Pathological gambling is an addictive disorder and a current important issue with substantial social and personal costs. It is associated with impaired functioning, criminal record, bankruptcy and mental health problems. There is a significant comorbidity between gambling disorder, mood disorders and other addictive behaviors like alcohol use. Suicidality is common, impulsivity being a major risk factor for suicidal acts.

Case presentation of gambling disorder associated with a suicide attempt

Review of the clinical file of a patient diagnosed with gambling disorder and non-systematic review on the topic on PubMed

A 35 old male patient is brought to our psychiatrical emergency unit by means of ambulance as he attempted to commit suicide by inflicting multiple deep cuts on his forearms. He has a positive history of gambling disorder, no prior suicide attempt, or criminal record. He has a precarious economic status, the trigger for his acts being the loss of a substantial financial amount. The risk factors in his case were a positive familial history of addictive disorders (his father was diagnosed with alcohol use disorder), aversive childhood events, comorbid depression, alcohol misuse and low income. The patient resumed his gambling behavior 7 months prior to admission, after a 5 year abstinence, motivated by the desire to rapidly pay a loan he recently took. The addictive behavior worsened after his wife experienced a miscarriage. He started borrowing money, engaging in antisocial acts like stealing money from his wife’s bank account, neglecting his job and ending up in financial debt. He experienced feelings of alienation and isolation from his social network and family, unable to verbalize his burden. He also feared a divorce. Psychological coping strategies such as thought and emotional suppression were present and also an important tendency to minimize the severity of the events. Cluster B traits were present but not clinically significant. The suicide attempt is described by the pacient as being impulsive, with no prior planning, as a mean of problem solving for his desperate situation of high financial and social burden.

In the hospital setting, pharmacological treatment with SSRI Escitalopram and opiate antagonist Naltrexone was initiated. The patient was referred to psychological counseling during hospitalisation and to CBT after he left the hospital. He had excellent social support.

Although suicide is initially seen as an impulsive act, in fact it includes a constellation of thoughts, emotions and behaviors which lead to the hopelessness and desperation preceding the suicidal attempt. Gambling disorder tends to have a chronic evolution, impacting many important life domains, complex management such as pharmacotherapy, psychological interventions and social support being necessary for a favorable outcome.

None Declared

Dementia with Lewy bodies(DLB) and Parkinson’s disease dementia(PDD) make up for about 20% of dementia cases, with a significant overlap of clinical features. They are described as separate entities in the DSM-5 with an arbitrary delimitation based on the onset of cognitive decline in relation to parkinsonism.Visual hallucinations are a common clinical feature. Treatment consists of low dose antipsychotics, generally quetiapine or clozapine being used.

Case presentation and reflection on pharmacological treatment

Review of the clinical file of a patient with DLB

A 76 year old female was referred to our clinic with a recent history of complex visual hallucinations and delusional thoughts. The onset of parkinsonism was made 8 months prior to admission and treatment with IMAO-B Rasagiline and a combination of Levodopa was initiated. The patient had no psychiatric hospitalization history. Her comorbidities include hypertension, dyslipidemia and osteoporosis, for which she received specific treatment. The onset of complex visual hallucinations was one month prior to admission. A trial with small dose clozapine was initiated in an out-patient setting and dropped out due to intolerance.

During the hospitalization she was describing recurrent complex visual hallucinations in the form of people engaging in sexual activities in front of her and suspected her husband of involvement in these acts. She was also experiencing tactile and proprioceptive hallucinations, interpreting them as harmful laser beams resulting in skin marks (age spots were present). Sun downing syndrome was present, consisting of fluctuating cognition, worsening of temporo-spatial orientation, marked anxiety as the visual hallucinations became more vivid. CT scan showed moderate atrophy and psychological testing indicated moderate cognitive decline.

Treatment with Rasagiline was interrupted as it can worsen psychotic features, by raising dopamine levels. Levodopa was reduced to the minimum efficient dose for parkinsonism as it can cause agitation and worsening of visual hallucinations. Treatment with small dose quetiapine (100 mg per day) was initiated, the patient experiencing severe hypotension due to neuroleptic sensitivity. Quetiapine was continued for about 3 months, with the aggravation of the visual hallucinations and encapsulated delusional thinking. Small dose Clozapine (25 mg per day) was rechallenged, with favorable outcome. Some visual disturbances were still present but less bothersome. Lorazepam was used for the management of insomnia and psychomotor agitation and the cholinesterase inhibitor Rivastigmine for managing the behavioral symptoms and cognitive decline.

Visual hallucinations are often a bothersome clinical feature in DLB. Treatment and diagnosis is often challenging. Clozapine is a good option for managing visual hallucinations in DLB.

None Declared

Nothing is taken more for granted than the feeling that we are in control of our own thoughts and actions. For those who experience thoughts insertion or delusion of control, known as first rank symptoms of schizophrenia, it becomes a luxury to rule their own thoughts. Kandinsky-Clerambault syndrome is characterized by pseudo-hallucinations, delusions of control, telepathy, thought broadcasting and thought insertion by an external force. The patient’s thoughts, emotions, perceptions or actions are under the control of a different agent, or sometimes he believes that the operator of control is inside his body.

Presentation of a clinical case of Kandinsky-Clerambault syndrome in a patient with treatment-resistant schizophrenia.

Case report

We present the case of a 38-year-old man, diagnosed with paranoid schizophrenia since 2014, who has followed several therapeutic plans, starting with Haloperidol followed by Risperidone, Paliperidone, Quetiapine, Clozapine. Since 2016 he had been under treatment with Xeplion injectable 150mg/month ambulatory, but the psychotic features never fully remitted. 10 days before admission he had last administration of Xeplion LAI. The patient reports the loss of control over his mental life and describes the triple automatism: ideo-verbal, sensory and motor. “There are some people in my body who control me, they move my limbs. I feel like my body is not mine.” He describes imperative and commentative auditory pseudo-hallucinations. The patient speaks intermittently in the 3rd person about himself, has circumstantial discourse, with elements of tangentiality, ideo-verbal and conceptual disorganization. He presents delusions of control, persecution and prejudice. The treatment received during admission – Riseridone 5ml/day, Amisulpride 600mg/day, Orfiril Long 1000mg/day.

After 14 days of hospitalization, the patient is discharged in an improved state, without mentioning spontaneously the delusional ideation. He affirms the intermittent presence of auditory pseudo-hallucinations, but with low intensity compared to the moment of admission. It is ironic how the loss of the self, along with the insertion of thoughts and auditory pseudo-hallucinations create a patient’s own reality, which at the same time is experienced as coming from the outside. From a phenomenological point of view, thought insertion is explained as an autoimmune disease. Thoughts are produced by our mind, but because we have lost the meaning of control and belonging to ourselves, those thoughts are attacked as foreign.

None Declared

The interest for academic background and investigational activities are essential in psychiatry. Several European-wide, early career psychiatrists-driven studies have been carried out completely independently, leading to high quality publications, where all the co-authors are junior researchers.

To further elaborate the European federation of psychiatric trainees (EFPT) platform of promoting the experience of collaborative work and research lead by psychiatric trainees in different countries all over Europe.

A review of EFPT collaborative trainee-led research initiatives since the beginning with the focus on published articles and their impact on psychiatric community in Europe.

Main topics of trainee research are related to postgraduate psychiatric training schemes in Europe raising awareness on enhancing and harmonizing standards of psychiatric education and training across Europe. Other research topics are related to treatment strategies while being a psychiatric in Europe, to migration and “brain drain” phenomenon of psychiatric trainees in Europe, to access to information in psychiatric training.

International cooperation's in research should be promoted since the training. Joining professional associations provides opportunities for participating in research activities and establishing networks with other colleagues. Collaboration between psychiatric trainees ensures a more effective use of individual talents and a quick way of accessing and transferring new knowledge and research expertise. Moreover it provides a supportive framework for multi-center research.

The authors have not supplied their declaration of competing interest.