Schizotypal personality is a condition suffered by 4% of the population. It is defined by presenting interpersonal, behavioral and perceptual features similar to the clinical features of psychotic disorders, such as schizophrenia, in less intensity and dysfunctionality, but at risk of reaching psychosis.

Presentation of a clinical case about a patient with premorbid schizotypal personality traits presenting with an acute psychotic episode.

Literature review on association between schizotypal personality and psychosis.

A 57-year-old woman with a history of adaptive disorder due to work problems 13 years ago, currently without psychopharmacological treatment, goes to the emergency room brought by the emergency services due to behavioral alteration. She reports that “her husband and son wanted to sexually abuse her”, so she had to run away from home and has been running through the streets of the town without clothes and barefoot.

Her husband relates attitude alterations and extravagant behaviors of years of evolution, such as going on diets of eating only bread for 40 days or talking about exoteric and religious subjects, as believing that the devil got inside her husband through a dental implant. He reports that these behaviors have been accentuated during the last month. She has also created a tarot website, and has even had discussions with several users. She is increasingly suspicious of him, has stopped talking to him and stays in his room all day long, with unmotivated laughter and soliloquies.

It was decided to admit him to Psychiatry and risperidone 4 mg was started. At the beginning, she was suspicious and reticent in the interview. As the days went by, communication improved, she showed a relaxed gesture and distanced herself from the delirious ideation, criticizing the episode.

In recent years, there has been increasing interest in understanding the association between schizotypy and serious mental disorder. Several theories understand schizotypy as a natural continuum of personality that reveals genetic vulnerability and that can lead to psychotic disorder when added to precipitating factors. Other theories define schizotypy as a “latent schizophrenia” where symptoms are contained and expressed in less intensity.

Around 20% evolves to paranoid schizophrenia or other serious mental disorders. It is complex to distinguish between those individuals in whom schizotypy is a prodrome and those in whom it is a stable personality trait. To date, studies applying early psychotherapeutic or pharmacological interventions have had insufficient and contradictory results, and the follow-up and treatment of these individuals could be a stress factor and a stigma. Some studies are looking for reliable markers of evolution to schizophrenia in order to establish adequate protocols for detention, follow-up and treatment.

None Declared

Delusional parasitosis, also known as delusional infestation or Ekbom’s syndrome, is a rare psychotic disorder characterized by the false belief that a parasitic skin infestation exists, despite the absence of any medical evidence to support this claim. These patients often see many physicians, so a multidisciplinary approach among clinicians is important. Many patients refuse any treatment due to their firm belief that they suffer from an infestation, not a psychiatric condition, so it is crucial to gain the trust of these patients.

The comprehensive review of this clinical case aims to investigate Ekbom syndrome, from a historical, clinical and therapeutic perspective.

Literature review based on delusional parasitosis.

A 65-year-old woman comes to the psychiatry consultation referred by her primary care physician concerned about being infested by insects that she perceives through scales on her skin for the last three months. She recognizes important impact on her functionality. She is also convinced that her family is being infected too. As psychiatric history she recognizes alcohol abuse in the past (no current consumption) and an episode of persecutory characteristics with a neighbor, more than ten years ago. On psychopathological examination, she shows delusional ideation of parasitosis, with high behavioral repercussions, cenesthetic and cotariform hallucinations, as well as feelings of helplessness and anger. Treatment with Pimozide was started and the patient was referred to dermatology for evaluation, a plan she accepted. Her primary care physician and dermatology specialist were informed about the case and the treatment plan. In the recent reviews, the patient is calmer, however, despite the corroboration of dermatology and in the absence of organic lesions in cranial CT, she is still unsatisfied with the results, remaining firm in her conviction of infestation. It was decided to start treatment with atypical neuroleptics (Aripiprazole), with progressive recovery of her previous functionality.

Despite the increase in the number of studies in recent years, there are still few studies on this type of delirium. The female:male ratio varies in the bibiliography (between 2:1 and 3:1). The onset is usually insidious, generally appearing as a patient who comes to his primary care physician convinced of having parasites in different skin locations. It is usual to observe scratching lesions or even wounds in search of the parasite. In the past, the most used and studied treatment was Pimozide. Currently the treatment of choice is atypical neuroleptics due to their lower side effects. The latest reviews on the prognosis of this disorder show data with percentages of complete recovery between 51% and 70%, and partial responses between 16.5% and 20%. Finally, for a good diagnosis and therapeutic management, it is important to achieve a multidisciplinary approach.

None Declared

The coronavirus disease 2019 (COVID-19) has serious physiological and psychological consequences. The long-term (>12 weeks post-infection) impact of COVID-19 on mental health, specifically in older adults, is unclear. We longitudinally assessed the association of COVID-19 with depression symptomatology in community-dwelling older adults with metabolic syndrome within the framework of the PREDIMED-Plus cohort.

Participants (n = 5486) aged 55–75 years were included in this longitudinal cohort. COVID-19 status (positive/negative) determined by tests (e.g. polymerase chain reaction severe acute respiratory syndrome coronavirus 2, IgG) was confirmed via event adjudication (410 cases). Pre- and post-COVID-19 depressive symptomatology was ascertained from annual assessments conducted using a validated 21-item Spanish Beck Depression Inventory-II (BDI-II). Multivariable linear and logistic regression models assessed the association between COVID-19 and depression symptomatology.

COVID-19 in older adults was associated with higher post-COVID-19 BDI-II scores measured at a median (interquartile range) of 29 (15–40) weeks post-infection [fully adjusted β = 0.65 points, 95% confidence interval (CI) 0.15–1.15; p = 0.011]. This association was particularly prominent in women (β = 1.38 points, 95% CI 0.44–2.33, p = 0.004). COVID-19 was associated with 62% increased odds of elevated depression risk (BDI-II ≥ 14) post-COVID-19 when adjusted for confounders (odds ratio; 95% CI 1.13–2.30, p = 0.008).

COVID-19 was associated with long-term depression risk in older adults with overweight/obesity and metabolic syndrome, particularly in women. Thus, long-term evaluations of the impact of COVID-19 on mental health and preventive public health initiatives are warranted in older adults.

Psychogenic nonepileptic seizures (PNES), the most common conversion disorder, are episodic alterations in behaviour that resemble epileptic seizures without its characteristic EEG changes. PNES presumably reflect a physical manifestation of underlying psychological distress and can be as disabling as epilepsy. Standardized treatment approaches for PNES care are lacking.

Our aim is to review the literature for therapeutic interventions in PNES.

A literature search was conducted in PubMed/MEDLINE database for randomized controlled trials (RCTs) examining the effect(s) of specific intervention(s) in patients with PNES. Search terms were “psychogenic-nonepileptic-seizures” and selection was based on the abstracts of all the studies retrieved. Priority outcome was frequency of PNES.

We identified 8 eligible RCTs. Samples ranged from 19 to 82 patients. Follow-up periods varied from 6 weeks to 18 months. Regarding reduction of PNES frequency, several interventions were effective: motivational interviewing combined with psychotherapy; cognitive behavioural therapy informed psychotherapy (CBT-ip); combination of CBT-ip and sertraline; immediate withdrawal of antiepileptic drugs after PNES diagnosis; a standardized diagnostic approach associated with psychiatric inpatient consultation. Treatment with sertraline alone and brief educational interventions didn’t reduce PNES frequency significantly. Beside PNES rate reduction, most interventions conveyed some type of benefit such as improvement in quality of life, mood or functionality.

The majority of the beneficial interventions included a structured communicational approach and/or psychotherapeutic treatment. Our analysis highlights the importance of a multidisciplinary strategy that includes psychotherapy. Further studies with larger samples and longer follow-up periods are needed to robustly inform evidence-based treatment for PNES.

No significant relationships.

The aim of this study is to test the psychometric properties of the Spanish validation of the Fear of COVID-19 Scale (FCV-19S) in a Paraguayan population.

Participants were recruited through an Internet-based survey. All participants whose scores in the Hospital Anxiety and Depression Scale (HADS) and The Fear Questionnaire (FQ) were greater than zero were included. 1245 subjects responded voluntarily: 1077 subjects, scoring >0, were considered.

To establish construct validity of the FCV-19S, an exploratory factor analysis was performed using the KMO test, which was adequate, and the Bartlett sphericity test, which was significant (p <.0001). The CFI, NFI, GFI, TLI and RMSEA indices were used to evaluate the model and showed good adjustment. Cronbach’s α showed valid internal consistency (α = 0.86). This validation was supported by significant correlation (p <.001) with the HADS scale for anxiety and depression and with the FQ scale for specific phobia.

The Spanish version of the FCV-19S is a 7-item scale with two dimensions, psychological symptoms and physiological symptoms, which demonstrated robust psychometric properties in a Paraguayan population.

53 patients and 47 matched controls were studied using a new questionnaire (SEXSAM Scale) measuring relevance of sexual and emotional relationships in patients’ daily life. A specific Psychotropic-Related Sexual Dysfunction Questionnaire (PRSexDQ-SALSEX Montejo 2001-2008), Sexual Activity Assessment Scale modified from Kinsey (Montejo 2006) and the HONOS Scale measuring bio-psychosocial functioning were also applied.

Sexuality (physic and emotional) was scored as high valuable and the main motivation for sexual activity was looking for love and fondness in both groups. No differences were found in the value of more affective behaviours such as kissing, caressing, hugging or massaging. Global satisfaction in sexual and emotional life was significantly superior in control group and linked to the higher frequency of sexual relations. Many patients suffered for sexual dysfunction related to the treatment use and many of then were dissatisfied with their sexual life. Just a few numbers of patients had regular sexual intercourses. Patients describe an improvement in the self-perception of mood, appetite, sleep, anxiety level, humour sense and self-esteem when they have sexual relations. Predominant sexual activity for patients was masturbation. Prostitution use was higher in patient group. All these findings are negatively influencing personal satisfaction and quality of life.

Relevance of sexual and emotional life in patients is as high as in normal population. These patients are more concerned about affection and companionship than about physical pleasure.

Neuroleptic malignant syndrome (NMS) is an uncommon but potentially fatal adverse effect of neuroleptic, both classic and atypical drugs.

To review the incidence, clinical characteristics, diagnosis and treatment of NMS.

We have described the case of a man of 32 years of age diagnosed with bipolar disorder treated with lithium. He precised high-dose corticosteroids after having tonsillitis. Then, he presented manic decompensation requiring neuroleptic treatment (oral risperidone). After 72 hours, he presented an episode characterized by muscular rigidity, fever, altered mental status and autonomic dysfunction. Life support measures and suspension of neuroleptic treatment were required.

A literature review of the NMS was performed using the PubMed database.

The frequency of NMS ranges from 0.02 to 2.4%. The pathophysiology is not clearly understood but the blockade of dopamine receptors seems to be the central mechanism. Some of the main risk factors described are: being a young adult, the concomitant use of lithium and metabolic causes, among others. NMS occurs most often during the first week of treatment or after increasing the dosage of the neuroleptic medication. Some issues of NMS are those related with diagnosis, treatment and reintroduction of antipsychotic treatment or not.

NMS can be difficult to diagnose due to the variability in the clinical symptoms and presentation. Because of it diagnosis is of exclusion, clinicians should always take it into consideration when a patient is treating with neuroleptic, especially when the dosage has been recently increased. NMS is a clinical emergency.

The authors have not supplied their declaration of competing interest.

Glucocorticoids are widely prescribed for a variety of diseases and are known to cause neuropsychiatric as well as somatic side effects.

To review the incidence, clinical characteristics, course and treatment of neuropsychiatric effects of glucocorticoids.

We have described the case of a 86-year-old woman. She had no personal and no psychiatric medical history in her family. She presented wrist arthritis requiring high doses of an oral corticoid treatment (prednisona 20 mg/d). After a week, she started with symptoms characterised by persecutory and surveillance delusions. Organicity was ruled out. The patient got a progressive recovery after starting anti-psychotic medication and progressive reduction of the steroid drugs.

We have performed a literature review of the neuropsychiatric complications of glucocorticoids using the PubMed database.

Neuropsychiatric effects of glucocorticoids involve affective, behavioural, and cognitive manifestations. The incidence is variable, between 2 and 60% of patients who receive steroids. Although the effects of glucocorticoids are unpredictable, the administered dose is the most significant risk factor for the development of neuropsychiatric symptoms. Dosage reduction typically results in clinical recovery. Although the limited data on this subject, it is a problem that clinicians face on their regular basis. The administration of anti-psychotics or mood stabilizers may be beneficial in the prevention and treatment of this syndrome.

The neuropsychiatric effects of glucocorticoids are unpredictable and non-specific. More controlled trials are needed in order to perform evidence-based clinical guidelines for the treatment with glucocorticoids and for the prevention of neuropsychiatric manifestations.

The authors have not supplied their declaration of competing interest.

Eating disorders (EDs) are an important public health problem and not all patients respond adequately to psychotherapy. In the last decade, researchers report a significant comorbidity of EDs and attention-deficit/hyperactivity disorder (ADHD), especially binge eating disorder and bulimia nervosa. Some studies postulate the hypothesis of a common neurobiological substrate, such as noradrenergic pathways among others.

To revise the possible use of atomoxetine, a highly selective noradrenergic reuptake inhibitor, for the treatment of EDs.

We describe the effect of atomoxetine in a young woman with purging disorder and history of ADHD in childhood added to cognitive behavioural therapy (CBT).

patient had selective/restrictive eating behaviours, daily purges and occasional binges for last five years. At age 14 she was diagnosed with ADHD by impulsivity/aggressiveness and poor school performance, but she did not take drugs and left medical consultations. She came to our specific unit of EDs in november-2015. Her BMI was 24.88 kg/m2. We initiated CBT and atomoxetine (80 mg/day). In this first year of treatment binges and purges have disappeared and exposure to new foods and body image have improved partially. We found clear improvement in mood, motivation and attention/concentration in relation with introduction of atomoxetine. These facts have positive impact on the clinical evolution. Her current BMI is 26.90 kg/m2.

Identify comorbid ADHD to assess the use of specific drugs for this disorder could be beneficial in the treatment and prognosis of EDs. However, more studies are needed to determine effectivenes, particularly of non-stimulant drugs.

The authors have not supplied their declaration of competing interest.

The association between cannabis and psychosis makes crucial the intervention on cannabis use disorder at first episodes of psychosis (FEP), especially among young population. In this group of patients, the harmful potential of cannabis is more evident by its influence on neurodevelopment. However, the nature of the association cannabis-psychosis is not clearly described. It seems to represent a mediating factor for an increased risk of psychosis in healthy and high-risk populations, determining an earlier age of onset and worsening long term outcome.

To assess the impact of cannabis in terms of functional and clinical prognosis in patients recruited after a FEP.

PAFIP is an early intervention program for early stages of psychosis. One hundred and sixty-three were included, followed-up at regular intervals of six months for three years with administration of clinical and functional scales (BPRS, SAPS, SANS, CDRS, GAF and Drake). Patients were divided into three groups: (1) those non-users neither before the onset nor during follow-up (nn) PEP, (2) consumers before the FEP and during follow-up (ss) and (3) consumers before the FEP that gave up consumption during follow-up (sn).

No statistically significant differences were observed in terms of functionality at three-year follow-up endpoint but a trend to a better-preserved functionality in the sn group. The sn group presented lower scores in scales for positive symptoms with respect to the comparison groups.

The interruption in cannabis use may have a beneficial effect on short-term clinical prognosis and functionality on long term.

The authors have not supplied their declaration of competing interest.

To evaluate the results of treatment of parotid pleomorphic adenoma, and the risk factors for secondary recurrence.

Single-centre, retrospective study of 32 patients with pleomorphic adenoma recurrence managed between 1988 and 2008.

The mean age at diagnosis of primary pleomorphic adenoma recurrence was 43.4 years. Twenty-eight per cent of patients had secondary recurrence; 32 per cent had undergone two or more surgical resections and external adjuvant radiotherapy. An age of less than 25 years was significantly associated with an earlier primary recurrence (p = 0.008). The most significant histopathological risk factor for secondary recurrence was the presence of a multifocal tumour (p = 0.019). Other histopathological criteria (i.e. cellularity and capsule rupture) were not significant. Radiotherapy was not associated with a decrease in recurrence. Nine per cent of patients progressed to malignancy. The main surgical complication was definitive facial palsy (14 per cent).

Pleomorphic adenoma recurrence requires surgery, with greatly increased risk to the facial nerve. Resection with clear surgical margins is required, especially in young patients with multifocal tumours. Radiotherapy may delay second recurrence in cases of multifocal tumour.