The population ageing is a reality associated with an increase in prevalence of Dementia. The use of benzodiazepines is often postulated as a risk factor in these syndromes.

Contrary to recommendations for its short-time use, long-term and chronic use are common, with an estimated 8,7% of elderly people in the US taking benzodiazepines.

To clarify the most recent evidence on the use of benzodiazepines and the risk of developing dementia.

Non-systematic review of literature, using PubMed as database and filtering the results for meta-analysis.

Four articles were included in this review.

Zhong G et al. concluded that risk of dementia increased in consumers of benzodiazepines and it was associated with higher doses.

In turn, AlDawasari A et al., when trying to clarify the use of different sedative-hypnotic drugs, found and increased risk with the consumption of benzodiazepines. After exclusion of articles with confounders and adjustment for protopathic bias, the risk was not maintained.

Lucchetta RC et al. concluded that the risk exists but without inferring differences between doses or duration of action.

Finally, Penninkilampi R e Eslick GD investigated this association, after controlling for the protopathic bias, concluding, contrary to AlDawasari et al., that the association benzodiazepines consumption and dementia do not result from this bias.

We cannot draw robust and concrete conclusions between benzodiazepines consumption and the pathogenesis of dementia because not only is the literature limited, but results are also heterogeneous.

However, these prescriptions must be carried out cautiously, especially in the elderly, due to the known adverse effects associated with them.

None Declared

Wernicke’s encephalopathy (WE) is a potentially reversible neuropsychiatric emergency caused by thiamine deficiency, whose classical triad consists of acute onset of confusion, gait ataxia, and oculomotor dysfunction. The diagnosis is missed in 75-80% of cases and approximately 80% of untreated patients develop Korsakoff Syndrome, which is characterized by memory impairment associated with confabulation. Early recognition of nutritional deficiency or any portion of the triad is critical and should prompt treatment, since WE is readily reversible if treated with adequate doses of parenteral thiamine.

Starting from a case report of suspected WE, we pretend to discuss the differential diagnosis of seizures in dual pathology.

Non-systematic review of the literature was performed in PubMed database using the keywords “Wernicke’s Encephalopathy”, “Seizures”, “Alcohol” and “Benzodiazepines”. The articles were selected according to their relevance. A patient´s clinical record was reviewed and presented.

We present a case of a 44-year-old Ukrainian man with suspected background of chronic alcohol abuse and psychiatric history of schizoaffective disorder, who presented with acute onset of confusion, psychomotor agitation, gait ataxia and nystagmus. Anamnesis was hampered by the language barrier and absence of past medical history and patient’s alcoholic habits remained unclear. After suspicion of WE it was introduced thiamine and diazepam, with significant improvement. After discontinuation of diazepam, the patient presented with several episodes of tonic-clonic seizures. He was medicated for seizures with clinical stabilization. At time of discharge the diagnostic discussion prevailed.

Seizures are a common presentation of various conditions associated with alcohol use, whose differential diagnosis is difficult, especially in patients with dubious alcohol consumption. Alcohol abuse is a major precipitant of status epilepticus as seizure threshold is raised by alcohol drinking. Seizures may also occur during alcohol withdrawal, for which treatment with benzodiazepines is recommended, however carefully, since both abrupt cessation and high-dose use are critical for the appearance of seizures. Although very rare, WE may also present with seizures, whereby overdiagnosis and overtreatment are preferred to prevent persistent neurocognitive impairments.

This case illustrates the complexity of neuropsychiatric diagnoses in dual pathology. It requires a longitudinal assessment for a better understanding of clinical conditions and establishment of the best therapeutic approach.

None Declared

Nowadays, In the exercise of psychiatric clinical activity, the prescription of atypical antipsychotics is a widespread practice.

However, despite the approval in the treatment of psychoses and bipolar affective disorder, where its effectiveness is clearly demonstrated, these drugs are off-label prescribed in most of the clinical situations.

This work aims to clarify which atypical antipsychotics are most frequent prescribed and the clinical conditions where their off-label prescription is more common.

Bibliographic research in the Pubmed® database using the terms “atypical antipsychotics and off-label use”

According to the scientific literature consulted, the off-label prescription of atypical antipsychotics may represent about 70% of the total prescription of these psychotropic drugs.

Risperidone, olanzapine, quetiapine and aripiprazole are the most off-label prescribed among the atypical antipsychotics.

The psychiatric conditions where atypical antipsychotics are most often off-label prescribed are addictive disorders, anxiety disorders, post-traumatic stress disorder, personality disorders, eating disorders, insomnia and dementia, where therapeutic benefits are demonstrated when carefully selected.

The off-label prescription can be interpreted from two points of view. On the one hand, it can guide innovation in clinical practice and improve symptoms in patients who do not respond to standard treatments. On the other hand, it may be associated with negative consequences due to the lack of data on safety and efficacy in these situations.

Despite widespread prescribing of atypical antipsychotics, there is no evidence-based recommendation beyond psychoses and bipolar affective disorder.

Thus, when prescribed, we must proceed with careful monitoring and consider the risks and benefits in relation to off-label prescription.

None Declared

Diabetes is one of the diseases in which treatment adherence is most fragile. Several factors seem to contribute to the lack of treatment compliance of the disease, from longer duration of diabetes to mental health issues. In this study, we try to identify the main factors affecting insight for diabetes (clinical, demographic, and narcissistic traits).

The main objective is to find clinical, demographic and narcisistic characteristics that differenciate good insight from poor insight diabetic patients.

A cross-sectional study was developed with inclusion of 100 patients with diabetes, aged over 18 years, carried out at the Associação Protetora dos Diabéticos de Portugal (APDP). All the participants gave their informed consent. Patients were submitted to DAS (Diabetes Awareness Scale), and NPI-13 (Narcissistic Personality Inventory-13), the two most used evaluations for insight in diabetes and narcisic personality traits. The clinical and demographic factors were obtained by the records from APDP whose Ethic Comittee gave permission for this study.

The clinical and demographic characteristics of the sample of 100 patients with diabetes, are described in Table 4.1.

Positive and statistically significant correlations were found between HbA1c and total DAS (r = 0.420, p < 0.001), Symptom Attribution (r = 0.362, p < 0.001), Awareness of Negative Consequences (r = 0.229, p = 0.025), and Awareness of Need for Treatment (r = 0.210, p = 0.040) - Table 5. In other words, patients who were metabolically poorly controlled and had higher levels of serum HbA1c, showed higher levels of insight into the disease.

There was a statistically significant negative low-moderate affect correlation between Symptom Attribution of the DAS and the E/E (Empowerment/Explorativeness) sub score of the NPI-13 (r= -0.243, p=0.05)-Table 8.

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Our results allowed us to conclude that the capacity for insight may sometimes arise in the context of already existing consequences of diabetes, in patients with poor metabolic control.Some studies had already highlighted the dubious role of increased individual perception of illness with diabetes regulation, while others were consistent with our observations, regarding the role of gender and family history in insight.

Despite these results, we propose that the knowledge of the profile of patients with insight and the anticipation of a low insight to the disease at the time of diagnosis or during follow-up allows the individualization of medical practice and the use of insight as a tool for better metabolic control of patients, ideally should arise before the development of vascular complications.

However, further studies are needed, ideally with a larger and more diverse, to understand if there are other factors that may be related to insight in the disease, as well as the development of techniques for acquisition of insight in patients with diabetes.

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Substance use disorders(SUDs) are a major health concern and current treatment interventions have proven only limited success. Despite increasing effectiveness, still about 50–60% relapse within 6–12 months after treatment [Cornelius et al., Addict Behav. 2003;28 381-386]. SUDs are defined as chronic disorders of brain reward system, motivation, and memory processes that have gone awry. Medication reducing craving and substance use is mainly available for alcohol dependence and to a lesser extent for other substances.

Hallucinogens may represent a group of agents with potential anti-craving properties subsequently reducing substance use in SUD patients. For instance, lysergic acid diethylamide(LSD) and psilocybin have previously been shown to effectively alleviate symptoms of alcohol and nicotine dependence.

New treatments preferably focusing on reducing craving and subsequent substance use are therefore urgently needed. The hallucinogen psilocybin may provide a new treatment option for SUD patients, given the beneficial results observed in recent studies

Systematic revision of literature.

In the 1950s, a group of drugs with potential to alter consciousness were discovered (hallucinogens). Several studies suggested their anti-SUD potential, improving self-acceptance and interpersonal relationships, reducing craving and alcohol use. As a result of its recreational popularity during the 1960s, they were banned in 1967, greatly hampering scientific research in this field. Recently, psilocybin, an hallucinogenic substance in psilocybin-containing mushrooms has gained popularity in neuropsychological research, showing to increase trait openness, cognitive and behavioral flexibility, and ratings of positive attitude, mood, social effects, and behavior and even reported persistent positive changes in attitude and behavior. These findings might suggest a valuable compound for the treatment of psychiatric conditions with several additional studies providing supportive evidence for the therapeutic potential of psilocybin for SUD treatment and relapse prevention.

With the reported limited amount of side effects and potential beneficial effects of psilocybin in SUD, there are valid reasons to further investigate the therapeutic efficacy and safety of psilocybin as a potential SUD treatment. On the one hand, psilocybin may exert its anti-addictive properties by beneficial effects on negative emotional states and stress. On the other hand, psilocybin may improve cognitive inflexibility and compulsivity. Research on the efficacy of psilocybin on SUD is still limited to a handful of published studies to date. As a result, many important questions related to the use of psilocybin as a complement to current treatment of SUD and its working mechanisms remain unanswered. Before psilocybin can be implemented as a treatment option for SUD, more extensive research is needed.

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The prevalence of mental illness has increased worldwide over the past few years. At the same time, and even in the sense, there is also an increase in suicide rates with special incidence in certain risk groups, among which health professionals stand out.

In this particular group, physicians seem to represent a class particularly vulnerable by the stress and demand associated with it, but also by access and knowledge about potentially lethal means.

For this very part, they have a higher risk of suicide than the general population.

This paper aims to better understand the phenomenon of suicide among physicians and identify which medical specialties are most vulnerable.

Bibliographic research in the Pubmed® database using the terms “suicide and physicians”.

The data obtained from the scientific literature consulted indicate that physicians have a higher risk of suicide than the general population, with greater emphasis on females who have higher rates compared to males.

Work factors that translate into higher levels of demand and stress combined with easy access and knowledge about the use of potentially lethal means seem to contribute very significantly to this phenomenon. Perfectionist personality traits with a high sense of responsibility and duty are also important characteristics that place these professionals in a position of greater vulnerability.

With regard to the different medical specialties, anesthesiology, psychiatry and general and family medicine are the ones with higher suicide rates among the medical class.

The risk of suicide, although admittedly high in the medical class, is not homogeneous among different countries, being naturally influenced by the satisfaction/gratification obtained in the performance of their profession. In this sense, countries such as Switzerland and Canada show higher levels of professional satisfaction. In the opposite direction, dissatisfaction in the exercise of clinical activity is associated with higher levels of fatigue and burnout.

Medical women, due to the need to combine the responsibility of family tasks with professional responsibility, are at greater risk.

In this sense, it is necessary to develop strategies that are more appropriate for the prevention and early identification of suicide risk situations that can be experienced not only by improving working conditions but also by better addressing professionals suffering from mental disorders.

None Declared

Psychosis is a frequent complication in patients diagnosed with Parkinson’s Disease (PD). Characterized mainly by visual hallucinations and paranoid delusions, it occurs most frequently, but not exclusively, as an adverse effect of antiparkinson medications. Nevertheless, cognitive impairment and dementia, as a frequent feature of PD, needs to be considered for differential diagnosis.

Our main objective is to report a case of PD Psychosis, its diagnosis and management and complement it with a non-systematic review of literature.

Patient file consultation and an additional research, based on the key words “Psychosis” and “Parkinson’s Disease”, using Pubmed as database.

A 53-year-old female, diagnosed with Juvenile Parkinson’s Disease since age 45 and, as expected, polimedicated with antiparkinson medication. Without any relevant psychiatric background, she was admitted to the emergency department for disorganized behaviour, with 2 weeks of evolution. There, it was also possible to determine the presence of auditive hallucinations and persecutory delusions, associated with marked anguish.

After exclusion of any underlying cause for this symptomatology, inpatient treatment was proposed and accepted by the patient. In collaboration with the Neurology Department, a gradual reduction and optimization of antiparkinson drugs was conducted, associated with introduction of low doses of antipsychotic drugs, in this case Olanzapine. With this medication adjustments, clinical improvement was accomplished, with eventual fading and cessation of psychotic symptoms. Additionally, an irregularly intake of antiparkinson drugs was considered the most probably cause of this clinical decompensation.

As present in literature, due to the chronicity and complexity of PD, stopping all antiparkinson drugs is not an option, even when psychotic symptoms, that could be a consequence of these drugs, are present. Therefore, a rigorous evaluation and management are mandatory, including the exclusion of other underlying causes and a careful therapeutic adjustment, with gradual reduction of antiparkinson drugs, addressing an eventual temporal relationship between the beginning of a specific drug and the onset of symptoms, and verification of therapeutic compliance, including an involuntary overdose. In cases of refractory symptoms, and after a risk-benefit assessment, pharmacologic treatment directed at these symptoms, low doses of anti-psychotics, may be necessary.

None Declared

Post-traumatic stress disorder (PTSD) is defined by an exaggerated fear responses (FA) which fails to extinguish over time and cannot be inhibited in safe contexts. Studies report that traumatic experiences (TE) affect hormonal systems mediated by the hypothalamic-pituitary-adrenal (HPA) axis and the oxytocinergic system. Oxytocin (OXT) is a neurohormone produced in the hypothalamus that has social functions like the promotion of prosocial and affiliative behaviors, increased self-confidence and positive social memories. In PTSD there is a diminished inhibitory top-down control over the FA, which is characterized by amygdala hyperactivity, ventromedial prefrontal cortex (vmPFC) hypoactivity and diminished structural and functional connectivity between both areas, which results in anxiety increase and dysregulated autonomic and endocrine FA. In parallel, TE decrease the synthesis and release of OXT, resulting in the dysfunction of the negative feedback mechanism on the HPA, leading to hypercortisolemia and maximizing the response to a stressful stimulus. Previous studies report that the administration of OXT can reduce cortisol levels as well as attenuating amygdala hyperactivity and normalizing the connectivity of this structure with frontal areas, diminishing the FA. Therefore, OXT has been investigated as a potential therapeutic agent administered intranasally early after trauma as a strategy to prevent PTDS on individuals having high risk.

The aim of this work is to review the potential of intranasal OXT administration as early preventive intervention for PTSD.

Systematic review of the literature published in Pubmed, using the terms “Oxytocin”, “Post-traumatic Stress Disorder”, “Stress”.

Studies found significant associations between TE and OXT and report that TE and PTSD are strongly associated with reductions in OXT. Literature report that the acute effects of OXT administrations in individuals with TE tend to be anxiolytic only in less severe forms, by modulating the HPA axis and the autonomic nervous system. Moreover, in recent TE, OXT seems to increase the re-experience of traumas and restore the function of different networks associated with fear control in PTSD patients. FMRI studies indicate that intranasal OXT attenuates amygdala hyperactivity and enhances amygdala´s connectivity with vmPFC, resulting in increased control over the FA. Finally, studies report that a single oxytocin administration increases neuronal fear processing but repeated administration reduces PTSD symptoms up to 6 months post trauma in patients with high acute symptoms.

Repeated administration of intranasal oxytocin early after trauma seems to diminish the acute symptoms in early stages of PTDS, being a potential pharmacological strategy to prevent PTDS in individuals at high risk by increasing the control of FA.

None Declared

Pregnancy and childbirth are moments of great vulnerability in a woman’s life, which can predispose her to the development of psychopathology, ranging from transient depressive symptoms (“baby blues”) to psychotic symptoms. Postpartum delirium is the psychiatric syndrome that some authors refer to as puerperal psychosis par excellence. It was first described in the 18th century and were thought to be associated with painful delivery, then became rare after the introduction of effective analgesia.

The objective of this work is to contribute to a better understanding of this condition, through a literature review.

Bibliographic research using Pubmed® and the keywords: postpartum delirium.

Clinical presentation of postpartum delirium includes: constantly varying degrees of consciousness; perplexity; hallucinations or pseudo-hallucinations of one or more organs of sense; delusions or delusive-type thoughts; great motoric unrest and considerable motoric and verbal abandon; and acute aggressive discharges can also occur. It is thought to be due to organic complications, such as infectious disease, abnormal loss of blood, thrombosis, neurological disease, obstetric disease, vitamin deficiencies, hormonal changes. An article from 1975 mentions how difficult was to treat postpartum delirium despite the development of psychopharmaceutical therapy. The patients remained psychotic for long periods and had many relapses. They mention a comparative study that found that the symptomatic treatment of this syndrome with a combination of perfenazine and lithium carbonate produced relatively favorable results. For that reason, at that time, it was the medication of choice. Nowadays the psychopharmacological treatment of puerperal psychosis, in general, still consists of the combination of lithium and an antipsychotic, such as haloperidol, and possibly a benzodiazepine, such as lorazepam.

Postpartum delirium is rarely mentioned in the literature and just a few cases have been described. It is considered a rare postpartum psychotic condition but would perhaps be less rare if its existence were recognized. On this note, it is important for clinical practice to research on the psychoses of pregnancy and not just the most common.

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The Default Mode Network (DMN) is a brain system with physiological and cognitive properties that make it a major pillar of cortical integration. It has been a subject of increased research on different psychiatric conditions such as schizophrenia. It was hypothesized that alterations in the brain connectivity of the DMN, at the level of its functional connectivity (FC) and structural connectivity (SC), may be at the basis of this pathology. Thus, the DMN has been associated with several clinical variables such as symptom severity, disease prognosis and response to antipsychotic treatment, making this system a potential future tool in the study of these variables for better clinical guidance in patients with schizophrenia.

The aim of this study is to review the role of DMN in the pathophysiological mechanisms underlying schizophrenia, as well as its potential role as a future biomarker in detecting patients at high risk of developing a first psychotic episode and predicting therapeutic response to antipsychotics.

Systematic review of the literature published on Pubmed using the terms: “Default Mode Network”, “Schizophrenia”, “First Psychotic Episode” and “Antipsychotics”.

A myriad of studies revealed the presence of dysfunctional DMN brain activity in patients with schizophrenia. However, increased FC of the DMN is the predominant outcome reported by literature in patients with and without chronic exposure to antipsychotic therapy, at high risk of developing psychosis and on both early and advanced disease stages, suggesting that the DMN may have a meritorious role on the pathophysiology of schizophrenia. Some studies have found SC changes associated with altered FC on patients at early stages of the disease without exposure to prolonged antipsychotic therapy. Regarding the relationship between DMN and antipsychotic therapy, studies suggested that DMN is shaped by antipsychotic therapy by regulating FC activity.

This work helped us to understand the importance of the future study of the connectivity of the DMN in a longitudinal perspective of the course of schizophrenia in order to potentiate the creation of brain signatures that might translate the alterations of the connectivity of the DMN in early stages of the disease, which in turn could work as potential future biomarkers for the detection of patients at high risk of developing a first psychotic episode but also work on predicting the therapeutic response to antipsychotics, allowing us to direct our clinical orientation towards a better prognosis of the disease.

None Declared

With natural hazards increasing in frequency and severity and global population aging, preparedness efforts must evolve to address older adults’ risks in disasters. This study elucidates potential contributors to the elevated older adult mortality risk following Hurricane Maria in Puerto Rico through an examination of community stakeholder preparedness, response, and recovery experiences.

In April 2018, qualitative interviews (n = 22) were conducted with stakeholders in 7 Puerto Rican municipalities. Interview transcripts were deductively and inductively coded and analyzed to identify salient topics and themes representing participant response patterns.

The hurricane’s detrimental impact on older adult health emerged as a prominent finding. Through 6 months post-hurricane, many older adults experienced unmet needs that contributed to declining physical and emotional health, inadequate non-communicable disease management, social isolation, financial strain, and excess morbidity and mortality. These needs were predominantly consequences of lengthy public service gaps, unsafe living conditions, interrupted health care, and the incongruence between preparedness and event severity.

In a landscape of increasing natural hazard frequency and magnitude, a pattern of older adult risk has become increasingly clear. Study findings compel practitioners to engage in natural hazard preparedness planning, research, and policy-making that considers the multiple facets of older adult well-being.

This study aimed to examine factors that may have contributed to community disaster resilience following Hurricane Maria in Puerto Rico.

In April 2018, qualitative interviews (n = 22) were conducted with stakeholders in 7 Puerto Rican municipalities (9% of total). Transcripts were deductively and inductively coded and analyzed to identify salient topics and themes, then examined according to strategic themes from the Federal Emergency Management Association’s (FEMA) Whole Community Approach.

Municipal preparedness efforts were coordinated, community-based, leveraged community assets, and prioritized vulnerable populations. Strategies included (1) multi-sectoral coordination and strategic personnel allocation; (2) neighborhood leader designation as support contacts; (3) leveraging of community leader expertise and social networks to protect vulnerable residents; (4) Censuses of at-risk groups, health professionals, and first responders; and (5) outreach for risk communication and locally tailored protective measures. In the context of collapsed telecommunications, communities implemented post-disaster strategies to facilitate communication with the Puerto Rican Government, between local first responders, and to keep residents informed, including the use of: (1) police radios; (2) vehicles with loudspeakers; (3) direct interpersonal communication; and (4) solar-powered Internet radio stations.

Adaptive capacities and actions of Puerto Rican communities exemplify the importance of local solutions in disasters. Expanded research is recommended to better understand contributors to disaster resilience.