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New-Onset Bipolar Disorder in Late Life: a case report and review of literature
- A. Sanz Giancola, E. Arroyo Sánchez, P. Setién Preciados, M. Martín Velasco, I. Romero Gerechter, C. Díaz Mayoral
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- Journal:
- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, p. S691
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Introduction
The elderly represents the fastest growing group of the population. It is fair to assume that the portion of old age patients suffering from bipolar disorder will grow in a similar manner. Elderly patients represent approximately 25% of the bipolar population. Summarizing, 5–10% of patients were 50 years of age when they experienced their first manic episode, constituting the subgroup of late onset bipolar disorder (LOBD).
ObjectivesThe purpose of this case report and literature review is to emphasise the importance of LOBD in old population and to highlight its still sparse-knowledge.
MethodsDescriptive case study and review of literature (Arnold,I. et al. Old Age Bipolar Disorder—Epidemiology, Aetiology and Treatment. Medicina 2021,57,587; Baldessarini et al. Onset-age of bipolar disorders at six international sites. J Affect Disord 2010;121(1-2):143-6).
ResultsA 60-year-old woman is brought to the emergency department for evaluation by her family. Over the past 7 days, the patient has become increasingly irritable and argumentative, is sleeping less, is talking faster than usual and has begun to express paranoid concerns about her students “stealing my exam”. The patient is a university professor.
In the assessment interview she is hyperverbal, expansive, and grandiose. The family has also just recently discovered that she has spent a large sum of money on the Internet.
She has no history of psychiatric contact or substance use disorders; however, she has a family history of severe depression.
In the absence of any plausible non-psychiatric condition that could mimic or induce mania, the working diagnosis is bipolar I disorder, most recent episode (MRE) manic with psychotic features.
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ConclusionsThe share of older age bipolar disorder will grow constantly in the next decades and further research on this neglected patient group is urgently required.
Disclosure of InterestNone Declared
Lithium management in pregnant patients with bipolar disorder
- I. Romero Gerechter, M. Martín Velasco, A. Sanz Giancola, E. Arroyo Sánchez, C. Díaz Mayoral, P. Setien Preciados
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- Journal:
- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, p. S198
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Introduction
Women with bipolar disorder often ask their treating clinician for information about family planning, as they are concerned about the impact of their illness on offspring. Pregnancy places additional stress on patients, and physiological changes are particularly acute during postpartum. On the other hand, the risk of abnormalities and teratogenicity from psychotropic drugs is significant. The decision wether resuming or discontinuating lithium is discussed.
ObjectivesWe present a theoretical review on the topic.
MethodsA bibliographic review is presented.
ResultsThe choice to continue medication during pregnancy balances the risks of an untreated illness with the risks of medication exposure. Abrupt discontinuation of psychotropic medications is associated with an increased risk for illness recurrence. Women with BD who discontinue their medications before or during pregnancy have a 71% risk of recurrence with new episodes occurring most frequently in the first trimester. Recurrent illness during pregnancy is associated with a 66% increase in the risk of postpartum episodes. Untreated or under-treated BD during pregnancy is associated with poor birth outcomes independent of pharmacotherapy exposure, including preterm birth, low birth-weight, intrauterine growth retardation, small for gestational age, fetal distress, and adverse neurodeve- lopmental outcomes. Women with untreated BD also have behavioral risk factors such as decreased compliance with prenatal care, poor nutrition, and high-risk behaviors. Impaired capacity to function may result in loss of employment, health care benefits, and social support. The biological and psychosocial risks of a BD episode are the justification for the risk of medication exposure.
Fetal exposure to lithium has been associated with an increased risk for cardiac abnormalities. The risk for Ebstein’s anomaly with first trimester exposure is 1 (0.1%) to 2 in 1000 (0.2%), but the absolute risk remains low. Folate supplementation with 5 mg reduces the risk and severity of congenital heart disease. Lithium toxicity causes lethargy, hypotonia, tachycardia, coma, cyanosis, and chronic twitching in the newborn.
Strategies to minimize fetal exposure and maintain efficacy include using the lowest effective dose, prescribing lithium twice daily to avoid high peak serum concentrations, and regular monitoring of lithium serum concentrations. The effective serum concentration must be established before pregnancy. If a therapeutic concentration has not been established, the lithium dose is titrated to a concentration within the therapeutic range. Breast feeding is discouraged in women taking lithium because of the high rate of transmission to the infant.
ConclusionsTreatment decisions for pregnant women with mood disorders must weigh the potential for increased risks of lithium during pregnancy, especially during the first trimester, against its effectiveness at reducing relapse.
Disclosure of InterestNone Declared
Clozapine use in drug induced psychosis in Parkinson´s disease: a case report and review of literature.
- A. Sanz Giancola, P. Setién Preciados, E. Arroyo Sánchez, I. Romero Gerecther, M. Martín Velasco, C. Díaz Mayoral
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- Journal:
- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, p. S1041
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Introduction
The occurrence of psychotic symptoms induced by dopaminergic drugs marks a new phase in the course of Parkinson’s disease (PD). The term drug induced psychosis may be used when other significant psychiatric diseases are excluded in patients with no history of psychosis. The prevalence of dopaminomimetic psychosis varies from 5% to 20%. Therefore, knowledge of the psychopharmacological management of this condition is essential.
ObjectivesThe purpose of this case report and literature review is to to learn the psychopharmacological management of this not uncommon medical complication.
MethodsDescriptive case study and review of literature
ResultsWe present the case of a 71-year-old man with a medical history of Parkinson’s disease with partial response to treatment with high doses of levodopa and carbidopa.
He was brought to the emergency department by his family due to the presence of behavioural alterations at home.
The patient reported seeing men in foam trying to harm his family. In a disjointed way in his speech, he links this idea with the delusional belief that he is being watched by electronic devices placed throughout the house. In a variegated manner he links this with a coelotypical type of discourse, however the delusional ideation remains unstructured throughout.
With no previous personal or family history of mental health and ruling out underlying organic conditions, a diagnosis of psychosis secondary to pharmacological treatment for Parkinson’s disease is presumed.
Considering the risks and benefits, it was decided to maintain the anti-Parkinson’s dose in order to avoid worsening the patient’s motor function. Therefore, after reviewing the literature, the best option was to introduce clozapine at low doses, up to 50 mg at night, with the respective analytical control. After a week’s admission, the patient began to improve psychopathologically, achieving an ad integrum resolution of the psychotic symptoms.
ConclusionsDespite the availability of other antipsychotic treatments such as quetiapine or the more recent pimavanserin, clozapine remains the treatment of choice for drug-induced psychosis in Parkinson’s disease.
Disclosure of InterestNone Declared
Psychotic denial of pregnancy: case report and narrative literature review.
- M. Martín Velasco, I. Romero Gerechter, C. Díaz Mayoral, E. Arroyo Sánchez, A. Sanz Giancola, P. Setién Preciados
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- Journal:
- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, p. S1129
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Introduction
Denial of pregnancy is the phenomenon where a woman fails to recognize or accept her pregnancy at >20 weeks gestational age. It associates with increased morbidity and mortality of mother and child, and can be classified as non-psychotic or psychotic. There is fewer medical literature regarding the latter, making it difficult to recognize, let alone to treat, since we do not have robust data regarding incidence nor approved interventions or treatment.
ObjectivesTo describe this unfamiliar entity in order to be able to perform a proper diagnosis and thus prevent possible negative outcomes.
MethodsWe present a case report alongside a narrative literature review on the topic.
ResultsWe report the case of a 39-year-old caucasian woman, foreign, undomiciled, with an advanced pregnancy, who was admitted to a Psychiatry in-patient unit due to psychotic symptoms such as mistrust and delusions. She showed scarce collaboration during assessment and did not give any plausible information about her identity. Her birthplace and prior medical records were therefore unknown. Apparently, she had no family nor social support network. Despite the obvious signs, she did not recognize being pregnant and showed great irritability when asked; her responses ranged from claiming she was suffering from a gastric tumor and making delusional attributions of symptoms clearly related to the pregnancy to partially acknowledging her state but refusing to answer any questions on the matter. Blood work showed no significant abnormalities and obstetric ultrasound revealed a low risk 35 weeks pregnancy.
With an estimated prevalence of 1:475 in general population, denial of pregnancy is not as rare as it may seem. The psychotic variant, however, is rather uncommon. Typically, women with psychotic pregnancy denial have prior history of major mental illness, most frequently schizophrenia, and suffer from extreme psychosocial vulnerability. They usually present previous or anticipated child custody loss, which hampers the process of developing antenatal attachment behaviours. Psychotic denial does not associate with concealing, since these women are mentally detached from the gestation and tend to create delusional explanations to their pregnancy symptoms. Not all of them show complete denial, some being able to acknowledge it, though mostly in an inconsistent way. These patients often fail to seek prenatal care or are noncompliant, they are at greater risk of drug exposure, and some are unable to recognize symptoms of labour, all of which increases the rate of negative outcomes for mother and baby, including neonaticide.
ConclusionsPsychotic denial is a rare diagnosis which should be properly assessed due to its clinical implications and the need to prevent potential negative outcomes for mother and baby.
Disclosure of InterestNone Declared
Application of family therapy in a case of anorexia nervosa
- C. Díaz Mayoral, I. Romero Gerechter, E. Arroyo Sánchez, M. Martín Velasco, A. Sanz Giancola, M. Martín de Argila
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- Journal:
- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, p. S848
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Introduction
Anorexia nervosa is a behavioral mental disorder, characterized by body dysmorphia, an intense fear of gaining weight and behaviors that interfere with this, in addition to a restriction of food intake, associated usually with medical complications, even a considerable risk of death.
Several psychotherapeutic approaches have been used along last decades. Until relatively recently, parents have been recognized as part of the problem, but nowadays we involve them into the therapeutic process through family therapy based on a systemic approach, recommended in current published clinical guidelines and research findings, with consistent evidence, as the first-line treatment of patients with anorexia nervosa.
ObjectivesA case of a patient with anorexia nervosa, is presented followed by a theoretical review on the topic.
MethodsA case is presented with a bibliographic review.
ResultsA 24-yeard-old female was hospitalized for renutrition due to a significant weight loss and multiple physical symptoms. After 4 months without progress, the patient was transferred to the psychiatric ward.
Once there, physical stabilisation was achieved with family therapy and pharmacological treatment, based on progressive administration of Clomipramine, previously assessed by Cardiology, which improved rumination and obsessive behaviour. We conduct daily individual and weekly family interviews, working on family dynamics, emotional regulation strategies and more adaptive ways of communication. Likewise, several lines of action were found in the systemic work: peripheral father; maternal over-involvement; fraternal rivalry; difficulties of interaction between all of them, derived from “the role of the sick person” and intra-family communication around the illness. Finally, showed effectiveness in terms of an improvement in interpersonal relationships, greater assertiveness and an optimistic attitude with an active search for coping strategies.
ConclusionsHistorically, parents have been recognized by a causal factor in the pathogenesis of this disorder. Nevertheless, the abolition of the emphasis on family responsibility, motivated by a philosophic and evidence-based, has allowed us to see them as an essential resource in aiding the patient in the improvement process. This parental involvement has resulted in a relevant reduction in morbidity, as well as a significant decrease treatment attrition rates. It has been noted a re-establishment in other individual and family factors such as self-esteem, quality of life, and some aspects of the experiences of caregiving, and behavioral symptoms have been resolved.
Disclosure of InterestNone Declared
Mania induced after corticosteroid treatment: a case report
- E. Arroyo Sánchez, A. Sanz- Giancola, P. Setién Preciados, I. Romero Gerechter, M. Martín Velasco, C. Díaz Mayoral
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- Journal:
- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, p. S697
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Introduction
Corticosteroids are drugs widely used in clinical practice for their anti-inflammatory and immunosuppressive properties. Despite their beneficial effects, a high association of these drugs with neuropsychiatric adverse effects such as psychosis, mania, depression, delirium or increased risk of suicide, among others, has been observed. We present the case of 54-year-old man who started treatment with hydroaltesone 20 mg/8h after undergoing surgery for a pituitary macroadenoma who began with maniform clinic.
ObjectivesTo know the prevalence, risk factors and treatment of mania as a side effect of corticosteroid drugs.
MethodsPresentation of the case and review of the available literature on the risk of developing mania after corticosteroid treatment.
ResultsSeveral studies confirm that the incidence of psychiatric adverse effects after the use of corticosteroids is around 6% if we refer to severe reactions; 28% moderate reactions; and 72% if we consider milder reactions. The direct relationship between these drugs and affective symptoms ranges in rates between 1-50% of cases, the most frequent being depression and mania. The risk of mania after treatment with corticosteroids is 4-5 times higher than if we compare it with a group of population not exposed to these drugs. There is a dose-response relationship, increasing the risk from a daily dose of 40 mg/day, with an average duration of symptoms of around 21 days. Female sex seems to be a risk factor in relation to the fact that diseases requiring this type of treatment are more common in this gender. As first-line treatment for mania secondary to corticosteroids, a decrease in treatment dose or its interruption, whenever possible, is proposed. Adjuvant treatment may be required, with atypical antipsychotics being the first choice.
ConclusionsCorticosteroid therapy has a direct dose-response relationship with the presence of psychiatric adverse effects such as mania. Dose and sex have been studied as possible adverse effects. Therefore, the pharmacological treatment of choice consists of a reduction in the dose of corticosteroids administered or withdrawal, if possible, and may be combined with an atypical antipsychotic such as olanzapine, quetiapine or risperidone. Re-evaluation is recommended until complete resolution of the clinical picture and then antipsychotic treatment can be progressively withdrawn.
Disclosure of InterestNone Declared
H+-PPase Distribution in Sieve Element-Companion Cell Complexes from Arabidopsis thaliana Wild Type Plants and Allelic Mutants
- A Patron-Soberano, J Paez-Valencia, A Rodriguez-Leviz, J Sanchez-Lares, C Sanchez-Gomez, P Valencia-Mayoral, G Diaz-Rosas, R Gaxiola
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- Journal:
- Microscopy and Microanalysis / Volume 17 / Issue S2 / July 2011
- Published online by Cambridge University Press:
- 08 April 2017, pp. 338-339
- Print publication:
- July 2011
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Extended abstract of a paper presented at Microscopy and Microanalysis 2011 in Nashville, Tennessee, USA, August 7–August 11, 2011.