Hyponatraemia occurs in 4% of schizophrenic patients. Dilutional hyponatraemia, due to inappropriate retention of water and excretion of sodium, occurs with different psychotropic medications and could lead to hippocampal dysfunction. This complication is usually asymptomatic but can cause severe problems, as lethargy and confusion, difficult to diagnose in mentally ill patients.

To describe a case of a patient with psychotropic poli-therapy, admitted three times due to hyponatremia and the pharmacological changes that improved his condition.

To broadcast the intermittent hyponatraemia and polydipsia (PIP), a not rare condition, suffered by treated schizophrenic patients and discuss its physiopathology and treatment thorough a case report.

A 56-year schizophrenic male was admitted for presenting disorganized behavior, agitation, auditory hallucinations, disorientation, ataxia, vomits and urinary retention. He was on clomipramine, haloperidol and clotiapine (recently added), quetiapine, fluphenazine and clonazepam. After water restriction his symptoms improved and he was discharged. Twenty-five days later, he was readmitted for presenting the same symptoms and after water restriction, he was discharged. Five days later, he was again admitted and transferred to the psychiatric ward.

Haloperidol, fluphenazine and clomipramine were replaced by clozapine. These changes lead him to normalize the hypoosmolality and reduce his water-voracity. Endocrinology team did not label this episode of SIADH due to its borderline blood and urine parameters.

Hyponatremia is frequent in schizophrenic patients and may have severe consequences. Therefore, a prompt recognition and treatment is warranted.

The authors have not supplied their declaration of competing interest.

Psychiatric morbidity in epilepsy is high, with prevalence rates of up to 50%, being higher in treatment-refractory cases. This co-morbidity worsen the quality of life. Psychiatric comorbidities are hampered by atypical presentations or disorders, which do not appear in the DSM-IV or ICD.

To describe the psychiatric morbidity in a group of patients with refractory-epilepsy.

To provide evidence of the high morbidity and show the prevalence of the different psychiatric disorders.

We cross-sectional assessed psychiatric disturbances in resistant-epileptic patients using SCID for DSM-IV and clinical interview for epileptic specific psychiatric conditions. We grouped psychiatric disturbances into six clusters:

– affective disorders;

– anxiety disorders;

– psychotic disorders;

– eating disorders;

– conduct disorder;

– substance use disorder.

We also considered epilepsy specific conditions as Interictal Psychotic Disorder (IPI) and Interictal Dysphoric Disorder (IDD) characterized by 3/8 symptoms: depressive mood, anergia, pain, insomnia, fear, anxiety, irritability, and euphoric mood.

The sample consist on 153 patients, with a mean age of 37. In total, 42.5% were males. One or more axis I diagnoses was seen in 38% of the patients. The most common condition was IDD (27.1%), followed by affective disorders (22%), anxiety disorders (15.3%), psychotic disorders (4%) and drug use (2%). There were no patients with eating or conduct disorders or IPI.

Psychiatric morbidity is frequent in resistant-epilepsy. Despite 38% of patients suffered from at least one axis I diagnoses, IDD was the most prevalent condition and not included in SCID interview.

The authors have not supplied their declaration of competing interest.

Systemic lupus erythematosus is a chronic disease that can give neuropsychiatric episodes and systemic manifestations. About 57% of patients with SLE have neuropsychiatric manifestations in the course of their illness, however an initial presentation with neuropsychiatric clinic is rare.

Describe how patients receiving corticosteroids as part of their treatment can develop mental disorders but not only them.

It will raise grounds with a case: 20-year-old woman recently diagnosed with SLE because of arthritis in his ankle. Treatment was initiated with prednisone 10 mg and chloroquine 200 MG. After 20 days the patient comes to the emergency after episode of turmoil at home with major affective clinical maniform. Presenting fever. The presence of fever downloads the possibility of a psychosis chloroquine or corticosteroids to be a small dose. Treatment was initiated with high doses of prednisone and immunosuppressants. In addition to associating specific anticonvulsant and antipsychotic drugs at usual doses for a manic episode.

Treatment of psychosis in SLE is essentially empirical, and depends on the etiology. It usually responds to the use of high doses of corticosteroids combined with immunosuppressive drugs. Psychosis induced by corticosteroids requires lowering them. It is valid concomitant use of antipsychotics.

The presence of psychotic symptoms in a patient with systemic lupus erythematosus forces to distinguish between various etiological possibilities.

Corticosteroids may cause a variety of psychiatric symptoms. And yet, in patients with SLE these syndromes are not always attributable to the use of corticosteroids.

The authors have not supplied their declaration of competing interest.

Parkinson's disease is caused by decreased dopaminergic neurons of the substantia nigra. Psychosis occurs between 20 and 40% of patients with Parkinson's disease. Dopaminergic drugs act as aggravating or precipitating factor. Before the introduction of levodopa patients had described visual hallucinations but the frequency was below 5%.

Illustrated importance of treatment, reassessment after its introduction and refractoriness to answer; as well as the importance of a differential diagnosis at the onset of psychotic symptoms later in life.

Clinical case: female patient 75 years tracking Neurology by parkinsonism in relation to possible early Parkinson disease. She was prescribed rasagiline treatment. Begins to present visual and auditory hallucinations, delusional self-referential and injury. She had no previous psychiatric history. She went on several occasions to the emergency room, where the anti-Parkinson treatment is decreased to the withdrawal point and scheduled antipsychotics did not answer. Doses of antipsychotics are increased despite which symptoms persist and even increase psychotic symptoms. In this situation it is agreed to extend the study. Subsequently an NMR of the skull where the image is suggestive of a right occipital meningioma appears.

With the emergence of psychotic symptoms later in life it will be important to ask a broad differential diagnosis, since in a large number of cases will be secondary to somatic or to drug therapies.

Parkinsonism can be a symptom of occipital meningioma, presenting in the psychotic clinic. Refractoriness, on one hand to the suspension of treatment for Parkinson's disease, such as poor response to antipsychotics, did extend the study, which ultimately gave us the diagnosis.

The authors have not supplied their declaration of competing interest.

Clozapine is the only drug approved for resistant schizophrenia, but remains underused because of its side effects. Sedation is common, but its management is unclear.

To analyze factors associated with clozapine-induced sedation and the efficacy of common treatment strategies.

To determine clozapine-induced sedation factors and possible therapeutic strategies.

Using two years’ electronic records of a community cohort of resistant schizophrenia spectrum disorder cases on clozapine, we performed three analyses: a cross-sectional analysis of which factors were associated with number of hours slept (objective proxy of sedation), and two prospective analyses: which factors were associated with changes in hours slept, and the efficacy of the main pharmacological strategies for improving sedation.

One hundred and thirty-three patients were included; 64.7% slept at least 9 hours/daily. Among monotherapy patients (n = 30), only norclozapine levels (r = .367, P = .033) correlated with sleeping hours. Multiple regression analyses confirmed the findings (r = .865, P < .00001). Using the cohort prospectively assessed (n = 107), 42 patients decreased the number of hours slept between two consecutive appointments. Decreasing clozapine (40%) or augmenting with aripiprazole (36%) were the most common factors. In the efficacy analysis, these two strategies were recommended to 22 (20.6%) and 23 (21.5%) subjects, respectively. The majority (81.8% and 73.9%) did not report differences in the hours slept.

Sedationis common and involves pharmacological and non-pharmacological factors. The only correlation was a weak correlation between norclozapine plasma levels and total sleeping hours. Reducing clozapine and aripiprazole augmentation were the most successful strategies to ameliorate sedation, although both strategies were effective only in a limited numbers of subjects.

The authors have not supplied their declaration of competing interest.

Psychiatric morbidity in refractory epilepsy is frequent and has a negative influence on quality of life. Treatment-refractory epileptic patients are at higher risk of developing psychiatric disturbances. The interictal dysphoric disorder (IDD) has been described as a pleomorphic pattern of symptoms claimed to be typical of patients with epilepsy. It is characterized by 3/8 symptoms: depressive mood, anergia, pain, insomnia, fear, anxiety, irritability, and euphoric mood.

To provide evidence that psychiatric morbidity is high in refractory epilepsy and to describe associations to IDD.

The present study aims to show that there are typical psychiatric conditions in epilepsy that can be unnoticed.

We cross-sectional analyzed the psychopathologic outcomes of patients with refractory epilepsy. The assessments methods included SCID for DSM-IV and clinical interview for epileptic specific psychiatric conditions.

The sample consists of 153 patients, with a mean age of 37. A total of 42.5% were males. One or more Axis I diagnoses was seen in 38% of the patients. The most common condition was IDD (27.1%), followed by affective and anxiety disorders (22 and 15.3% respectively). Considering patients with IDD, we found differences in locus (P = 0.001) (present in 34.3% of non-stablished locus, 8.6% of extra-temporal locus and 57.1% of temporal locus) but not with hemisphere, sex, type of crises, treatment. We neither found correlation with age, number of crisis or number of treatments.

Psychiatric comorbidities as IDD do not appear in the DSM-IV but are prevalent and could be related with temporal locus.

The authors have not supplied their declaration of competing interest.

Within the various cultures and throughout the centuries has observed the relationship between emotional states and heart function, colloquially calling him “heartbroken”. Also in the medical literature are references to cardiac alterations induced by stress.

Takotsubo is a rare cardiac syndrome that occurs most frequently in postmenopausal women after an acute episode of severe physical or emotional stress. In the text that concerns us, we describe a case related to an exacerbation of psychiatric illness, an episode maniform.

Woman 71 years old with a history of bipolar I disorder diagnosed at age 20. Throughout her life, she suffered several depressive episodes as both manic episodes with psychotic symptoms. Carbamazepine treatment performed and venlafaxine. He previously performed treatment with lithium, which had to be suspended due to the impact on thyroid hormones and renal function, and is currently in pre-dialysis situation.

She requires significant adjustment treatment, not only removal of antidepressants, but introduction of high doses of antipsychotic and mood stabilizer change of partial responders. In the transcurso income, abrupt change in the physical condition of the patient suffers loss of consciousness, respiratory distress, drop in blood pressure, confusion, making involving several specialists. EEG was performed with abnormal activity, cranial CT, where no changes were observed, and after finally being Echocardiography and coronary angiography performed when diagnosed Takotsubo.

In this case and with the available literature, we can conclude that the state of acute mania should be added to the list of psychosocial/stressors that can trigger this condition.

The authors have not supplied their declaration of competing interest.

The frontal lobes are the brain structures of latest development and evolution in the human brain. It is considered that the frontal lobes represent the “executive center of the brain”. The frontal tumors represent 16% of all supratentorial tumors. Symptoms are easily confused as psychiatric rather than neurological.

Can see the alterations of the executive functions in a case of frontal affectation, for future cases know where to focus our attention and develop concepts associated with frontal lobe.

Thirty-year-old patient without relevant medical history. Go to the emergency department with major episode of agitation. After performing cranial CT abnormality, it is detected in the front area. Sign up study. It presents amnesia episode before admission, whereupon shown stunned and worried. The patient describes a change in your life 12 months ago, when it begins to be more nervous, increasing their impulsiveness, she has episodes of binge eating, purging behavior with subsequent occasional alcohol abuse. Jealousy. The patient is informed as much as your family of the possible impact of the injury on the behavioral sphere and impulse control when it is still unknown origin.

From a neuropsychological point of view the frontal lobes represent a system of planning, regulation and control of psychological processes; coordination and allow selection of multiple processes and various behavioral options and strategies available to the human being. Tumour research is important as it provides enough information we cognitive impairment. These patients exhibit symptoms that are easily confused as psychiatric rather than neurological.

The authors have not supplied their declaration of competing interest.

Non-attendance at initial appointments is an important problem in outpatient settings and has consequences, such as decreased efficient use of resources and delayed attention to patients who attend their visits, and that compromises quality of care.

To identify and describe the characteristics of patients who do not attend the first appointment in an adult outpatient mental health center, located in Barcelona.

Retrospective study. The sample was made up from all patients who had a first appointment during 2014 in our outpatient mental health centre. Socio-demographic and clinical data (type of first appointment, reason for consultation, origin of derivation, priority, history of mental health problems) were described. The results were analyzed using the SPSS statistical package.

A total of 272 patients were included. Twenty-six per cent did not attend their first appointment; with mean age 39.75 years and 51.4% were male. Most frequent problems were anxiety (41.7%), depression (26.4%) and psycosis and behavioural problems (11.2%). The origin was primary care (83.3%), social services (4.2%) and emergencies (2.8%). Most of them were not preferent or urgent (86.1%). The 51.4% of non-attendees had history or psychiatric problems and 13.9% nowadays are patients of our mental health centre.

It is important to develop mechanisms that can reduce the incidence of first non-attended appointments. In our case, most of them are attended by primary care so we can establish better communication with our colleagues and try to contact to the patients prior to the date of the appointment.

The authors have not supplied their declaration of competing interest.

Schizophrenia is a developmental disorder that includes non-psychiatric abnormalities [2]. Metabolic abnormalities prior to antipsychotic treatment exist. The clozapine metabolic profile causes clozapine underuse in resistant schizophrenia [1].

To correlate metabolic profile with psychiatric severity and compare the correlations between clozapine/non-clozapine patients.

To determine possible contributory factors to metabolic abnormalities in schizophrenia.

We cross-sectionally analyzed all patients from a Spanish long-term mental care facility (n = 139). Schizophrenic/schizoaffective patients were selected (n = 118). N = 31 used clozapine. We paired clozapine and non-clozapine patients by sex and age and assessed metabolic and psychopathologic variables.

We compared psychopathologic variables between patients with/without cardiometabolic treatment and the differences between clozapine/non-clozapine groups.

We analyzed: 27 clozapine/29 non-clozapine patients. A total of 67,9% males with a mean age of 51.3 (SD 9.6) years. In the whole sample TG negatively correlated with Negative-CGI (r: −0,470, P: 0.049) and HDL-cholesterol correlates with Global-CGI(r: 0,505, P: 0.046). Prolactin correlated with the number of antipsychotics (r: 0.581, P: 0.023) and IMC (r: 0.575, P: 0.025). Clozapine group took less antipsychotics [Fisher (P: 0.045)] and had higher scores in total BRPS scale [t-Student (P: 0.036)]. They did not use more cardiometabolic treatment. There were no psychopathological differences between cardiometabolic treated/non-treated patients. In the non-cardiometabolic treated group (n = 35/62,5%), IMC negatively correlated with positive and total BPRS, positive, cognitive and global-CGI. We found negative correlations between metabolic parameters and psychopathology in clozapine (40%) and non-clozapine subgroups (60%). In the cardiometabolic treated group (n = 21/37,5%), we did not find these correlations in either of clozapine (61.9%) or non-clozapine (38.1%) subgroups.

Severity [2], prolactine [3] and treatment [1] could play a role in metabolic parameters. In our sample we found negative correlations between psychopathological and metabolic parameters.

References not available.

The authors have not supplied their declaration of competing interest.

For resistant schizophrenia, the only approved treatment is clozapine. However, clozapine is underused, mainly due to its wide range of side-effects. Secondary effects differ amongst antipsychotics (Leucht et al., 2009). Despite that there is no good evidence that combined antipsychotics offer any advantage over the use of a single antipsychotic, combination increases the frequency of adverse events (Maudsley guidelines).

To compare the side-effect profile between clozapine and non-clozapinepatients.

To provide evidence that clozapine patients do not show a worse side-effects profile.

We cross-sectionally analysed all patients from a Spanish long-term mental care facility (n = 139). Schizophrenic/schizoaffective patients were selected (n = 118) and their treatment was assessed, 31 patients used clozapine. We paired clozapine and non-clozapine patients by sex and age and assessed antipsychotic side effects and possible confounder variables.

Our sample was 27 clozapine patients and 29 non-clozapine patients. 67,9% were male with a mean age of 51.3 (SD 9.6) years. For continuous variables: age, BMI, waist/hip, cholesterol, TG, glucose, prolactin, heart-rate, blood pressure, sleeping hours, the only statistical differences found were lower heart-rate (P = 0.001) in clozapine group and higher salivation subscale of SAS (P = 0.002) in clozapine group. For discrete variables: monotherapy, obesity, overweight, metabolic syndrome or possible confounders as propranolol, laxative, diet, antiglycemiant or insulin, fibrates or statins, antihypertensive or anticholinergic, no statistical differences were found.

We did not find differences in cardiometabolic parameters, which are the main barrier to prescribing clozapine, probably due to the concomitant use of other drugs in both groups.

The authors have not supplied their declaration of competing interest.

Clozapine (CZP) is the only antipsychotic approved for resistant schizophrenia 1. Due to its side effects, CZP is not the first therapeutic option in a psychotic episode. Its anticholinergic effects often cause constipation, however, diarrhea have also been described in literature.

We describe a patient with two episodes of severe diarrhea after clozapine initiation, which lead to CZP discontinuation.

Discuss about the differential diagnosis of diarrhea in CZP patients and the needing of a further studies for clarify the more appropriate management in CZP induced diarrhea.

We present a case report of a 46 years man diagnosed with schizoaffective disorder who presented two episodes of severe diarrhea with fever, which forced his transfer to internal medicine and UCI after CZP initiation.

At the first episode analytical, radiological and histological findings led to Crohn's disease diagnosis, which required budesonide and mesalazine treatment. In the second episode, the digestive team concluded that the episode was due to clozapine toxicity despite the controversial findings (clostridium toxin and Crohn's compatible biopsies)

Diarrhea caused by CZP has been controversial in the literature. However due to the severity of digestive episodes and the paucity of alternative treatments further studies for a better understanding of its physiopathology are warranted.

The authors have not supplied their declaration of competing interest.

Cannabinoid hyperemesis syndrome (CHS), is characterized by recurrent episodes of severe nausea and intractable vomiting, preceded by chronic use of cannabis. A pathognomonic characteristic is compulsive bathing in hot water. The resolution of the problem occurs when cannabis use is stopped. However, patients are often reluctant to discontinue cannabis. Treatment with anti-emetic medication is ineffective. Case series suggested haloperidol as a potential treatment. Other antipsychotics as olanzapine has been used as anti-emetic treatment in chemotherapy.

To describe three cases of patients with CHS whom showed a successful response to olanzapine, even when, haloperidol had failed.

To present an alternative treatment for CHS which can offer benefits over haloperidol.

We present three cases of patients who suffered from CHS and were admitted to emergency department. All patients were treated with olanzapine after conventional anti-hemetic treatment failure. One patient was also unsuccessfully treated with haloperidol.

All three patients showed a good response to olanzapine treatment. Different presentations were effective: velotab and intramuscular. Their nausea, vomits and agitation were ameliorated. They could be discharge after maintained remission of symptoms.

Olanzapine should be considered as an adequate treatment for CHS. Its suitable receptorial profile, its availability in different routes of administration and its side effects profile could offer some benefits over haloperidol.

The authors have not supplied their declaration of competing interest.