The silent waitress. A case report of mutism without catatonia

Introduction Mutism, defined as an inability or unwillingness to speak, resulting in an absence or reduction of speech, has a wide differential diagnosis. It rarely presents as an isolated disability and often occurs in association with other disturbances in behavior, thought processes, affect, or level of consciousness. Mutism is typically associated with catatonia, usually in schizophrenia, but also depression, bipolar disorder, intoxication, and neurological conditions. Objectives To describe a case of mutism without catatonia. Methods We describe a clinical case of a patient admitted to our psychiatric inpatient unit with mutism as the presenting symptom. The literature on this subject is also selectively reviewed. Results A 49-year-old woman was found mute at home by her brother and brought to our emergency room. Not a word had come out of his mouth for the past month. She would show up at the restaurant where she worked as a waitress and do her job, but she didn’t talk. As a result, she had been fired. Her routine daily chores and her vegetative functions were maintained. She had no prior history of medical or psychiatric illness or substance abuse. In addition to the mutism, the patient showed an important psychomotor restlessness and performed repetitive hand movements suggestive of occupational delirium. There was no rigidity, stupor, negativism, catalepsy, echosymptoms or any other catatonic symptomatology. She was then admitted to our inpatient unit, where a complete blood test, EKG, brain CT, brain MRI, EEG and a lumbar puncture with biochemistry and neuroimmunology studies were performed, none of them showing any abnormalities. The clinical presentation suggested the diagnosis of either a psychotic disorder or a major depressive episode. The patient was then started on olanzapine up to 20 mg/d, fluoxetine up to 20 mg/d and lorazepam up to 6 mg/d. Due to persistence of symptomatology despite pharmacological treatment, she was started on Electroconvulsive Therapy (ECT). At the time of issuance of this report, 7 bilateral ECT courses have been carried out and absolute mutism persists. Although she has presented an improvement of the anxiety and the repetitive behaviors noted on admission have disappeared, she hasn´t resumed speaking. Conclusions Mutism occurs in a number of conditions, both functional and organic, and an accurated diagnosis is important for the management. One must perform a thorough physical and systemic examination to rule out organic causes for mutism. An observation for some time period may be warranted and should be done to reach final diagnosis in our case. Disclosure of Interest None Declared

Introduction: To present a clinical case that reflects the causal relationship between the administration of high-dose corticosteroids and the appearance of maniform-type psychopathology.
Objectives: Descriptive study of a case report and literature review on the subject.Methods: 32-year-old woman with alcohol abuse detected, added Antabus 250 mg / day to her treatment.Results: After 2 months of treatment, she was admitted to the Digestive Service due to acute hepatitis.After a liver biopsy and autoimmunity study was diagnosed as Autoimmune Hepatitis.Treatment with Antabus was withdrawn, and Prednisone 60 mg/day was prescribed.Seven days after starting treatment with corticosteroids, she presented maniform symptoms (psychomotor restlessness, expansive mood, dysphoria, megalomanic delusions, alteration of biological rhythms with decreased need for sleep and risk behaviors), and she was admitted in a psychiatric hospitalization unit.After considering various differential diagnoses she is diagnosed with Substance-Induced (corticosteroids) Mood Disorder with manic features.Psychiatry agrees with the Digestive Service to start treatment with Paliperidone and progressively lower the dose of corticosteroids until suspending it and prescribe an immunosuppressant.Finally, the maniform symptoms that led to admission remitted completely and control and outpatient treatment were continued.Conclusions: Its important to always keep in mind the great risk of the appearance of psychiatric disorders that treatment with high doses of corticosteroids entails, especially in susceptible patients or with a psychiatric history or genetic susceptibility.It is necessary to know the possible appearance of these neuropsychiatric adverse effects in order to prevent them, and if it appear, to assess, if possible, the suspension or reduction of corticosteroid treatment.

EPP1032
The silent waitress.A case report of mutism without catatonia Introduction: Mutism, defined as an inability or unwillingness to speak, resulting in an absence or reduction of speech, has a wide differential diagnosis.It rarely presents as an isolated disability and often occurs in association with other disturbances in behavior, thought processes, affect, or level of consciousness.Mutism is typically associated with catatonia, usually in schizophrenia, but also depression, bipolar disorder, intoxication, and neurological conditions.Objectives: To describe a case of mutism without catatonia.Methods: We describe a clinical case of a patient admitted to our psychiatric inpatient unit with mutism as the presenting symptom.The literature on this subject is also selectively reviewed.Results: A 49-year-old woman was found mute at home by her brother and brought to our emergency room.Not a word had come out of his mouth for the past month.She would show up at the restaurant where she worked as a waitress and do her job, but she didn't talk.As a result, she had been fired.Her routine daily chores and her vegetative functions were maintained.She had no prior history of medical or psychiatric illness or substance abuse.In addition to the mutism, the patient showed an important psychomotor restlessness and performed repetitive hand movements suggestive of occupational delirium.There was no rigidity, stupor, negativism, catalepsy, echosymptoms or any other catatonic symptomatology.She was then admitted to our inpatient unit, where a complete blood test, EKG, brain CT, brain MRI, EEG and a lumbar puncture with biochemistry and neuroimmunology studies were performed, none of them showing any abnormalities.The clinical presentation suggested the diagnosis of either a psychotic disorder or a major depressive episode.The patient was then started on olanzapine up to 20 mg/d, fluoxetine up to 20 mg/d and lorazepam up to 6 mg/d.Due to persistence of symptomatology despite pharmacological treatment, she was started on Electroconvulsive Therapy (ECT).At the time of issuance of this report, 7 bilateral ECT courses have been carried out and absolute mutism persists.Although she has presented an improvement of the anxiety and the repetitive behaviors noted on admission have disappeared, she hasn´t resumed speaking.Conclusions: Mutism occurs in a number of conditions, both functional and organic, and an accurated diagnosis is important for the management.One must perform a thorough physical and systemic examination to rule out organic causes for mutism.An observation for some time period may be warranted and should be done to reach final diagnosis in our case.Introduction: Combatants who are exposed to events which transgress deeply held moral beliefs might face lasting psychopathological outcomes, referred to as Moral Injury (MI).However, knowledge about pre-deployment factors which might moderate the negative consequences of MI is sparse.

Disclosure of
Objectives: In this prospective study, we examined pre-enlistment characteristics and pre-deployment personality factors as possible moderators in the link between exposure to potentially morally injurious events (PMIEs) and psychiatric symptomatology among Israeli active-duty combatants.Methods: A sample of 335 active-duty Israeli combatants participated in a 2.5-year prospective study with three waves of measurements (T1: 12 months before enlistment, T2: 6 months following enlistment-pre deployment, and T3: 18 months following enlistment-post deployment).Participants' characteristics were assessed via semi-structured interviews (T1) and validated selfreport measures of personality factors: emotional regulation, impulsivity, and aggression (T2) and combat exposure, PMIEs, psychiatric symptomology and post traumatic symptoms (T3) between 2019-2021.Results: Pre-enlistment psychiatric difficulties and negative life events contributed to higher exposure to PMIEs post deployment.Higher levels of pre-deployment aggression and lower levels of emotional regulation and impulsivity moderated the association between betrayal, PMIEs and psychiatric symptomology post deployment, above and beyond pre-enlistment psychiatric difficulties and life events.Conclusions: Our results highlight that pre-deployment emotional regulation, impulsivity and aggressiveness levels should be assessed, screened, and identified among combatants, as they all facilitate psychiatric symptomology (and PTSS) after combatants are exposed to PMIEs of betrayal.Such pre-assessment will enable identification of at-risk combatants and might provide them with tailor made preparation regarding moral and ethical situations that should be investigated in future researches.
Disclosure of Interest: Y. Levi-Belz: None Declared, G. Zerach Shareolder of: no, Grant / Research support from: no, Consultant of: no, Employee of: no, Paid Instructor of: no, Speakers bureau of: no Schizophrenia and other psychotic disorders 09 EPP1034 Association between cannabis use and symptoms of psychosis: a mega-analysis Introduction: It remains debated in the scientific literature whether cannabis aggravates psychotic symptoms or is used as a self-medication.Regular cannabis use (RCU) was found associated with the severity of positive symptoms of psychosis i.e., delusion or hallucinations.However, the association with negative symptoms, i.e. blunted affect or social withdrawal, is less straightforward.Confounding variables such as the criteria for other Substance Interest: None Declared EPP1033 Moral Injury and Pre-Deployment Personality Factors as Contributors to Psychiatric Symptomatology among Combatants: A Two-Year Prospective Study Y. Levi-Belz 1 * and G. Zerach 2