New drugs in the treatment of dual psychosis: use of cariprazine in schizophrenia, other psychotic disorders and use of cocaine. A case series in a specific outpatient psychiatric clinic for substance use disorders.

The main objective of this case series is to observe and describe the tolerability and clinical response to different doses of cariprazine in a series of patients with dual psychosis, especifically cocaine users; with a special attention upon psychotic symptoms, disruptive behaviour, affective symptoms and cocaine use pattern.

This series consists of an observation of a total of 20 patients treated on an outpatient basis. All of them had a either a diagnosis of Schizophrenia or Other Non Specified Psychotic Disorder meeting the DSM-5 criteria, as well as a Cocaine Use Related Disorder meeting the DSM-5 criteria. All of them received treatment with cariprazine in different doses from 1,5mg to 6mg per day, as a solo treatment or as an adjuvant to another previous antipsychotic treatment when antipsychotic augmentation was justified. We observed patients that had started cariprazine in the past three months and that had active drug use or had had one in the past three months.

We monitored the tolerance to the treatment, the clinical response in terms of positive and negative symptoms of schizophrenia, affective symptoms, disruptive behavior, and the response in terms of substance use; for a period of six months of follow-up, with psychiatric consultation at least every month and nurse consultation every two weeks in our clinic.

95% of the patients did not present any side effect related to cariprazine. In one patient (5%) the treatment had to be stopped due to akathisia that did not disappear after two weeks and symptomatic treatment with benzodiacepines. 60% of patients either stopped using (50%) or reduced their use frequency (50%). 70% of the patients presented an improvement in positive symptoms and behavior. Also, one third of them presented a slight improvement in negative symptoms. 20% of patients referred a significant improve in depressive symptoms.

The main conclusion of this case series is that cariprazine at any dosis between 3mg and 6mg per day has a positive outcome, both in the psychotic domain and the substance use disorder. We hope this case series will help our colleagues treat their patients suffering from these pathologies in an optimal way. This could also set a basis to encourage a proper clinical trial to assess if new antipsychotics such as cariprazine could be a new standard for the treatment of Dual Disorders.

None Declared

Numerous countries, notably within Europe, have sanctioned the practice of euthanasia. Extant legal frameworks meticulously define the extent, essence, and application of euthanasia, encompassing divergent characterizations, explications of entitlements, procedural modalities, and provisions for access. Nonetheless, the precise function of psychiatrists within these legislative contours remains conspicuously nebulous.

The present inquiry undertakes a comprehensive evaluative review of the euthanasia phenomenon vis-à-vis the intricate tapestry of European legislative paradigms, with an emphasis on elucidating the multifaceted involvement of psychiatry within this evolving landscape.

A nuanced narrative review is undertaken, encapsulating the contemporary state-of-affairs, fundamental conceptual architectures, the tenets of the Spanish Organic Law 03/2021, and the pharmaceutic armamentarium deployed in the orchestration of euthanasic practices. Additionally, the methodological blueprint employed within a prominent tertiary healthcare institution situated in Madrid is meticulously expounded.

To date, euthanasia has garnered legal imprimatur across diverse jurisdictions including, but not limited to, the Netherlands, Belgium, Colombia, Canada, Spain, and New Zealand. The ambit of assisted death and its application to the domain of mental infirmities is meticulously deconstructed. Within the overarching realm of foundational concepts, a rigorous delineation is rendered between euthanasia, medical succor in the throes of mortality, assisted self-termination, facilitated demise, provision of mortal release, judicious calibration of therapeutic enterprise, and the contours of palliative sedation. Distinction between the principal executor and the advisory consultant is rendered salient. The rubric of conscientious objection emerges as an inviolable entitlement of healthcare practitioners enmeshed in the provisionary matrix.

The enduring incumbency of the psychiatrist as a pivotal appraiser of cognitive and volitional faculties holds firm. The conspicuous influence of psychopathological constellations upon the contours of euthanasia eligibility precipitates cogent deliberation.

As the frontiers of euthanasia expand to encompass an augmented array of legal jurisdictions, this study underscores the increasingly intricate role inhabited by psychiatrists in the matrix of evaluative assessments. The proclivity of mental maladies to exert a substantial gravitational pull upon determinations of eligibility for euthanasia accentuates the exigency for refined explication of roles and responsibilities within this evolving sphere, a clarion call resonant not only within the precincts of psychiatry but reverberating across the broader firmament of medical praxis.

None Declared

The spectrum of suicidal behavior is a core factor of the prognosis and care of Borderline Personality Disorder (BPD).

Identify possible BPD specific personality traits that could act as protective factors of nonsuicidal self-injuries (NSSI).

We performed a cross-sectional, observational and retrospective study of a sample of 134 BPD patients aged from 18 to 56. We assessed the presence or absence of suicidal behavior and NSSI as well as different sociodemographic variables. Millon, Zuckerman-Kuhlman and Structured Clinical Interview for DSM personality questionnaires were also applied. The analysis of the association between variables was carried out with a multivariate negative binomial logistic regression model.

A statistically significant association between NSSI and suicidal behavior was found. Elseways, statistically significant differences were also found in the association between NSSI and the SCID variables for Narcissistic Disorder, which appears as protective variables. These results provide an idea of the dynamic relationship between NSSI and suicidal behavior in a BPD population with particularly severe characteristics.

The role of narcissistic personality traits appears to be important in identifying protective factors for NSSI and suicidal behavior in BPD patients and could be the subject of further research projects.

No significant relationships.

The authors have not supplied their declaration of competing interest.

We report the case of a 19-year-old male who was brought to our psychiatry consultation by his family for behavioural disorders and poor school performance of years of evolution.

We found ourselves before a tall, thin, childish, suspicious, perplex, inhibited and minimizer patient, so we sent him to our hospital for psychiatric admission, where he showed a flowery delirium of mystic, religious and megalomaniac content; complex visual and auditory hallucinatory phenomena; and where he was diagnosed of acute polymorphic psychotic disorder and autism spectrum disorder with marfanoid habit. Therefore, we suspected a Lujan–Fryns syndrome and requested genetic confirmation. Risperidone was prescribed as solo treatment, with a rapid control of the symptoms.

Lujan–Fryns syndrome, first described in 1984, corresponds to a sequence mutation in exon 22 of med12 gene of chromosome X. It is hard to suspect and diagnose before puberty. Those affected have marfanoid habit and also other psychiatric manifestations such as autistic behaviour, mild-moderate mental retardation (there are some reported cases with normal intelligence), language disorders, emotional instability, aggressiveness, hyperactivity, shyness which can be extreme, obsessive-compulsive disorder, isolation, delusions, visual and auditory hallucinations, and there are cases that describe schizophrenia. Its diagnosis requires adequate physical and psychopathological examination, and it is established with clinical suspicion and genetic confirmation. There are very few cases described and there is little bibliography available about Lujan–Fryns syndrome [1].

The authors have not supplied their declaration of competing interest.

We report the case of a 41-year-old woman brought by her husband for behavioral disorder during the last week. As background, she had her first vaginal delivery after a risky pregnancy a fortnight ago, which required uterine arteries embolization for intense uterine bleeding; and an adjustment disorder eight years ago.

The patient presents a wordy and inadequate speech, as well as insomnia for the last seven nights. She has injuries in both of her hands due to intensive cleaning of her home and genitalia. Her condition is fluctuant, remaining for hours in the bathroom after breastfeeding and behaving strangely at night, with an irritable mood and being unable to care for their child.

She also has a fever of 39 °C, with thrombocytosis (850,000 platelets) and a c-reactive protein up to 20 as relevant alterations, attributed to mastitis and consequences of the recent intervention. Olanzapine at a dose of 10 mg per day was introduced after stopping breastfeeding, with very good tolerance and complete clinical remission within a few days, with the diagnosis of postpartum psychosis and suspected affective disorder of the bipolar spectrum.

Puerperal psychosis is misdiagnosed in at least 50% of cases, with a prevalence of 1–2/1000 births, and appears more frequently between the 3rd and 9th day after delivery. The risk for both mother and child is severe and it must be treated immediately, being its evolution in general favorable. Most of the risk factors and clinical manifestations for this condition are described in this case.

The authors have not supplied their declaration of competing interest.

Depression is a disease with high prevalence all over the world. Selective serotonine reuptake inhibitors (SSRIs) and dual antidepressants (DA) are worldwide used to treat the different types of depressive episodes. Between the adverse events of these compounds, an unusual but potentially severe side effect is the syndrome of inapropriate antidiuretic hormone secretion (SIADH).

Several cases published, and an amount of cases series have documented the association of SIADH to the use of SSRIs and DA. All SSRIs and DA are at risk of producing SIADH (fluoxetine, paroxetine, fluvoxamine, sertraline, citalopram, escitalopram, venlafaxine and duloxetine). Old age has been found as a risk factor for developing SIADH. There are not enough data to conclude that other risk factors can play a role in the development of this adverse event. Treatment should include the immediate withdrawal of the antidepressant. The introduction of other antidepressants is controversial, as SIADH has been related with all antidepressive treatments; but the risk of relapse into a depressive episode must be considered also. Between symptomatic treatments, the control of water intake and the use of low doses of loop diuretics can be recommended. Severe cases can be treated with higher doses of loop diuretics and saline hypertonic solution.

SIADH has been related with SSRIs and DA antidepressants and it is an infrequent but severe adverse event. Its risk must be considered when prescribing treatment with them. If this adverse event is produced, the substitution of the antidepressant should be done.

The authors have not supplied their declaration of competing interest.

We report the case of a 45-year-old male diagnosed with mixed personality disorder brought the hospital for strange behavior. He is being treated with fluoxetine, lorazepam and topiramate; and visited his psychiatrist 72 hours ago.

He has an adequate level of consciousness and describes retrograde amnesia of the last 72 hours. We found blocks of thought and abnormal behaviors such as dressing and undressing or sorting his belongings repetitively. Urine was only positive for benzodiazepines. In arterial blood gas analysis it performed highlights compensated metabolic acidosis. After ruling out neurological diseases and administrating fluids i.v. the symptoms remitted, persisting only the amnesia, establishing the diagnosis of suicide attempt with topiramate.

The use out-of-guidelines of topiramate in personality and eating disorders is an increasingly common habit in daily clinical practice, as well as suicide attempts with this drug. In therapeutic doses, over 40% of patients taking topiramate, have asymptomatic metabolic acidosis, which in stressful situations may have clinical relevance. In case of acute poisoning, metabolic acidosis is more frequent and severe, manifesting itself by hyperventilation, hypertension and varying degrees of impaired consciousness and cognitive functions. There is also a paradoxical increase in the frequency of seizures. Treatment is supportive and there is no antidote, being lethal cases exceptional. Gastric lavage and administration of activated charcoal have limited use. The determination of plasma concentrations of topiramate is not available for most centers and is not useful in acute poisoning.

Several studies point to the importance that the complex formed by GABA and the benzodiazepine receptor play for cerebral dopaminergic transmission and, hence, to the pathophysiology of psychotic symptoms. The decrease in GABA neuratransmisión or the hypofunction of the system in the hippocampus, cortex and other limbic prefrontal or subcortical regions has consequences as emotional dysregulation, cognitive impairment and development of positive psychotic symptoms.

We intended to show an additional practical example to the limited literature available based on a case linking the emergence of psychotic symptoms due to acute benzodiazepine withdrawal.

We present the case of a 21 year old man who was sent to the emergency room of our hospital after an episode of aggressiveness on the street. The patient showed a psychotic schizophrenic syndrome with significant emotional and behavioural impact with aggressive and bizarre movements. In parallel, restlessness, sweating, tremor, increased blood pressure and tachycardia were observed. Symptoms had started abruptly two hours earlier. The patient companion explained that he usually took Alprazolam at an of over 40 mg per day. He had decided to give up this consumption abruptly four days earlier.

GABAergic deficits cause the imbalance between excitatory and inhibitory neurotransmission that may relate the pathophysiology of psychotic symptoms. The dysfunction of the GABAergic cortical interneurons could affect to the modulating response from the association cortex, which, could also relate with the appearance of these symptoms.

This case could relate a decrease in GABAergic transmission with the appearance of psychotic symptoms.

The authors have not supplied their declaration of competing interest.

Smoking is an addictive and chronic disease. Twenty-four percent of the Spanish population in 2012 smoked daily.

To evaluate a smoking cessation program in a Primary Care Center.

Observational, prospective study. We describe an individualized smoking cessation in Plaza del Ejército Health Center (Valladolid). Inclusion criteria: active smoker, ≥ 18 years old and belonging to the Health Center. Exclusion: severe mental illness. Included patients from November 2013 until January2014. Ended in July 2014. Four Medical residents participated, we present the results of one of them. During the first consultation motivational interviewing was conducted, physical examination and treatment was prescribed (cognitive behavioral therapy or drug treatment: varenicline). In subsequent consultations interview and follow-up. Variables: age, gender, pack-years, nicotine dependence (Fagerstrom) and Prochaska and DiClemente phase, weight, treatment used, dropout rate and final withdrawal of snuff.

Eleven patients, mean age 48.18 (13.61), 7 (63.6) women. Comorbidity: 6 (54.5) anxious-depressive pathology, 1 (9.1) dysthymia, 2 (18.2) endocrine pathology and 1 (9.1) respiratory disease. Four (36.4) showed high dependency and 2 (18.2) extreme. Media packages 20.50/year (19,20). Seven (63.6) were in action phase of Prochaska and DiClemente and 2 (18.2) in preparation. Visits range: 1-11. The average was 4.55 (3.64). Three (27.27) patients attended only the first visit. Four (36.4) achieved complete abstinence, 3 (27.27) met maintenance phase. One (9.1) reduced consumption in half. Patients gained average 0.5 kg (2.47).

The results are similar to those reported in other series. Modest dropout rate. No pharmacological treatment was used due to high coexistence of comorbidities, the only patient who used varenicline suffered insomnia. Average age and media packages were superior to other series.

The authors have not supplied their declaration of competing interest.

The endogenous opiate system (EOS) has been linked to social attachment in classical animal experiments, to addictive disorders (AD) and, more recently, to specific traits of personality through research in genetic polymorphisms and neuroimaging techniques.

To expose the relation between social bonding and AD, via the latest neurobiological findings in the EOS. To propose a theoretical framework which may allow a clinical approach based upon respect and no stigmatization.

Literature review in MEDLINE database with the keywords “opioid”, “polymorphism”, “object attachment”, “addictive behavior”, “personality”.

Polymorphisms in the mu-opioid receptor gene lead to different attachment behaviors in primates. The EOS in humans has been related to pain and placebo effect and recently, to social rejection and acceptance. Thus, some authors talk about “social pain”. Interestingly, the EOS has a role in harm avoidance and in the reward system. These traits of personality (harm avoidance and reward dependence) predispose to AD, and likely, pathological models of social bonding may drive to a need of palliating excessive discomfort originated by an altered opioid function through addictive behaviors. The origin of AD must be focused on the individual vulnerability rather than in the addictive substance/behavior.

The latest findings in the EOS yield concrete evidences that support the classical hypothesis of an opioid nexus between social attachment and AD, and shift the spotlight from the addictive object to the vulnerable subject. This theoretical framework may ease a clinical approach based upon respect and no stigmatization.

The authors have not supplied their declaration of competing interest.

We expose a woman diagnosed with schizoaffective disorder 2 years ago, before she received several diagnostics. She was admitted to the psychiatry unit with hyperactivity, pressured speech without taking an appropriate turn, flight-of-ideas, irritability, expansiveness, emotional liability, ideas of reference and insomnia without diurnal tiredness. In addition, she admitted having abandoned the medication one month ago. She was diagnosed with maniac episode with psychotic symptoms and the medication was reintroduced. After two weeks, no response was observed so we decided to introduce ability depot 600 mg/3 weeks.

We want to show that is possible the use of ability depot off-label in patients with a special difficulty in handling. Also, we want to show that higher doses are not dangerous and it's possible to study new treatment guidelines for ability depot.

We use the Positive and Negative Syndrome Scale (PANSS) pre (the day of the introduction) and post (at two weeks) treatment with aripiprazol depot; the Clinical Global Impression rating scale (CGI), also pre and post.

We have obtained a punctuation of 180 in PANSS the day of the introduction of the aripiprazol depot and 45 at two weeks. In addition, we obtained 6 in CGI the day of the introduction and 3 at two weeks.

In this case, aripiprazol depot has shown good tolerability and efficacy for the acute phase of schizoaffective disorder at higher doses than recommended in clinical guidelines. The efficacy and safety data are consistent with short-term, placebo-controlled studies of aripiprazol depot conducted in similar populations.

The authors have not supplied their declaration of competing interest.

Methanol poisoning is uncommon but potentially lethal. The way of poisoning is usually oral. However, in a small number of cases, inhalated methanol poisoning was described. Most of these occurred among patients suffering a disorder by use of this substance. This type of poisoning has an insidious presentation, that complicates its diagnosis. This poisoning may be lethal. It may produce a chronic and severe affectation of the central nervous system in those who survive to the poisoning. After diagnosis, it is compulsory to act quickly, and it often requires advanced vital support and hemodialysis.

Educate the Mental Health professionals about a type of disorder by consumption increasingly more frequent in some cities across Europe. This is a high fatality related poisoning that emergency and general psychiatrists should know as it is increasingly common in Europe.

We present the case of a 20-year-old patient, treated at the emergency department of our hospital in context of metanol inhalation. The patient regularly attended to our Dual Pathology outpatient unit due to a severe inhalant use disorder. Several stays at the intensive care unit had been recorded and he already presented with severe optic nerve affectation.

In recent years there has been an increase in inhalant abuse in Europe, which is still underestimated by our poor knowledge about its potential toxicity.

Inhalated methanol poisoning occurs with a typical presentation, and may appear after suicide trial or overdose. Mental health professional should become aware of its potential lethality to approach properly to these patients.

The authors have not supplied their declaration of competing interest.

Obtain and analyze information on treatment guidelines, with particular emphasis on the use of antipsychotics, in patients diagnosed with bipolar disorder I and bipolar disorder II who are treated at a mental health center in a district of Madrid (Spain) under the conditions of habitual clinical practice.

Then, compare with recently published literature.

We performed a descriptive study of a sample of 100 patients diagnosed with bipolar disorder (type I and type II) at any stage of the disease who receive regular treatment in a mental health center in a district of Madrid. Information regarding the treatment used, especially the use of antipsychotics (either in a single therapy or in combination with other drugs such as mood stabilizers, antidepressants, hypnotics or anxiolytics), was collected retrospectively from the data obtained from the medical record.

Ninety-four percent of patients are taking mood stabilizer treatment (68% lithium, 24% valproate, 1% and 1% carbamazepine and lamotrigine). Four percent take lithium and valproate in combination. Forty-eight percent of patients are taking some antipsychotic (atypical about 90%). Of these, only 10% in injectable form, and 5% take both oral and injectable antipsychotics.

The diminished use of injectable antipsychotics, well below recent publications, draws the attention. You can probably explain this low proportion of injectable medication because we are generally dealing with stable patients with a long-term disorder.

The authors have not supplied their declaration of competing interest.

We present the case report of a 21-year-old Chinese female, who was brought to the emergency department. We open the debate between the operative criteria stablished by DSM-5 of the clinical entity dissociative amnesia and Shenjing Shuairuo - the Chinese “culture-bound syndrome”.

To expose the relevance of the cultural formulation in the clinical evaluation of patients with a different non-Western culture in Psychiatry.

The Shenjing Shuairuo syndrome (“nervous system weakness”) was originally descripted in China, it has a gradual onset, usually after a stressful event. It involves a minimum 3 of 5 symptoms group: weakness, emotions, excitement, neurological pain and sleep. This complex group of symptoms overlap with dissociative syndrome such as dissociative amnesia.

The cultural formulation interview (CFI) was used for the diagnostic and subsequent treatment of dissociative amnesia with fugue in a different culture patient who met the clinical criteria of this two divergent clinic entities.

In our clinical practice, we will deal with different culture patients, who could present common clinical entities or with the so-called “culture-bound syndromes”. The cultural formulation of the clinical cases will help the clinicians to diagnose and have better treatment's options in clinical manifestations do not correspond to the conventional entities included in mostly Western-based nomenclatures.

The authors have not supplied their declaration of competing interest.