Before October 2012 there was no service level agreement for psychiatry cover in Whiston Hospital, an acute trust in the UK. The Crisis team would visit on goodwill to assess patients. This changed when a Liaison Psychiatry (LP) service was commissioned to provide 24 hour cover, Monday to Sunday for the Emergency Department (ED) for adults.

To quantify waiting times to be assessed by psychiatry, comparing the new LP Service (intervention group) to its predecessor (control). The null hypothesis being that the waiting time for the control and intervention group are the same.

The authors prospectively collected data on all referrals received by the LP service in the first three months of operation n=305 and retrospectively collected data on a random sample of 50 patients referred from ED in the same months 2011 (control).

The median time from referral to the time of psychiatric assessment in the control group was 162.5 minutes [IQR 130–330], the mean time was 246.16 [95% CI 180 to 312]. The median time from referral to the time of psychiatric assessment following the introduction of the LP service was 30 minutes [IQR 15-90], the mean time was 79.63 [95% CI 65 to 93]. When the two samples were compared using an independent t test they were significantly different p<0.002.

The new LP service has decreased the median wait for a psychiatry assessment by 132 minutes. The team currently seeS 82% of referrals within 60 minutes. This improves patient safety and encourages appropriate and timely discharge.

To examine treatment, comorbidity status and diagnosis among the French sample of the Caregiver Perspective of Pediatric ADHD (CAPPA) survey.

Carers in 10 EU countries, including France, completed an Internet survey regarding ADHD diagnosis, treatment and comorbidities. Descriptive statistics were calculated for categorical [n (%)] and continuous variables [mean, standard deviation (SD), median, range].

EU carers representing 3688 children/adolescents (6–17 years) with ADHD completed the survey; 486 were from France (median age 10 years, 84% male). Most (77%) French children/adolescents were currently receiving pharmacological treatment(s): 74% stimulant, 15% non-stimulant and 22% antipsychotic. Across countries, stimulant use ranged from 60% (Italy) to 93% (Germany/Netherlands), non-stimulant use from 1% (Germany) to 18% (Sweden) and antipsychotic use from 8% (Germany) to 46% (Italy). Many French children/adolescents received behaviour therapy (BT) after ADHD diagnosis (59%). Among those receiving BT, 52% began prior to starting medication. BT was often discontinued within 6 months (44%) or 6–12 (30%) months. 52% of carers reported ≥ 1 comorbidity; they reported the highest rates of conduct (24%), sleep (11%), eating (6%) and motor-coordination (6%) disorders, and the second-highest rates of anxiety (22%), learning difficulties (15%), oppositional defiant disorder (5%), bipolar disorder (4%) and epilepsy (2%). Time to diagnosis from first doctor's visit averaged 7 months (SD 11, median 3). 81% received a specialist referral. French carers reported the highest perceived difficulty (‘great deal’/’a lot’ of difficulty) obtaining a diagnosis (43%) and a specialist referral (53%).

This sample of French children/adolescents with ADHD had higher non-stimulant and antipsychotic use than most other countries and higher reports of certain comorbid conditions. Carers perceived greater difficulty in obtaining a diagnosis and seeing a specialist, although time to diagnosis was lower compared with a number of other countries.

to evaluate sleep modifications induced by chronic benzodiazepines (BDZs) abuse.

cohort study, comparison of sleep measures between BDZs abusers and controls. Drug Addiction Unit (Institute of Psychiatry) and Unit of Sleep Disorder (Institute of Neurology) of the Catholic University in Rome. Six outpatients were enrolled, (4 men and 2 women, mean age 53.3±14.8, range: 34 - 70 years) affected by BDZ chronic abuse; 55 healthy controls (23 men and 32 women, mean age 54.2 ±13.0, range: 27–76 years). All patients underwent clinical evaluation, psychometric measures, ambulatory polysomnography, scoring of sleep macrostructure and microstructure (power spectral fast-frequency EEG arousal, Cyclic Alternating Pattern - CAP), Heart Rate Variability.

BDZs abusers had relevant modification of sleep macrostructure and a marked reduction of fast-frequency EEG arousal in NREM (Patients: 6.6±3.7 events/hour, Controls 13.7±4.9 events/hour, U-test: 294, p=0.002) and REM (Patients: 8.4±2.4 events/hour, Controls 13.3±5.1 events/hour, U-test: 264, p=0.016), and of CAP rate (Patients: 15.0±8.6%, Controls: 51.2±12.1%, U-test: 325, p<0.001).

BDZs abusers have reduction of arousals associated with increased number of nocturnal awakenings and severe impairment of sleep architecture. The effect of chronic BDZs abuse on sleep may be described as a severe impairment of arousal dynamics; the result is the inability to modulate levels of vigilance.

La prévalence des hallucinations chez les enfants et les adolescents est de 4,9 % à 9 % [1]. Il s’agit d’un symptôme polysémique dont le repérage précoce reste un enjeu majeur du fait du risque évolutif vers un trouble psychotique cependant rare.

Nous rapportons deux cas d’hallucinations auditives et cénesthésiques. Dans le premier cas, une adolescente de 13 ans présentait un syndrome de stress post-traumatique suite à une agression. Les hallucinations survenaient lorsqu’elle était seule dans la rue. L’approche systémique du symptôme mettait à jour un mythe familial de menace. En effet, l’agression renforçait un sentiment ancien de persécution par la société, notamment concernant ses parents handicapés par une surdité congénitale. Dans le second cas, un enfant de 9 ans présentait des hallucinations auditives se manifestant par une mélodie agréable et s’inscrivant dans un contexte de violents conflits entre sa mère et son beau-père. Contemporain d’un repli sur soi et de mouvements anxieux et tristes, ce symptôme semblait également traduire une souffrance familiale.

Concomitamment à l’amendement des hallucinations, la mise en perspective relationnelle du symptôme a permis de retrouver une vitalité du lien. En effet, par ce premier lien de vulnérabilité établi avec les soignants, les familles ont retrouvé confiance dans leur capacité à s’ouvrir au monde extérieur offrant ainsi une opportunité pour le changement.

Une vision intégrative tenant compte non seulement des avancées de l’imagerie et des nombreux modèles neurobiologiques et neurocognitifs [2,3], mais aussi du contexte relationnel du patient, semble fondamentale à la prise en charge globale des hallucinations de l’enfant et de l’adolescent.

Skin Picking behavior is characterized by repetitive episodes of digging, squeezing or picking the skin causing tissue damage, functional impairment and distress.

The aim of the study was to investigate the skin picking frequency and the picking episodes’ characteristics in the Polish students’ population.

The participants were 436 university students, 297 (68,11%) women and 139 (31,88%) men. The age of participants ranged from 19 to 30 years (M=23,21 (SD=8,84). All participants were assessed by the Skin Picking Scale and the Skin Picking Impact Scale translated into Polish by authors. They also completed the list of items concerning skin picking site, picking frequency, methods of picking and affective consequences of picking.

Two hundred ten (48,16%) of the participants reported that they currently pick their skin. One hundred thirty students (29,81%) endorsed the functional impairment caused by picking, ninety three of them (21,33%) felt distressed as a consequence of picking. Most participants, who endorsed the picking behaviors, pick from their faces, fingers and scalps, but numerous other sites were endorsed. Participants usually pick with their fingers and nails and were aware of picking during picking episodes. Forty three participants (20,47%) reported that their picking was preceded by an urge always or in most cases; however 66 participants (31,43%) claimed that they had never felt urge prior to picking. The commonest consequences of picking reported by participants were the experience of relief and the feeling of anger.

Skin picking is a common behavior among the Polish students.

Fréquemment associés [1], le syndrome catatonique et les troubles du spectre autistique présentent une part symptomatologique commune pouvant conduire à une confusion diagnostique. De plus, aucune échelle diagnostique spécifique de ces deux entités n’est actuellement décrite dans la littérature médicale.

Nous rapportons le cas d’un patient de 19 ans atteint d’un trouble du spectre autistique qui présenta plusieurs épisodes de rupture avec son état habituel se déroulant sur plusieurs dizaines de minutes. Ces épisodes se manifestaient par un moins bon contact avec autrui, une opposition, une anxiété, une rigidité motrice, des sueurs, une déambulation et des mouvements stéréotypés inhabituels. Un retour à l’état antérieur était systématiquement constaté entre les crises. Le bilan paraclinique réalisé était normal et éliminait notamment une encéphalopathie et une épilepsie. Les recherches sur les effets secondaires connus du traitement suivi (rispéridone, escitalopram et triptoréline) ne retrouvaient pas de lien avec la symptomatologie présentée. Ces observations nous permirent de poser le diagnostic d’épisodes catatoniques agités et d’instaurer un traitement par lorazepam à raison d’1,25 mg le soir, après quoi aucun épisode ultérieur de ce type ne fut rapporté.

Chez ce patient, les symptômes autistiques déjà présents pouvaient nous amener à remettre en cause le diagnostic de catatonie. Cependant, la symptomatologie catatonique de survenue récente et en rupture avec l’état habituel contrastait clairement avec les symptômes autistiques installés depuis l’enfance.

L’intrication sémiologique du syndrome catatonique et des troubles du spectre autistique nous amène à préconiser l’utilisation au moindre doute d’une échelle diagnostique générale de catatonie telle que celle de Bush [2] en la confrontant à la fois à la notion de rupture avec l’état habituel et aux critères spécifiques de l’étude de Wing et Shah [3]. Dans une logique de simplification, une échelle diagnostique unique regroupant les deux entités pourrait être proposée.

Trichotillomania is a psychiatric disorder characterized by an urge to pull out hair from the scalp or other parts of the body (Impulse Control Disorder) relatively uncommon in children.

The following two clinical vignette highlight varying presentation of trichotillomania in children from two differing age groups (>6 yrs and <12 yrs)

To showcase 2 cases of trichotillomania with differing co-morbidities.

ICD 10 (WHO) was the primary diagnostic tool used here. MGH Hair Pulling Scale was used for rating the severity of Trichotillomania. As both patients had suspected mental sub normality, WISC was used for IQ assessment.

Case 1: Trichotillomania with OCD and ?Secondary depression with MR

14 year old female, presented with compulsive eyebrow pulling for 1 year. For last 6 months showing OCD and depressive symptoms. She scored 32 on YBOCS with main obsession – excessive concerns with germs and main compulsions - excessive or ritualized hygiene. On MGH hair Pulling scale she scored 21. Her IQ score was 65, suggesting Mild Intellectual Disability.

Case 2: Trichotillomania with Pica and MR

5 year old female, presented with compulsive hair pulling and ingesting it (Trichophagia) for 18 months. Also eating non edible things like soil and paper (Pica). No major physical illness found. On MGH Hair Pulling Scale, she scored 17. X-ray of GIT showed no Trichobezoar (hair ball). Her IQ was 60, (Mild Intellectual Disability).

The study illustrates how trichotillomania can be a part of a more complex psychiatric presentation with co-morbidities

Le parcours de soins des patients atteints de TDA/H est mal connu. Cette enquête nationale a pour objectif de préciser les étapes d’évaluation successives menant au diagnostic ainsi qu’au traitement du TDA/H et d’identifier des éléments susceptibles d’être améliorés.

Enquête transversale menée en France du 04/11/2013 au 31/01/2014 auprès d’un échantillon national de 61 médecins prenant en charge des enfants atteints de TDA/H, à l’aide d’un auto-questionnaire remis aux patients/parents.

Quatre cent soixante-treize questionnaires analysés. Les premiers signes (troubles du comportement [78,2 %] et de l’attention [70 %]) sont repérés vers 4,5 ans, principalement hors du milieu familial. Le diagnostic est posé à l’âge de 8,1 ans, environ 4 ans après l’observation des premiers signes. Les familles consultent en moyenne 3,5 professionnels de santé avant que le diagnostic ne soit évoqué. Le psychiatre/pédopsychiatre est le plus consulté quelle que soit l’étape d’évaluation. Lors de la 1re étape, seuls 10,7 % des patients sont diagnostiqués. Ce délai pourrait en partie expliquer les taux élevés de redoublement (31,5 %), notamment en CP et CE1, et d’insatisfaction vis-à-vis de la prise en charge, principalement lors de la 1re étape d’évaluation (38,6 % d’insatisfaits). Deux groupes de patients ont été mis en évidence par une analyse en cluster : le premier (89,9 % de garçons) présente des problèmes de comportement, d’agitation, et des difficultés familiales ; le 2e (49 % de garçons), dont l’hyperactivité est moins prononcée, a mis une année supplémentaire pour recevoir un diagnostic de TDA/H. Dans cet échantillon, plus de 2/3 des patients bénéficient d’un traitement médicamenteux, du méthylphénidate dans 98 % des cas. Le diagnostic tardif a été la principale source de préoccupation des proches.

Le délai d’environ 4 ans, des premiers signes au diagnostic, pourrait constituer une perte de chance pour les enfants atteints de TDA/H.

The use of clozapine (CLZ) for treatment-resistant schizophrenia is well established in adults. However, it is seldom used in children and adolescents with early onset schizophrenia (EOS) largely because of lack of clarity about its risk benefit ratio. This review synthesises and evaluates available evidence regarding the efficacy and tolerability of CLZ in EOS with the aim to assist clinical decision-making.

We conducted a systematic review of the primary the literature on the clinical efficacy and adverse drug reactions (ADRs) observed during CLZ treatment in EOS. We also identified relevant practice guidelines and summarised current guidance.

CLZ showed superior efficacy than other antipsychotics in treating refractory EOS patients; short-term clinical trials suggest an average improvement of 69% on the Brief Psychiatric Rating Scale that was sustained during long-term follow-up. No fatalities linked to CLZ treatment were reported. Sedation and hypersalivation were the most common complaints (90% of patients). Other common ADRs (10-60% of patients) were enuresis, constipation, weight gain, and non-specific EEG changes. Neutropenia was reported in 6-15% while agranulocytosis was rare. Seizures were also uncommon. Metabolic changes were relatively common (8-22%). Overall the rate of discontinuation was low (3-6%). Current guidelines recommend the use of CLZ in treatment-resistant EOS patients and provide detailed schedule of assessments to evaluate and assess potential ADRs both prior to initiation and throughout CLZ treatment.

Available data is consistent in demonstrating that CLZ is effective and generally safe in the treatment of refractory EOS provided patients are regularly monitored.

Culture-bound syndromes are defined as 'episodic and dramatic reactions specific to a particular community'. 'Dhat' syndrome or 'loss of semen' leading to weakness, is a culture bound sex neurosis in the Indian subcontinent not common in rest of the world.

To highlight how Culture Bound Syndromes can transcend geographical boundaries.

A detailed history of the presenting complaints, past and family history and use of ICD 10 (WHO) for diagnosis/excluding other major mental illness.

15 year old unmarried, Afghani male whose family migrated to Australia before his birth (never went back to Afghanistan), presented with anxiety, difficulty in falling asleep, poor appetite, and weakness for 6 months. His symptoms started after being introduced to pornographic films by friends. He began masturbating 3-4 times everyday which soon became a concern to him, believing it to be 'excessive and harmful' (masturbatory guilt). For the next 3 months, he tried to abstain from masturbation, leading to problems like passage of 'whitish' discharge in urine (?precome) and nocturnal emissions, leading to more anxiety and low mood. He did not fulfil ICD 10 criteria for depression.

Fluoxetine 20 mgs daily was started with sexual counselling,(psycho education about masturbation). He showed improvement within 6 weeks and at follow-up 6 months showed complete resolution.

'Dhat Syndrome' a Culture Bound Syndrome, not normally reported in Modern Western world may still present in 2nd generation immigrants, with no overt contact with their original culture, possibly due to deep rooted trans-generational cultural ties.

For some adolescents surfing the web can turn into a psychological defense and to be in contrast with a healthy mental development. It happen if the internet surfing becomes a compulsive need (Drusian, 2005). Massive use of the internet can promote the development of behavioral addictions such as pathological gambling (Cantelmi, D’Andrea, 2000).

The study investigates the correlation between social introversion, modality of the internet surfing and propensity to pathological gambling in a sample of Italian adolescents.

The research used a questionnaire divided into four areas: school performance, use of the internet, social introversion (SI scale of the MMPI-A); experiences of gambling (LIE/BET Questionnaire). 583 adolescents (45% males and 54% females, mean age 17 years) responded to the questionnaire.

Adolescents with high social introversion (high scores on Si scale) are 7.4% of the sample. These teenagers use the Internet many hours per day. They state that surfing the internet is a way to drive away negative thoughts about their lives. They think that life would be boring without the internet. Many adolescents with social introversion have high scores to LIE/BET Questionnaire. The study does not show a correlation between school performance and the others variables (social introversion, use of internet and propensity to pathological gambling).

Social introversion seems to be a predictor of psychological disease such as internet addiction and pathological gambling.

Attention-deficit hyperactivity disorder (ADHD) affects not only children but persists for up to 4.4% in the general population. Comorbidity is common among adults with ADHD, including substance abuse. Patients who have both ADHD and SUD have to cope with the interrelated consequences of both disorders. Substance-dependent subjects have greater health, economic, work, and legal problems

The aim of this study was to estimate effect of co morbidity of adult ADHD with substance use disorders on being prone to legal problems.

This cross-sectional comparative study was conducted in addiction treatment center at El Maamoura psychiatric hospital. One hundred and two adult males were assessed using Arabic version of Wender Utah Rating Scale (WURS) and Arabic version of Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist were used to screen for adult ADHD. DSM IV TR criteria were used for final diagnosis. Past history of legal problems was assessed using hospital records and self report questionnaire. Data were fed to the computer using the Predictive Analytics Software (PASW Statistics 18). Significance of the obtained results was judged at the 5% level.

Thirty sex patients fulfilled the DSM – IV TR criteria for adult ADHD. Fourteen patients of the ADHD group had history of legal problems (38.9%), while only 12 patients of the non ADHD group gave such history (18.2%) and the difference was statistical significant (c2 = 5.259, p = 0.022).

Presence of adult ADHD was associated with significant increased risk of legal problems.

Pathological skin picking (PSP) is a repetitive picking of skin which leads to tissue damages and significant distress. According to the emotion regulation hypothesis, picking behaviors are initiated in order to regulate pathologically high or abnormally low stimulation level associated with various emotional states.

The aim of the study was to investigate the relationship between different activation levels, negative affective states and skin picking of various picking styles.

Participants, 51 university students with PSP symptoms selected on the basis of the Skin Picking Scale and 62 students without the history of PSP filled out questionnaires concerning activation levels, positive and negative affect, anxiety, depression and boredom. The participants with skin picking were also assessed by The Milwaukee Inventory for Dimensions of Adult Skin Picking in order to determinate whether they represent automatic or focused picking style.

The hierarchical regression analysis indicated that skin picking is positively predicted by general activation, and negatively by high activation (tension). Individuals with skin picking are also characterized by low level of calmness.

The results obtained in the study show that skin picking could play an important role in coping with negative emotional states, especially those related to low tension, and could reveal itself once the level of calmness is particularly low. Skin picking can also be initiated when one experiences high activation associated with high energy level. The focused and automatic picking style are engaged in the general activation and high activation regulation, whereas the general deactivation could be modified predominantly by the focused picking.