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Short-term skin carotenoid changes following consumption of a typical Australian diet versus a healthy Australian diet: findings from a randomised crossover feeding trial
- E.D. Clarke, J. Stanford, M. Gómez Martín, J.J.A. Ferguson, Burrows, L. Wood, C.E. Collins
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- Journal:
- Proceedings of the Nutrition Society / Volume 83 / Issue OCE1 / April 2024
- Published online by Cambridge University Press:
- 07 May 2024, E91
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Carotenoids, a group of phytochemicals found in plant-based foods with yellow, red, or orange pigments, have been shown to be stored in the skin upon consumption of carotenoid-rich foods(1). Skin carotenoid levels can be measured using skin reflectance spectroscopy, which assesses skin lightness (L*), redness (a*), and yellowness (b*)(2). Previous research has demonstrated significant increases in skin yellowness (b*) after a 4-week high-carotenoid diet(2). The aim was to examine shorter-term changes (two weeks) in skin yellowness following the consumption of a Healthy Australian Diet rich in carotenoids compared to a Typical Australian Diet with low carotenoid content. The study analysed data from an eight-week randomised, cross-over feeding trial involving 34 adults (53% female, aged 38.44 ± 18.05 years). Participants were randomly assigned to each diet for two weeks, separated by a two-week washout period. The Healthy Australian Diet adhered to the Australian Dietary Guidelines(3), emphasising the consumption of carotenoid-rich fruits and vegetables such as carrots, pumpkin, tomatoes, red capsicum, and sweet potatoes. In contrast, the Typical Australian Diet was formulated based on apparent consumption patterns in Australia(4) and emphasised the intake of fruits and vegetables low in beta-carotene, such as white potatoes, onions, cauliflower, and pears. Skin carotenoids were measured using skin reflectance spectroscopy at three sites (palm, inner and outer arm), and each measurement was taken thrice. Overall skin yellowness (b*) was calculated as the average of all three measurements at all three sites. Measurements were conducted at four key visits: week 0 (end of run-in; baseline 1), week 2 (post-feeding phase 1), week 4 (end of washout; baseline 2), and week 8 (post-feeding phase 2). Differential changes in skin carotenoid levels between intervention groups were assessed using linear mixed-effect models, adjusting for diet sequence, feeding phase, body fat percentage, total fat intake, and subject ID as a random variable to account for potential autocorrelation. Post-hoc pairwise comparisons were conducted to evaluate the relative effects of each diet. Although there was a trend towards higher skin yellowness (0.215 ± 0.517; p = 0.41) following consumption of the Healthy Australian diet relative to baseline, and an inverse trend following the Typical Australian Diet (−0.118 ± 0.539, p = 0.56), the difference in change between the two diets was not statistically significant (p = 0.32). Notably, baseline values within this participant cohort were higher than previously reported at b* = 16.7(1) (baseline 1 b*: 17.57 ± 2.23, baseline 2 b*: 17.71 ± 2.26), which may influence the magnitude of observable change. The findings suggest that the two-week intervention duration may be insufficient to achieve statistically significant changes in skin carotenoid levels. Future investigations into whether plasma carotenoids increase first, with skin changes occurring later, could offer valuable insights into the potential utility of this as a biomarker validation of change in fruit and vegetable intake.
Short-term impact of a healthy and typical Australian dietary pattern on cardiometabolic outcomes: insights from a randomised, cross-over feeding study
- J. Stanford, E.D. Clarke, M. Gómez Martín, J.J.A. Ferguson, T. Burrows, L. Wood, C.E. Collins
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- Journal:
- Proceedings of the Nutrition Society / Volume 83 / Issue OCE1 / April 2024
- Published online by Cambridge University Press:
- 07 May 2024, E122
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Immune Health Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, 2305 Australia.Cardiovascular disease (CVD) remains a major cause of global mortality. Poor diet quality, characterised by excessive consumption of energy-dense, nutrient-poor foods and insufficient intake of fruits, vegetables, and whole grains, is associated with an increased risk of CVD(1). This study compares the impact of two short-term dietary interventions, a Healthy Australian Diet adhering to national guidelines and a Typical Australian Diet representing current national consumption patterns, on several cardiometabolic outcomes. These outcomes include body weight, waist circumference (WC), body fat percentage (BFP), blood pressure (BP), fasting blood lipids and glucose concentrations. Data from an eight-week randomised, cross-over feeding study involving 34 adults (53% female, age 38.4 ± 18.1 years) were analysed, with participants randomly assigned to consume each diet for two weeks, separated by a two-week washout period. During each feeding phase, all food items were provided to ensure compliance. The Healthy Australian Diet adhered to the Australian Dietary Guidelines(2), including a balanced intake of the five food groups and meeting Acceptable Macronutrient Distribution Range targets(3), with saturated fat limited to ≤10% of energy. The Typical Australian Diet was formulated based on apparent consumption patterns in Australia(4), setting total fat intake at 40% of energy and total saturated fat at 15% of energy. Comprehensive data collection occurred at four key visits: week 0 (end of run-in; baseline 1), week 2 (post-feeding phase 1), week 4 (end of washout, baseline 2), and week 8 (post-feeding phase 2). Trained personnel measured WC using a tensible tape, while body weight and BFP measurements were obtained using bioimpedance analysis (Inbody 270; Biospace Co, Seoul, Korea). Blood pressure was recorded using the Uscom BP+ supra-systolic oscillometric central blood pressure device. Blood glucose and lipid (triglycerides, total-, low-density lipoprotein- [LDL] and high-density lipoprotein- [HDL] cholesterol) concentrations were measured after a 12-hour fast by an accredited pathology service. Differential changes in cardiometabolic variables between intervention groups were evaluated using linear mixed-effect models, adjusting for diet sequence, feeding phase, and subject ID as a random variable to account for potential autocorrelation. Post-hoc pairwise comparisons were conducted to assess the impact effects of each diet. There were no significant differences between the Healthy Australian Diet and the Typical Australian Diet with respect to weight, BFP, WC, blood triglycerides, systolic and diastolic BP. However, the Healthy Australian Diet led to a significantly greater decrease in total-, LDL-, HDL- and non-HDL cholesterol, and fasting blood glucose relative to the Typical Australian Diet (p<0.001). The results underscore the importance of promoting dietary intakes that align with Australian Dietary Guidelines for optimising the risk of CVD and impaired glucose tolerance. Conversely, the Typical Australian Dietary pattern demonstrated detrimental cardiometabolic effects over a short period of just two weeks.
Fermentation of whey-derived matrices by Kluyveromyces marxianus: alcoholic beverage development from whey and fruit juice mixes
- Gabriel A. Gómez, Facundo Cuffia, Orlando G. Nagel, Rafael L. Althaus, Roberto J. Ceruti
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- Journal of Dairy Research , First View
- Published online by Cambridge University Press:
- 18 March 2024, pp. 1-8
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This research paper addresses the hypotheses that Kluyveromyces marxianus can be cultured with good alcohol production on different whey-derived matrices, and that the fermented product can be used in order to develop alcoholic beverages with acceptable sensory characteristics by mixtures with yeast-fermented fruit-based matrices. Growth and fermentative characteristics of Kluyveromyces marxianus LFIQK1 in different whey-derived matrices were explored by culturing (24 h, 30°C) on reconstituted whey, demineralized whey, heat-treated whey and milk permeate media. High lactose consumption, ethanol production and yield were observed. Reconstituted whey matrix was selected for mixing with orange or strawberry juices fermented using Saccharomyces cerevisiae to obtain alcoholic beverages (W-OR and W-ST, respectively). Consumer evaluation of beverages was performed using acceptability and Check-All-That-Apply (CATA) questions. Good acceptance was observed, significantly higher for W-ST than for W-OR. CATA questions gave information about organoleptic characteristics of beverages. Penalty analysis showed W-R and W-ST were positively associated with smooth/refreshing and fruity/natural, respectively. Liking was represented, accordingly with penalty analysis, by natural/refreshing. A novel alternative for utilization of whey and whey-related matrices by alcoholic beverages production with natural ingredients is presented.
Clinician treatment choices for post-traumatic stress disorder: ambassadors survey of psychiatrists in 39 European countries
- Martina Rojnic Kuzman, Frank Padberg, Benedikt L. Amann, Meryam Schouler-Ocak, Zarko Bajic, Tarja Melartin, Adrian James, Julian Beezhold, Jordi Artigue Gómez, Celso Arango, Tihana Jendricko, Jamila Ismayilov, William Flannery, Egor Chumakov, Koray Başar, Simavi Vahip, Dominika Dudek, Jerzy Samochowiec, Goran Mihajlovic, Fulvia Rota, Gabriela Stoppe, Geert Dom, Kirsten Catthoor, Eka Chkonia, Maria João Heitor Dos Santos, Diogo Telles, Peter Falkai, Philippe Courtet, Michal Patarák, Lubomira Izakova, Oleg Skugarevski, Stojan Barjaktarov, Dragan Babic, Goran Racetovic, Andrea Fiorillo, Bernardo Carpiniello, Maris Taube, Yuval Melamed, Jana Chihai, Doina Constanta Maria Cozman, Pavel Mohr, György Szekeres, Mirjana Delic, Ramunė Mazaliauskienė, Aleksandar Tomcuk, Nataliya Maruta, Philip Gorwood
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- Journal:
- European Psychiatry / Volume 67 / Issue 1 / 2024
- Published online by Cambridge University Press:
- 07 March 2024, e24
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Background
Considering the recently growing number of potentially traumatic events in Europe, the European Psychiatric Association undertook a study to investigate clinicians’ treatment choices for post-traumatic stress disorder (PTSD).
MethodsThe case-based analysis included 611 participants, who correctly classified the vignette as a case of PTSD, from Central/ Eastern Europe (CEE) (n = 279), Southern Europe (SE) (n = 92), Northern Europe (NE) (n = 92), and Western Europe (WE) (N = 148).
ResultsAbout 82% woulduse antidepressants (sertraline being the most preferred one). Benzodiazepines and antipsychotics were significantly more frequently recommended by participants from CEE (33 and 4%, respectively), compared to participants from NE (11 and 0%) and SE (9% and 3%). About 52% of clinicians recommended trauma-focused cognitive behavior therapy and 35% psychoeducation, irrespective of their origin. In the latent class analysis, we identified four distinct “profiles” of clinicians. In Class 1 (N = 367), psychiatrists would less often recommend any antidepressants. In Class 2 (N = 51), clinicians would recommend trazodone and prolonged exposure therapy. In Class 3 (N = 65), they propose mirtazapine and eye movement desensitization reprocessing therapy. In Class 4 (N = 128), clinicians propose different types of medications and cognitive processing therapy. About 50.1% of participants in each region stated they do not adhere to recognized treatment guidelines.
ConclusionsClinicians’ decisions for PTSD are broadly similar among European psychiatrists, but regional differences suggest the need for more dialogue and education to harmonize practice across Europe and promote the use of guidelines.
25 Exploring Phonemic and Semantic Fluency Ability Across Multiple Generations
- Krithika Sivaramakrishnan, Dorthy Schmidt, Krissy E Smith, Brittany Heuchert, Adriana C Cuello, Natalia L Acosta, Miriam Gomez, Isabel D Munoz, Yvette D Jesus, Daniel W Lopez-Hernandez
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 438-439
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Objective:
Verbal fluency tasks evaluate executive functioning by requiring a person to provide words within a certain time period that start with a certain letter (phonemic fluency) or category (semantic fluency). Research shows that age impacts test takers’ phonemic and semantic verbal fluency performance. In fact, it has been suggested that phonemic verbal fluency peaks around age 30 to 39 and begins to decline at older ages. In contrast to phonemic fluency, research suggests that semantic fluency increases steadily between test takers until age 12 and begins declining around age 20. A generation is a cohort of people born within a certain period who share age and experiences. Studies show that Generation X individuals (persons born between 1965-1980) outperform Generation Y (persons born between 19811995) and Generation Z individuals (persons born between 1965-1980) on the Cordoba Naming Test. To our knowledge, no study has investigated verbal fluency performance across generational groups. We predicted that Generation X individuals would outperform individuals from Generation Y and Z on both verbal fluency measures.
Participants and Methods:The sample of the present study consisted of 107 participants with a mean age of 27.39 (SD = 9.16). Participants were divided into three groups: Generation X (n = 19), Generation Y (n = 52), and Generation Z (n = 36). The phonemic verbal fluency task consisted of three trials and the semantic verbal fluency task consisted of one trial, one minute each. A series of ANCOVAs with Bonferroni post-hoc tests were used to evaluate verbal fluency performance between generational groups. All participants passed performance validity testing.
Results:We found significant differences between our generational groups on both verbal fluency tasks. Post-hoc tests revealed that the Generation Y group outperformed both Generation X and Z groups on both verbal fluency tasks, p’s <.05, np2 =.11 -.16. No significant differences were found on either verbal fluency task between the Generation X and Z groups.
Conclusions:Contrary to our hypothesis, Generation Y individuals possessed better phonemic and semantic fluency than both Generation X and Z individuals. Meanwhile, Generation X individuals did not significantly differ on any of the verbal fluency tasks compared to Generation Z individuals. Speaking multiple languages has been shown to impact verbal fluency performance. In our sample, the Generation X and Z groups consisted primarily of bilingual speakers compared to the Generation Y group. Examining generational differences is essential to understand the unique characteristics and impact of the times in which various individuals have grown up. Future research, for instance, should evaluate the influence of bilingualism across generational groups on verbal fluency performance.
30 Analyzing Spanish Speakers Cordoba Naming Test Performance
- Raymundo Cervantes, Isabel D.C. Munoz, Estefania J. Aguirre, Natalia Lozano Acosta, Mariam Gomez, Adriana C. Cuello, Krissy E. Smith, Diana I. Palacios Mata, Krithika Sivaramakrishnan, Yvette De Jesus, Santiago I. Espinoza, Diana M. R. Maqueda, David J. Hardy, Tara L. Victor, Alberto L. Fernandez, Daniel W. Lopez-Hernandez
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 443-444
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Objective:
A 30-item confrontation naming test was developed in Argentina for Spanish speakers, The Cordoba Naming Test (CNT). The Boston Naming Test is an established confrontation naming task in the United States. Researchers have used the Boston Naming Test to identify individuals with different clinical pathologies (e.g., Alzheimer’s disease). The current literature on how Spanish speakers across various countries perform on confrontational naming tasks is limited. To our knowledge, one study investigated CNT performance across three Spanish-speaking countries (i.e., Argentina, Mexico, and Guatemala). Investigators found that the Guatemalan group underperformed on the CNT compared to the Argentine and Mexican groups. The purpose of this study was to extend the current literature and investigate CNT performance across five Spanish-speaking countries (i.e., Argentina, Mexico, Guatemala, Colombia, United States). We predicted that the Argentine group would outperform the other Spanish-speaking countries.
Participants and Methods:The present study sample consisted of 502 neurologically and psychologically healthy participants with a mean age of 29.06 (SD = 13.41) with 14.75 years of education completed (SD = 3.01). Participants were divided into five different groups based on their country of birth and current country residency (i.e., United States, Mexico, Guatemala, Argentina, & Colombia). All participants consented to voluntary participation and completed the CNT and a comprehensive background questionnaire in Spanish. The CNT consisted of 30 black and white line drawings, ranging from easy to hard in difficulty. An ANCOVA, controlling for gender, education, and age, was used to evaluate CNT performance between the five Spanish-speaking country groups. Meanwhile, a Bonferroni post-hoc test was utilized to evaluate the significant differences between Spanish-speaking groups. We used a threshold of p < .05 for statistical significance.
Results:Results revealed significant group differences between the five Spanish speaking groups on the CNT, p = .000, np2 = .48. Bonferroni post-hoc test revealed that the United States group significantly underperformed on the CNT compared to all the Spanish-speaking groups. Next, we found the Guatemalan group underperformed on the CNT compared to the Argentinian, Mexican, and Colombian groups. Additionally, we found the Argentinian group outperformed the Mexican, Guatemalan, and United States groups on the CNT. No significant differences were found between the Argentinian group and Colombian group or the Mexican group and Colombian group on the CNT.
Conclusions:As predicted, the Argentinian group outperformed all the Spanish-speaking groups on the CNT except the Colombian group. Additionally, we found that the United States group underperformed on the CNT compared to all the Spanish-speaking groups. A possible explanation is that Spanish is not the official language in the United States compared to the rest of the Spanish-speaking groups. Meanwhile, a possible reason why the Argentinian and Colombian groups demonstrated better CNT performances might have been that it was less culturally sensitive than the United States, Mexican, and Guatemalan groups. Further analysis is needed with bigger sample sizes across other Spanish-speaking countries (e.g., Costa Rica, Chile) to evaluate what variables, if any, are influencing CNT performance.
Scaphanocephalus spp. (Trematoda: Opisthorchiidae) in intermediate and definitive hosts of the Yucatán Peninsula, Mexico, with a re-description of Scaphanocephalus expansus
- M. T. González-García, M. García-Varela, A. López-Jiménez, M. P. Ortega-Olivares, G. Pérez-Ponce de León, L. Andrade-Gómez
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- Journal:
- Journal of Helminthology / Volume 97 / 2023
- Published online by Cambridge University Press:
- 14 December 2023, e98
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Scaphanocephalus is a small trematode genus belonging to the family Opistorchiidae. The genus currently contains only three species associated with marine fish as intermediate hosts and fish-eating birds as definitive hosts. Here, specimens of Scaphanocephalus were collected from the Osprey, Pandion haliaetus, and the White mullet, Mugil curema in the Yucatán Peninsula, Mexico. We report for the first-time DNA sequences of adult specimens of Scaphanocephalus, particularly S. expansus, as well as a sequence of a different species sampled as metacercaria. Morphological comparisons of Scaphanocephalus expansus confirmed the identity of the adult specimens, with minor morphological variations; Scanning electron photomicrographs were included, and the species was re-described. Phylogenetic analysis based on 28S rDNA sequences showed that Scaphanocephalus is monophyletic within Opisthorchiidae and consists of three independent lineages. Sequences of adults are identical to those of S. expansus. Instead, the sequence of the metacercaria sampled from the mesentery of Mugil curema nested with specimens reported as Scaphanocephalus sp. from a labrid fish in the Mediterranean Sea, herein named it as Scaphanocephalus sp. 2.
The Effect of Genetic Predisposition to Alzheimer’s Disease and Related Traits on Recruitment Bias in a Study of Cognitive Aging
- Lina M. Gomez, Brittany L. Mitchell, Kerrie McAloney, Jessica Adsett, Natalie Garden, Madeline Wood, Santiago Diaz-Torres, Luis M. Garcia-Marin, Michael Breakspear, Nicholas G. Martin, Michelle K. Lupton
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- Twin Research and Human Genetics / Volume 26 / Issue 3 / June 2023
- Published online by Cambridge University Press:
- 21 July 2023, pp. 209-214
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The recruitment of participants for research studies may be subject to bias. The Prospective Imaging Study of Ageing (PISA) aims to characterize the phenotype and natural history of healthy adult Australians at high future risk of Alzheimer’s disease (AD). Participants approached to take part in PISA were selected from existing cohort studies with available genomewide genetic data for both successfully and unsuccessfully recruited participants, allowing us to investigate the genetic contribution to voluntary recruitment, including the genetic predisposition to AD. We use a polygenic risk score (PRS) approach to test to what extent the genetic risk for AD, and related risk factors predict participation in PISA. We did not identify a significant association of genetic risk for AD with study participation, but we did identify significant associations with PRS for key causal risk factors for AD, IQ, household income and years of education. We also found that older and female participants were more likely to take part in the study. Our findings highlight the importance of considering bias in key risk factors for AD in the recruitment of individuals for cohort studies.
Effects of intrahipocampal nmda on re-extinction of an aversive emotional memory task in rats
- E. P. Ruiz Gonzalez, D. M. Gómez Ordoñez, L. F. Cárdenas, M. N. Muñoz Argel
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- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, p. S613
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Introduction
N-Methyl-D-aspartate (NMDA) receptors are involved in learning and memory. It is known that ventral hippocampus is a crucial structure involved in emotional memory formation mainly for fear and anxiety situations. The aim of this research is to identify the effect of the stimulation of ventral hipocampal NMDA receptors on the reextinction of an aversive emotional memory task. NMDA (0.2 ug/μl; 0.2 μl) or saline (0.9 %; 0.2 μl) was bilateral and locally administered in the ventral hippocampus of male Wistar rats, before the re-instatement trial.
The experimental group consisted of 10 animals and the control group by 9 subjects. The results suggest that the activation of ventral hipocampal NMDA receptors induces an increase in the time needed to re-extinguish the conditioned fear, suggesting a possible potentiating effect on re-installation.
ObjectivesTo evaluate the effect of NMDA at the intrahippocampal level, on the reinstatement and re extinction of a conditioned fear response in male Wistar rats.
MethodsThis study is experimental, where two groups of adult male Wistar rats were used. The bilateral cannulas was implanted, the animals were injected intraperitoneally with a mixture of ketamine (Rotexmédica) and xylacin (Bayer; 75 mg/Kg and 5 mg/Kg), respectively, then the animals were placed in a stereotaxic apparatus (Narishige) and injected with veterinary antibiotic.The (21G) caliber cannulas were bilaterally implanted in HPv at the following coordinates: AP = -5.2 mm relative to Bregma; ML = ± 5 mm in relation to the midline and DV = 5.1 mm in relation to the skull and according to the atlas (Paxinos & Watson, 1985).
ResultsIt was observed that in the first phase of extinction there were no statistically significant differences between the two groups, experimental and control, as in the second phase of extinction. The results obtained for the re-extinction phase 1 and 2 showed that there were significant statistical differences between the groups. This difference was only evident in the first three minutes in the two phases of re-extinction.
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ConclusionsStatistically significant differences were observed between the two groups, in the phases of re-extinction, seeing a longer time of the freezing response in the experimental group, as an effect of the application of NMDA in the ventral hippocampus (HPv), which suggests that this substance has a memory-enhancing effect, and therefore contributes to increasing the permanence of the fear response. It should be noted that this difference was only evident in the first three minutes in the two re-extinction phases. These results may be related to other studies where it has been shown that LTP is dependent on the N-methyl-D-aspartate receptor in the CA1 region in vivo (Zhong, Cherry, Bies, Florence, & Gerges, 2009)
Disclosure of InterestNone Declared
Do attention-deficit/hyperactivity symptoms influence treatment outcome in gambling disorder?
- C. Vintró-Alcaraz, G. Mestre-Bach, R. Granero, M. Gómez-Peña, L. Moragas, F. Fernández-Aranda, M. N. Potenza, S. Jiménez-Murcia
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- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, pp. S58-S59
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Introduction
Numerous studies point to the comorbidity between gambling disorder (GD) and attention deficit hyperactivity disorder (ADHD). However, there is a lack of research exploring how ADHD symptoms might influence psychological treatment outcomes for GD.
ObjectivesTherefore, we aimed to explore differences between patients with GD with and without ADHD symptoms regarding psychopathology, personality, sociodemographic and especially treatment outcome measures.
MethodsThis longitudinal study included n=170 patients with GD receiving 16 sessions of cognitive behavioral therapy (CBT) in a specialized unit of a public hospital. Multiple self-reported instruments were used to assess GD severity, personality, ADHD and other symptoms and sociodemographic measures prior to treatment.
ResultsA clinical profile characterized by greater GD severity, higher psychopathology and impulsivity, and less adaptive personality features was observed in patients with self-reported ADHD symptoms compared to those without. No significant differences in treatment response (measured by dropout and relapse rates) were reported between the two groups. However, patients with ADHD symptoms described more severe relapses (more money gambled) and GD patients who relapsed scored higher on measures of ADHD, particularly inattention.
ConclusionsIndividuals with GD and ADHD may experience more severe relapses following treatment, suggesting a need for more vigilant follow-up and interventions for patients with this comorbidity.
Disclosure of InterestC. Vintró-Alcaraz: None Declared, G. Mestre-Bach: None Declared, R. Granero: None Declared, M. Gómez-Peña: None Declared, L. Moragas: None Declared, F. Fernández-Aranda Consultant of: Novo Nordisk and editorial honoraria as EIC from Wiley, M. Potenza Consultant of: Opiant Pharmaceuticals, Idorsia Pharmaceuticals, AXA, Game Day Data, Baria-Tek and the Addiction Policy Forum; has been involved in a patent application with Yale University and Novartis; has received research support (to Yale) from Mohegan Sun Casino and Connecticut Council on Problem Gambling; and has consulted for and/or advised gambling and legal entities on issues related to impulse-control/addictive disorders, S. Jiménez-Murcia: None Declared
Hyperammonemic Encephalopathy: valproic acid-induced adverse reaction
- E. Gómez, L. Gallardo, R. Fernández, E. Talaya, L. Al Chaal, E. Rybak
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- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, pp. S1053-S1054
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Introduction
Hyperammonemic encephalopathy is an unusual but fatal consequence of patients being treated with valproic acid (VPA). The most relevant clinical features in cases of valproic acid-induced hyperammonemia include confusion, lethargy, vomiting, and increased seizure frequency and may progress to stupor, coma, and lead to death in isolated cases. The causes are not fully elucidated, but studies suggest alterations in liver and kidney function with abnormalities in the urea cycle causing increased ammonium levels.
ObjectivesClinical review and treatment approach for VPA-induced hyperammonemia encephalopathy.
MethodsClinical case and literature review.
ResultsA 23 - years - old male, admitted to the psychiatric unit for a psychotic episode in the context of drug use and associated affective symptoms. Treatment with antipsychotic (Risperidone 6mg per day) and mood stabilizer (valproic acid up to 1000/mg per day) was prescribed. After ten days of treatment, the patient started with low level of awareness and abnormal behaviour. Neurological examination showed marked somnolence, dysarthric language, unstable gait and behavioral alterations. In the physical examination the constants are stable with discrete tachycardia. Laboratory tests revealed hyperammonemia (609μg/dL), with normal liver function and serum concentration of total valproic acid was therapeutic (69mg/L). Brain computed tomography (CT) revealed no significant anomalies. Doctors initiated treatment with daily cleansing enema and VPA was suspended immediatly. After forty-eight hours the patient’s mental status gradually improved back to baseline and the ammonium levels were normalized in medical tests.
ConclusionsValproate-induced hyperammonemic encephalopathy is an unusual but serious complication. It is often underdiagnosed, with an unclearly incidence. The consequences of undertreatment can be potentially deadly. Clinical suspicion should be established in all patients with decreased level of consciousness in patients receiving VPA. Hyperammonemia can be asymptomatic in half of the cases and can occur in people with normal therapeutic doses and normal serum valproate levels. The mechanism of VPA-induced hyperammonemic encephalopathy is unclear. At present, it is thought to be primarily due to propionic acid, a metabolite of VPA, which inhibits an enzyme necessary for the elimination of ammonia in the urea cycle. In addition, VPA can raise plasma ammonia levels through interaction with carnitine, leading to increased renal excretion of carnitine. In terms of treatment, the main recommendations agree that discontinuation of valproate is the most effective therapy, followed by administration of lactulose to reduce ammonium levels. Carnitine supplementation may be useful in the following cases: for seizure disorders in children at risk of developing carnitine deficiency, in VPA poisoning and in VPA-induced hepatotoxicity.
Disclosure of InterestNone Declared
ATYPICAL DEBUT OF BIPOLAR DISORDER IN AN ADOLESCENT: POST-COVID SYNDROME, PARANEOPLASTIC SYNDROME, OR SOMETHING ELSE?
- I. Ezquiaga Bravo, R. M. Cámara, I. Gómez, A. Vilar, A. Rodríguez, M. T. Nascimento, S. Batlle, L. M. Martín
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- Journal:
- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, pp. S768-S769
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Introduction
Paraneoplastic syndromes (PNS) can be expressed with a wide variety of neurological and psychiatric symptoms: alterations in consciousness, cognition, behaviour, mood or perception. Testicular tumours have been related to different expressions of PNS, but, to date, no relationship with bipolar disorder has been described.
On the other hand, the relationship between SARS-CoV2 infection and subsequent affective conditions has also been recently described. Between 30-40% of people affected by the infection present symptoms of depression in the following months.
ObjectivesTo describe a case of a 17-year-old patient with an atypical onset of bipolar disorder a few months after a SARS-CoV2 infection and a few months before a testicular germ cell tumour was detected.
MethodsDescription of a clinical case, its differential diagnosis and the literature review associated.
ResultsThis is a 17-year-old adolescent with no previous psychiatric history, who is referred to a day centre after committing a suicide attempt. The patient presented an average premorbid functioning. Stands out, a SARS-CoV2 infection 3 months before the onset of symptoms. He presents repeated and self-limited episodes (maximum 3 weeks) of major depressive symptoms: autolytic ideation, hypothymia, asthenia, clinophilia, isolation, anhedonia, mutism, psychomotor retardation, lack of hygiene, hyporexia, hypersomnia; that alternates with periods of stability and with others of symptoms of hypomania (sudden improvement in mood, increased activity and plans), also lasting a few days. Paradoxic response to treatment with antidepressants, presenting irritability and exacerbation of suicide ideas. Good tolerance and response to treatment with low doses of aripiprazole and quetiapine. The patient was diagnosed as type II bipolar disorder with rapid cycling.
A few days after definitive diagnosis, a testicular germ cell tumour was detected, for which he had to undergo surgical intervention and chemotherapy treatment. At this point, it is suggested that the symptoms could be included in a paraneoplastic condition prior to the tumour. Months after the remission of the cancer, the patient does not present symptoms of relapse or metastasis, but mood swings persist, of lesser intensity, every few weeks. Treatment with lamotrigine was started at increasing doses, with good response and tolerance from the start.
ConclusionsThe onset of mental health disorders in adolescents can be complicated by the non-specific or atypical early or prodromal symptoms. This degree of complexity increases when somatic pathologies coexist and even more if those pathologies have yet to be fully understood and studied, such as paraneoplastic syndromes or SARS-CoV2 infections. It is necessary to continue investigating the interrelationship between somatic and psychiatric conditions in order to provide more specific and rapid clinical responses.
Disclosure of InterestNone Declared
TRANVIA: A program for continuum mental health assistance in transition period
- L. Pérez Gómez, A. González Álvarez, M. A. Reyes Cortina, E. Lanza Quintana, N. Álvarez Alvargonzález, C. Rodríguez Turiel, E. Lago Machado, J. J. Martínez Jambrina
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- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, p. S728
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Introduction
Transition between adolescence and adulthood represents the most important challenge for personal development and involves several transformations: physical, psychological and social. It is a complex age bracket, concurring the transition from youth psychiatric units to adult ones, with an increased risk for the appearance of mental disorders and risky behaviours. TRANVIA program, developed in Avilés, provides psychiatric assistance to patients between 15 and 25 years old, diagnosed with a severe psychiatric disorder or with an increased risk of having one.
ObjectivesOur objectives are: ensuring clinical continuity assistance, promoting communication among professionals and the empowerment of our patients to improve their functionality and quality of life.
MethodsDescriptive study including patients involved in TRANVIA program from November 2019 to November 2021.
ResultsDuring this two-years period there have been 44 referrals to the program, 11 of them were rejected for failure to comply with diagnostic criteria. In November 2021 there were 33 patients included in the TRANVIA program with an average age of 17 years old (range: 15-22). 70% of them were men and 30% women. All of them had psychiatric assistance from different sources: youth mental health units, neuropediatrics… About 75% of the patients were diagnosed with autistic spectrum disorder and approximately three-quarters of the sample needed pharmacological treatment. Risperidone was the most prescribed drug. We have also developed other assistance alternatives as home-based care, relaxation sessions, social worker interventions and coordination with schools.
ConclusionsTRANVIA program has allowed us to provide continual attention to vulnerable patients that shift from youth psychiatric units to adult ones. Patients that meet inclusion criteria were enrolled independently the type of assistance they have previously received. Accessibility and flexibility were our priority. During the described period there was only one dropout, three patients required psychiatric hospitalization and two others visited the emergency department. There have been no cases of completed suicide.
Disclosure of InterestNone Declared
Efficacy of paliperidone palmitate 3-month formulation in preventing hospital admissions and emergency room visits. 66 months of follow-up
- S. L. Romero Guillena, B. O. Plasencia Garcia de Diego, J. Gomez Gonzalez, F. Gotor Sánchez-Luengo
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- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, p. S487
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Introduction
Paliperidone Palmitate 3-month formulation (PP3M) has shown a significantly longer time to relapse compared to placebo, with similar efficacy and safety to Paliperidone Palmitate 1-month (PP1M) (Carpiniello et al. Drug Des. Devel. Ther. 2016; 10 1731–1742).
ObjectivesThe main objective of this study was to determine the effectiveness of PP3M in preventing hospital admissions and emergency room visits, in people with non-acute schizophrenia in a naturalistic psychiatric outpatient setting
MethodsSample: 30 people with diagnosis of schizophrenia (DSM 5 criteria), who had started treatment with PP3M, after being stabilized with PP1M (the dose was not modified in the four months prior to inclusion in the study)
Quarterly basis, the following evaluations were performed during a follow-up period of 66 months:
The Clinical Global Impression-Schizophrenia scale (CGI-SCH)
Treatment adherence, concomitant medication and the number of hospitalizations and emergency visits
Efficacy values: Percentage of patients who remained free of admissions at the end of 66 months of follow-up.
Other evaluation criteria: Percentage of patients who never visited the emergency department at the end of 66 months of follow-up. Average change from baseline visit to the final evaluation as assessed by score obtained on the following scale: GSI-SCH, percentage of patients on antipsychotic monotherapy and treatment adherence rate.
ResultsThe mean dose of PP3M was 401. 55 mg
The percentage of patients who remained free of admissions at the end of the 66 months was 83.25% and the percentage of patients who never visited the emergency department at the end of 66 months was 79.92%
Mean variations from baseline scores at 66 months were: (-0.36 ±0-37) on the GCI-SCH.
The percentage of patients on antipsychotic monotherapy at the end of the 66 months was 76.56%
The rate of adherence was 86.58%
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ConclusionsIn our study, we found that paliperidone palmitate 3-month formulation was effective in reducing the number of admissions and visits to the emergency department, under conditions of daily clinical practice.
Disclosure of InterestNone Declared
Acute mutism in a young female. A case report of a 20-year-old female who presents a 3-month mutism
- A. Gonzalez-Mota, A. Gonzalez-Gil, C. Martin-Gomez, J. A. Benito-Sanchez, I. M. Peso-Navarro, L. Fernandez-Alonso
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- Journal:
- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, pp. S177-S178
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Introduction
A 20-year-old female presents with a progressive 3-month mutism, hyporexia (20kg weight loss), abulia, anhedonia, apathy, social isolation,seeking company of her parents even at night, bradypsychia, sialorrhea, psychomotor slowdown and hypomimia. She is hospitalized in the Psychiatric Brief Hospitalization Unit (PBHU).Her parents relate the beginning of this symptomatology to a breakup and gender violence,which the patient confirms during the interview by eye/cephalic movements and single words jotted down.
ObjectivesThe objective of this study is to describe the evolution of the patient during her hospitalization in the PBHU of Salamanca and to look into the available bibliography about mutism related to stress and sialorrhea.
MethodsWe carried out a follow-up of the hospitalization of the patient and a structured search in PubMed with the keywords “mutism”,“sialorrhea” and “stress” in the last 10 years in English,Spanish and French.
ResultsFew or no articles where found.Therefore, the articles about mutism and stress were analyzed, which focused mostly in selective mutism. Regarding fear,the response to cope with the threat(fight, flight, freeze) is mediated by the autonomic system. The “Polyvagal Theory” speaks about the vagus nerve participating in emotion regulation (social communication and mobilization). Dissociation, in this context,has adaptive and defensive purposes and its threshold can be reduced by repeated stress situations.Long-term alteration of the autonomic nervous system has been described in selective mutism.This malfunction can be related to an elevated production of saliva due to the activation of the parasympathetic in the salivary glands, causing sialorrhea in our patient.
The patient began treatment with sertraline 100mg and risperidone 2mg with the aim of its antidepressive and major tranquilizer effects, she also began individual and family psychotherapy, we assured her sleep and intakes and she began to progressively recover her speech and mobility,identifying a possible trigger for the symptomatology: a physical beating of gender violence after her breakup.
ConclusionsDissociation and “freeze” response can be a maladaptative mechanism to fear.The malfunction of the autonomic nervous system can explain the disconnection,poor gaze,low facial and body expression and inability to speak.
Disclosure of InterestNone Declared
Antiandrogenic treatment of obsessive compulsive neurosis: A case review
- L. Huerga García, I. Careno Baez, G. Oropeza Hernández, A. Marcos Rodrigo, C. Delgado Torres, G. Garriga Rocío, P. Gómez Pérez
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- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, p. S927
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Introduction
Obsessive-compulsive disorder (OCD) is a mental disorder in which patients who suffer from it have repetitive and undesirable thoughts, feelings, ideas, sensations (obsessions) and behaviors that drive them to do something over and over again (compulsions).
Often the person tries to get rid of the obsessive thoughts through compulsions, but this only provides short-term relief. Not carrying out the obsessive rituals can cause enormous anxiety and suffering.
ObjectivesTo describe a 23-year-old male patient, who suffers from anxiety and mood symptoms, reacts to ego-dystonic obsessive ideas and sexual content, of months of evolution, and who manages to calm down through compulsive masturbation or watching sexual videos on the internet. All this clinic negatively interferes with their quality of life, asking the patient for medical help to calm these ideas.
MethodsWe carried out a review in Pubmed with the terms Antiandrogens and TOC, in order to make a better description of the clinical case.
ResultsAfter several treatment attempts (Sertraline, Paroxetine, Clomipramine, Clomipramine + SSRI), reaching maximum doses according to clinical guidelines, and with poor therapeutic response, it was decided to discuss the case with the endocrinology department of our hospital, deciding to start treatment with antiandrogens, in order to alleviate the persistent intrusive ideas of a sexual nature. The administration of antiandrogens in men can cause a decrease or increase in the development or involution of secondary sexual characteristics in men, reducing the activity or function of accessory sexual organs, and hyposexuality, with decreased sexual desire or libido.
After several weeks, there was improvement in the obsessive symptoms with a decrease in compulsive rituals. However, after the 3rd mo, some symptoms reappeared, but not with the same severity and intensity as before treatment. In addition, we cannot ignore the adverse effects that have occurred, such as involution of secondary sexual characteristics. However, and taking into account the negative repercussion that this clinic had on the patient’s quality of life, the benefit obtained exceeded the risk, having noted clear improvement with this therapy, and maintaining evolutionary controls by both psychiatry and endocrinology.
ConclusionsPatients suffering from obsessive-compulsive disorder can be effectively treated with anti-androgenic pharmacological agents with various modes of action. The most effective group of such agents is the long-acting analogues of the gonadotropin-releasing hormone. The objective of this review is to elucidate the possibility of using such powerful anti-androgenic agents in the treatment of obsessive-compulsive disorder.
Disclosure of InterestNone Declared
Intranasal Esketamine administration in catatonia: a case report.
- J. Romay, C. Sevilla, P. Hernandez, I. Lastra, G. Isidro, L. Cayon, G. Cortez, O. Anabitarte, P. Ijalba, M. Gomez Revuelta
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- Journal:
- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, p. S956
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Introduction
Catatonia is a complex psychomotor syndrome that often goes unrecognized and, consequently, untreated. Prompt and correct identification of catatonia allows for highly effective treatment and prevention of possible complications. Benzodiazepines and electroconvulsive therapy (ECT) are the most widely studied treatment methods. However, no uniform treatment method has yet been brought forward and no previous attempts to treat catatonia on a patient suffering concomitant major depressive disorder (MDD) with NMDA receptor antagonists have been documented so far.
ObjectivesTo describe the unknown and novel management of catatonia and MDD with intranasal esketamine, a NMDA receptor antagonist.
MethodsA 55-year-old woman with a diagnosis of long-standing recurrent major depressive disorder who was admitted to the psychiatric inpatient unit of UniversityHospital Marqués de Valdecilla (Santander, Spain) suffering a complex catatonic, mutative state framed on a severe MDD. Different ineffective therapeutic interventions were deployed during the course of her illness. After failing to improve under conventional pharmacological treatment and ECT, and given the complexity of peripheral venous access on this patient (which disabled the option for iv ketamine use), we decided to initiate compassionate treatment with intranasal esketamine.
ResultsIntranasal esketamine was effective in the resolution of patient’s complex catatonic state. Clinical response from catatonia was observed after 6 intranasal esketamine administrations (2-week follow-up), reaching full catatonia and MDD remission after 12 sessions in absence of significant adverse events
ConclusionsEsketamine showed promising effectiveness for the treatment of catatonia in the context of MDD, although further research on this topic is needed.
Disclosure of InterestNone Declared
A clinical case of anosognosia in a CADASIL disease.
- E. Talaya Navarro, L. Gallardo Borge, E. Gómez Fernández, R. Fernández Díaz, L. Al Chaal Marcos, E. Rybak Koite
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- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, pp. S1000-S1001
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Introduction
CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy) is a cerebrovascular disease, tht appears in 1.98/100,000. It´s caused by a mutation of the Notch3 gene and is characterized by accumulation of granular osmiophilic material in the middle layer of the small and median sized cerebral arteries.
Sypmtoms are migraine, recurrent cerebral ischemic episodes, dementia, neuropsychiatric disorders (anosognosia, character disorders, apathy and cognitive impairment). It usually appears between 30-60 years, although there is an important variability. There is no curative treatment, only palliative.
ObjectivesClinical review of anosognosia and its presence in CADASIL disease.
MethodsClinical case and literatura review.
ResultsWe presented the clinical case of a 68-year-old man, who was diagnosed with CADASIL after a stroke 3 years earlier. In his family, his brother was diagnosed also with CADASIL. The patient had previously presented disturbances in impulse control (hyperorality) and important executive failures. He currently presented anosognosia, deficits in verbal memory, spatial perception and executive functions, in addition to behavioral alterations and apathy. Due to these deficits he was prohibited from certain activities (driving, hunting).
The patient was not aware of these deficits and becouse of his “no knowledge of his illness”, he disagreed with these prohibitions, so he showed rage and anger at the impotence of not understanding why certain actions are prohibited.
In the consultation, mnesic errors and in naming objects were also objectified, for which it was recommended to carry out cognitive stimulation on a daily basis. In addition, he presented failures of sphincter incontinence, especially of urine and occasionally also of the anal sphincter. He had previously had episodes of myoclonus or fasciculations.
A genetic study by massive sequencing confirmed the heterozygous presence of the pathogenic variant c.1819C>T p.(Arg607Cys) in the NOTCH3 gene, a CADASIL disease.
ConclusionsThe anosognosia that many patients with CADASIL disease present constitutes a problem because it contributes to the delay in consultation and, therefore, the delay in the adequate diagnostic approach, therapeutic possibilities and family genetic counseling. Due in part to anosognosia, CADASIL is considered an underdiagnosed entity. Due to the lack of awareness and the consequent lack of recognition of the deficit, these people are often seen as stubborn and difficult to deal with by people in their immediate environment.
In addition, there is general difficulty in the rehabilitation process, since patients do not think the neccesity to be treated. This can generate frustration and despair both in their relatives and in the health personnel.
For all these reasons, both in anosognosia and in CADASIL disease, adequate psychological support is needed for both those affected and their families.
Disclosure of InterestNone Declared
How do men differ from women? Case-Control study on clinic and personality characteristics of eating disorders
- F. Ruiz Guerrero, J. Gonzalez Gómez, C. Cobo Gutierrez, L. Castro Fuentes, C. Hernández Jimenez, J. Romay González, A. Gómez del Barrio
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- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, pp. S849-S850
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Introduction
A review of the literature shows how female sex is a crucial factor in the development of ED, being the proportion of women and men 10 to 1 regardless of the location of the sample (Duncan, Ziobrowski & Nicol, 2017) and different clinical subtypes (AN, BN) (Swanson et al., 2011). However, male population has always been less studied, some works find that only 1% of the articles published in AN is aimed at the study of males (Galusca, 2012).
Nowadays it is accepted that the etiopathogenesis of these disorders is multifactorial and in addition to female gender other risk factors have been identified, such as neurobiological alterations, psychological predictors, personality traits, low self-esteem, extreme perfectionism or thinness values focused on body and figure. On the other hand, certain impulsive behaviours such as self-harm, substance use, physical activity or diets are factors that may be confused as predisposing or as symptoms of the pathology itself (Connan et al., 2003, Treasure, Stein and Maguire, 2015).
Recently, Kinasz, Accurso, Kass and Le Grange (2016) have compared the clinical characteristics that differentiate men (59) from women (560) in a sample of children and adolescents between 6 and 18 years-old, finding that males presented an earlier start of the ED and not appreciating differences in the duration of the disease, income, episodes of purgue and psychiatric comorbidity of anxiety, behaviour disorders or impulsivity.
ObjectivesThe aim of this study was to evaluate gender differences in clinical characteristics, levels of depression, previous obsessiveness and personality dimensions in eating disorders (ED) compared with controls.
MethodsA total of 80 participants was divided into 4 groups, 20 men and 20 women with ED and 20 men and 20 women without ED (healthy control), matched by age and socioeconomic status. The design of the study was case-control, and data was collected through clinical interview and a battery of cuestionaires.
ResultsMen with ED only differ in vigorous physical activity (measured by IPAQ) from controls and women with pathology. Regarding personality traits, men and women with ED do not differ among them, although they do differ in novelty search and harm avoidance respect to their controls.
ConclusionsBehaviors such as physical activity in males frame a slightly different way of reducing their discomfort, however, clinical implication indicates that the treatment may be similar according to gender.
Disclosure of InterestNone Declared
Psychosomatic symptoms according to psychiatric diagnosis
- R. Fernández Fernández, L. Fontecha Banegas, C. Suárez Pérez, D. Gómez Olmeda, I. D. L. M. Santos Carrasco
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- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, p. S299
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Introduction
Psychosomatic symptoms are an important problem that is frequently presented in medical consultations. These symptoms are often associated with psychiatric disorders, especially depressive and anxiety disorders.
ObjectivesTo study the association between anxiety disorders and psychosomatic symptoms in a sample of patients referred for pathology of functional origin.
MethodsWe made a descriptive retrospective study through the use of electronic medical records. The symptom onset and diagnosis were obtained for all patients referred to outpatients for psychosomatic symptoms during a 1-year period. We performed χ² Tests to assess the association of the diagnosis with the occurrence of psychosomatic symptoms.
ResultsThe only diagnosis that presented statistically significant association was anxiety disorder (χ² = 11.1; p<0.001).
Anxiety disorder Psychosomatic symptoms No Si Total No Observed 312 7 319 Expected 306 13.47 319 Yes Observed 119 12 131 Expected 125 5.53 131 Total Observed 431 19 450 Expected 431 19 450 ConclusionsOur study finds results that follow the line of other studies that show this association, such as Campo’s study which finds that functional somatic symptoms are consistently associated cross-sectionally with anxiety and depressive symptoms (Campo, 2012) or Imran’s study which finds that higher levels of somatization independently and significantly predicted higher anxiety (β=.37, p=.0001) (Imran et al., 2013). However, our results show no association with depressive disorders whereas frequent associations are found in the literature; for example, a recent meta-analysis found that neuroticism and depression had the strongest influence on the association of medically unexplained physical symptoms and frequent healthcare use (den Boeft et al., 2016). This lack of association is probably due to greater ease in identifying depressive disorders as the main pathology versus anxiety disorders.
ReferencesCampo J. V. (2012). Annual research review: functional somatic symptoms and associated anxiety and depression--developmental psychopathology in pediatric practice. Journal of child psychology and psychiatry, and allied disciplines, 53(5), 575–592. den Boeft, M., Twisk, J. W., Terluin, B., Penninx, B. W., van Marwijk, H. W., Numans, M. E., van der Wouden, J. C., & van der Horst, H. E. (2016). The association between medically unexplained physical symptoms and health care use over two years and the influence of depressive and anxiety disorders and personality traits: a longitudinal study. BMC health services research, 16, 100
Imran, N., Ani, C., Mahmood, Z., Hassan, K. A., & Bhatti, M. R. (2014). Anxiety and depression predicted by medically unexplained symptoms in Pakistani children: a case-control study. Journal of psychosomatic research, 76(2), 105–112.
Disclosure of InterestNone Declared