms and therapeutic groups in psychiatry are evaluated. Furthermore, we also wish to contribute to the evaluation of how Portugal received and implemented innovations in drug therapy.
Quantitative and qualitative document analysis of the above mentioned formulary, using the comparative method.
The edition of this formulary arose from the need to standardize specific medication for mental patients. In the Formulario, 61 medicinal products are proposed. There were 8 different pharmaceutical forms. The potions were the most commonly referred (32). Hypnotics represented approximately half of the medicinal products (28), followed by hypokinetics (9), and analgesics and antipyretics (8).
The formulary was in line with foreign scientific innovations. Pharmacotherapeutic variety of drugs was short and resorting to non-drug therapies was also usual. The edition of this formulary was mainly due to the work conducted by the psychiatrist Miguel Bombarda (1851–1910), a prominent public figure in medicine and in the political and cultural arena.
Compulsive hoarding has been generally described as the compulsive acquisition of possessions and the inability to discard them. It has been considered as a syndrome consisting of compulsive acquisition, difficulty discarding and clutter. It is described mainly in association with obsessive-compulsive disorders (OCDs) and in geriatric populations, although it may be seen in a range of other disorders.
Compulsive buying or shopping disorder has been characterized by excessive or poorly controlled preoccupations, urges, or behaviours regarding shopping and spending that lead to subjective distress or impaired functioning. Although it has been considered as part of impulse control disorders, it has also been reported associated with other disorders.
These two entities have raised relevant questions regarding whether they are part of dimensional or categorical constructs, symptoms or well established disorders. By presenting two case reports, the authors address some of these issues and the existing scientific literature.
The term somatoparaphrenia was firstly used by Gerstmann to describe a form of asomatognosia in which unawareness of ownership is accompanied by delusional misidentification and/or confabulation. This is a rare phenomenon and the few published case reports showed an association of this psychopathological entity with brain-damage. We present a patient with schizophrenia who believed his right arm and right foot were not his own. According to his delusion of foreign ownership, his foot didn’t belong to him because it was a “big foot only suited for work” and his right arm belonged to Maria, a woman from his neighbourhood. Remarkably, no organic causes were found to exist. To our knowledge, this is one of the rare cases of schizophrenia in which somatoparaphrenia can be identified. We further elaborate on the phenomenology of this particular patient.
The efficacy of electroconvulsive therapy (ECT) is widely recognized and indications are well defined for acute treatments. Surprisingly, the use of continuation and maintenance ECT (M-ECT) is uncommon after acute remission. This is partly because of the scarcity of scientific evidence. Indications are poorly defined and the practice is based on case reports and small open studies. Recent data suggest that M-ECT is a viable treatment option in severe affective and psychotic illnesses, especially in recurring, drug-resistant or medically compromised patients who suffer toxic effects with psychotropics.
Studies regarding the duration and frequency of treatment sessions are laking. The time interval between sessions and duration of treatment vary according to clinical requirements, and should be individualized. The length of treatment and deciding when to stop it are still uncertain. Controversial data about the relation between the frequency of sessions and diagnostic is found. An inverse relation between good prognostic factors for each patient and the frequency of M-ECT was described. During continuation and maintenance ECT, seizure threshold increases until a plateau not being clear when the plateau is reached and if it depends on other treatment variables.
The risk of cognitive dysfunction following M-ECT is one major concern. A transient memory and attention dysfunction are described after acute ECT. Recent studies seem to suggest that M-ECT is cognitively safe.
Combination therapy of peginterferon and ribavirin for HCV has been recommended as a first choice for chronic hepatitis C. INF therapy has been associated with various IFN-related adverse events, such as psychological disturbances. Beyond that preexisting mental disorders are considered risk factors for INF-alfa-induced severe psychiatric side effects such as depression and/or suicidality, consequently many of these patients remain untreated even tough they fulfil the medical criteria for antiviral treatment of chronic hepatitis C.
The authors relate the case of a patient, 56 year's old, sent to infecciology consultation because she had alterations in abnormal liver function tests. She had a previous history of mental disorder with neurotic personality traits and she was treated with psychiatric medication.
She had treatment for chronic hepatitis C with peginterferon and ribavirin as well psychiatric and psychotherapeutic support.
A low sustained virologic response was obtained however the depressive picture has been difficult to handle so she had had already had a psychiatric hospitalization. There were several adverse life events that can not be forgotten as they certainly trigger and exacerbate the depressive symptomatology.
We assume that psychiatric patients have more depressive symptoms before and during treatment compared with patients without no psychiatric history. This shows that this patients have an increase need for treatment with antidepressants and that a close cooperation with a psychiatrist is always needed.
Although probably undereported, musical hallucinosis is very rare and usually bilateral. It refers to auditory complex hallucinations, for which the patient has full insight, and includes melodies, tunes, rhythms and timbres.
A 71-year-old women was seen for a history of hearing music in the right ear. She had mild hypertension and auricular fibrillation, being chronically medicated with aspirine, bisoprolol and hydroclorothiazide. Three months previously she started hearing some popular folk Portuguese songs in the right ear. She could identify the lyrics and sing the songs she heard. Weeks later fado and classical music were added to the repertoire, and later on she started hearing less well-formed sounds like “dlam... dlam” or “uhh... uhh”. There were no other auditory or visual hallucinations. She was seen by an otorhinolaryngologist, and made an audiogram showing bilateral, right-predominant, pre-coclear deafness with normal evoked brainstem auditory potentials. An MRI showed small deep subcortical lacunar lesions. EEG was normal. PET scan showed left temporal hypometabolism. On benzodiazepines she had discrete improvement.
Musical hallucinosis has been found mainly in deaf patients, and a similar mechanism to that of Charles-Bonnet syndrome has been proposed. Sensory deprivation of primary auditory cortex would “release” the secondary auditory cortex, to produce complex auditory hallucinations with full insight. In our patient we were able to demonstrate the integrity of the brainstem pathway, supporting a direct link between diminished right ear sound transmission and left temporal lobe diminished activation as ascertained by the pet scan.
To estimate the prevalence of depression and of depressive symptoms among older people living in retirement homes within Penacova county. to estimate the percentage of elderly depressed people receiving adequate treatment. to study associations between recorded clinical variables and depression.
We visited all the retirement homes of Penacova County to interview institutionalized men and women older than 64 years, applying a semi-structured protocol that included GDS (geriatric depression screening scale), MMSE, pain scale, Clock Drawing Test, Barthel Index and BSI (Brief Symptom Inventory).
We included 78 subjects (22 Men and 56 Women) with a mean age of 81.3 years. among them 29 were illiterate, 34 had < 4 years of education, 13 had 4 years of education and 2 had a university degree. 56 were widowers and 49 were born in Penacova. the mean GDS value was 17.27. 19,2% were not depressed, 46.1% were depressed and 34,6% were severely depressed.
These results suggest that depression is a common problem affecting older people living in retirement homes. A significant percentage of depressed patients were not adequately treated. This study highlights the importance of screening this population for depression.
The boundaries of simulation and dissociative amnesia are thin and not rarely unclear. Diagnostic criteria and a thorough clinical history are sometimes not enough to shed light on the nature and essence of one's will and conduct. Throughout history, psychiatry has been challenged to testify before society over patients’ truth and deceit. Do they share common grounds or must we accept that uncertainty is the inevitable price of truth?
The authors present a clinical case of a young man coming to the emergency services with multiple lacerations in the upper abdomen and limbs, referring “amnesia” for the last five years of his life. The patient had no previous psychiatric record or any known family or social dysfunction. Approach, management and diagnosis are discussed.
Rehabilitation or terciary prevention refers to the set of appropriate measures to minimize the consequences of disease and reintegration the patients in their home environment, social and professional. Patients with severe mental illness need of psychosocial rehabilitation programs through the training of activities of daily life, especially in areas that present the greatest difficulties.
The advantage in the group approach is that the patient is confronted with its limits and possibilities. This observation allows us to recognize another important similarities and contrasts, expanding your vision of treatment and enhancing its effect. Group assistance seems to be more motivating and can further reduce costs in attendance with good results.
The creation of this psychoeducational group appears to foster the promotion / preservation of independence and functional capacity of patients in its maximum exponent, mean they can live without assistance for activities of daily living. The rehabilitative scheme is performed without isolating the patient from his family and his social environment. Looking for a comprehensive care that meets individual needs and possibilities, centered on the patient, with a view to their rehabilitation and social reintegration. Involves both professionals and patients, actively, in the development of skills that may lead to a better quality of life.
Provided with his biological and psychological circumstances, the adolescent frames within a context of interactions, life experiences and disruptive situations. The plethora of changes taking place at this period of transition sets the stage for a wield between physical and psychological growth potential and the process of illness.
Successful management of circumstances versus lacking of coping strategies will determine, respectively, favorable or unfavorable prognostic implications for development outcomes. It depends on the youths' individual traits, but also on the resources provided by his social context.
The authors seek to identify the main psychosocial factors associated with self-cutting in the youth, aiming for an expedient identification and prompt intervention.
The authors used a sample of 50 adolescents gathered from a larger ongoing study. They were referred to the Child and Adolescent Psychiatry Department between January and June of 2014, identified with self-cutting history.
The authors resorted to the International Classification of Diseases (10th edition), specifically to its psychosocial axis (V). Each case was searched for the risk factors contemplated in this axis.
Even though being preliminary, results allow identification of some psychosocial patterns suggestive of increased risk for self-cutting. They highlight the importance of timely identification and prompt intervention.
Adolescent's individual characteristics (biology, temperament, resilience) interact with environmental circumstances. Different developmental outcomes are determined, some of which unpredictable. However, self injurious behaviors, such as self-cutting seem to associate with specific psychosocial patterns. A proper assessment of the psychosocial contexts may allow identification and timely intervention.
Symptomatic neurosyphilis in immunocompetent patients is nowadays a rare diagnosis. Yet, if not properly diagnosed and treated, consequences for the patient's health are severe. Known as “the great imitator”, its detection involves both a high degree of suspicion and adequate diagnostic tests. Psychiatric symptoms are often the presenting symptoms of this illness.
The authors report four cases of neurosyphilis with psychiatric symptoms (general paresis) in immunocompetent patients. all four patients were initially referred for observation by a psychiatrist in the emergency room. Special diagnostic features of each case and potential diagnostic pitfalls are highlighted.
To raise awareness to the importance of this rare but highly disabling disease.
Review of clinical records and complementary exams.
All patients were male, two Caucasian and two African Black, with ages ranging from 41–56 years old. Clinical presentations were quite distinct, showing the symptomatic heterogeneity of paretic neurosyphilis. Blood VDRL test was negative in one case, CSF VDRL was negative in another case. TPHA was always positive in blood and CSF. White cell count and protein quantification in the CSF remains important to confirm diagnosis.
Current prevalence of symptomatic neurosyphilis in Western Europe is unknown. Atypical cases presenting with heterogeneous psychiatric and neurologic symptoms, with no previous history of mental illness, should undergo blood VDRL testing, and specific blood treponemal testing should be considered in specific situations. A high index of clinical suspicion is needed. Confirmation of diagnosis is only possible through further CSF analysis.
There is robust evidence recommending electroconvulsive therapy (ECT) in treating severe acute affective disorders. The clinical use of bitemporal electrode placement is still favoured to unilateral placement with just a relative disadvantage in cognitive side effects. Recently, bifrontal placement has gained popularity but there is still limited evidence on its relative benefits.
Compare bitemporal and bifrontal ECT efficacy in patients with pharmacologically resistant affective disorders, based on the number of acute phase treatments required to reach symptomatic remission.
Review of all patients' charts submitted to acute phase ECT, between June 2006 and June 2011. A total of 70 ECT treatment courses performed in a group of 67 patients met inclusion criteria. Thirty-eight of the total 70 courses received bitemporal ECT, and 32 received bifrontal ECT. A statistical analysis was performed. An attempt to use t-test was foiled due to breach of population variance homogeneity (p = 0,021). The non-parametric Mann-Whitney test was the alternative choice (M-W = 534;p = 0,377).
Bitemporal and bifrontal groups matched for age and sex. Bitemporal patients received on average five ECT treatments, while the average of bifrontal treatments to remission was six, but this difference was not statistically significant (p > 0.05).
Our results showed that bitemporal and bifrontal placements are equally effective. According to the largest randomised controlled trial conducted on ECT in depressive illness (Kellner et al,2010), bitemporal placement led to a faster rate of improvement. Additional studies and larger samples are required to understand if bifrontal placement's efficacy and cognitive advantages justify its popularity.
Executive functions (EF) are associated to frontal lobes and cognitive decline (CD) with worse results on EF tests.
Analyze if the Frontal Assessment Battery/FAB assessing EF discriminates elders with CD (vs. with no CD; Montreal Cognitive Assessment/MoCA), and if the results obtained with the Rey Osterreith Complex Figure Test/ROCF (copy's quality, immediate, and delayed memory) are associated with the CD presence/absence. Moreover, we wanted to assess if copy's quality and 3 minutes memory test are associated with FAB results, since these two tests are supposedly associated with EF and with frontal lobes assessed by the FAB, contrarily to the 20 minutes memory (supposedly related to the temporal area).
556 institutionalized elders (age: M ± SD =80.2 ± 5.23; range=60-100) filled in voluntarily a sociodemographic questionnaire, ROCF, MoCA and FAB.
FAB and all ROCF tests were associated with the absence/presence of CD. Regarding variables stratified by age and education, FAB was associated with immediate memory but not with copy's quality nor with delayed memory. With no stratified ROCF and FAB, correlations confirmed the previous associations, but also between FAB and copy's quality.
Results follow the literature regarding the association between immediate memory and EF (associated to frontal lobes), in contrast to the long-term memory which is associated with the temporal area and that was not associated with FAB. Results concerning copy's quality (ROCF) are not consensual.
Beginning with classic Hollywood melodramas of the1940s, cinema has maintained a prolific output of films with their own take on mental illnesses – none more so than the rare syndrome of Dissociative Identity Disorder (DID). The DSM-5 provides criteria to diagnose dissociative identity disorder, 'two or more distinct identities or personality states are present, each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self”, is the main one.
A brief description and discussion about the controversies surrounding the diagnosis and approaches to treatment of Dissociative Identity Disorder are presented, followed by a reflection about the use of this disorder in cinema.
A non-systematic literature review was performed in PubMed, about Dissociative Identity Disorder. Only original articles in English language were included. An informal search about films contemplating DID and their plot was also conducted.
Clinical findings suggest that DID involves an authentic mental disorder related to factors as traumatization and disrupted attachment. A competing view indicates that DID is due to fantasy proneness, suggestibility and role-playing. As patients tend to switch personality states when there is a perceived psychosocial threat, the treatment goal is the fusion of the personality states while retaining the entire range of experiences contained in all of the alters. DID representations in cinema correspond closely to contemporary thinking about its phenomenology and aetiology.
Art imitates Life, but sometimes Life can fake the Art…DID may have had its turn…
Schizophrenia is a chronic syndrome of unknown etiology, predominantly defined by signs of psychosis. Over the years, schizophrenia is speculated to be associated with immune or inflammatory reactions mediated by cytokines. It is proposed that chronic inflammation might damage the micro-vascular system of brain and hamper cerebral blood flow. Lupus Erythematosus is an autoimmune disease with multiple manifestations in several organs and systems.
Aims and methods
To review the Inflammatory Hypothesis of Schizophrenia though the study of a case report.
We present a case of a 33-years-old with the diagnosis of Lupus Discoid since 17-years-old and with episodic psychotic symptoms developed within 2 years of the diagnosis of the autoimmune disease. He was admitted in our inpatient unit. Neuroimaging and laboratory tests were done in the inpatient unit without significant alterations. He was treated with Olanzapine, Quetiapine and Haloperidol with improvement of the psychotic symptoms and without important side effects. At the time of hospital discharge, psychotic symptoms had almost disappeared and no behavioral disorder was observed.
The comorbility between Schizophrenia and Autoimmune Diseases seems much more common than previously thought. Even when the autoimmune process does not seem to be the direct cause of the psychosis, the inflammatory setting may be considered an important further piece in the puzzle in a genetic-environmental diathesis model.