João Gama Marques

The Proximity between Hallucination and Delusion Dimensions: An Observational, Analytic, Cross-Sectional, Multicentre Study

In psychiatric classifications, hallucinations (mainly auditory hallucinations) are one of the fundamental criteria for establishing a schizophrenia diagnosis or any of the related psychotic disorders diagnoses. The conceptual proximity between delusions and hallucinations was maintained until the end of the XIX century, with several supporters during the XX century. Their limits were not yet definitely defined in terms of Descriptive Psychopathology, and much less so in terms of biochemical and anatomical models. In this article we aimed to analyse the dimensions of both hallucinations and delusions in a sample of patients with schizophrenia and schizoaffective disorder. We also intend to find the determinants of the main dimensions of hallucinations. One hundred patients with schizophrenia (80) or schizoaffective disorder (20), 64% males, mean age 39.75, from the outpatient and inpatient units of the Psychiatry Department of Hospital de Santa Maria and the Centro Hospitalar Psiquiátrico de Lisboa were assessed by means of the Psychotic Symptom Rating Scales (PSYRATS) and a structured interview. In this study we designed an empirical based model by means of bivariate Spearmans rank correlation coefficient, and multivariate statistics (linear regression and multiple multivariate linear regression), where the main dimensions of hallucinations are determined by the central dimensions of delusions.

Equal access for all? Access to medical information for European psychiatric trainees

Access to medical information is important as lifelong scientific learning is in close relation with a better career satisfaction in psychiatry. This survey aimed to investigate how medical information sources are being used among members of the European Federation of Psychiatric Trainees. Eighty-three psychiatric trainees completed our questionnaire. A significant variation was found, and information availability levels were associated with training duration and average income. The most available sources were books and websites, but the most preferred ones were scientific journals. Our findings suggest that further steps should be taken to provide an equal access to medical information across Europe.

Mitsuda psychosis and holodysphrenia revisited: an atypical psychosis in a patient with parieto-occipital paroxysmal electroencephalographic activity and high unconjugated bilirubin.

psychiatric disorder. After admission, an initial treatment of oral haloperidol (1 mg/day) was administered, rather than second-generation antipsychotics (which are associated with tendency of metabolic syndrome and increased risk of stroke), along with a physical work-up to test for possible organic etiology. The auditory hallucination was still noted and haloperidol was increased to 5 mg/day. A brain magnetic resonance imaging (MRI) scan revealed no evidence of an interval change or new intracranial lesions, compared with MRI scans performed 2 years prior. Functional MRI (fMRI) was not performed, so we failed to specify the relation between clinical hallucinations and fMRI modifications. The complete blood cells, electrolyte levels, and renal and liver function were normal. The antiphospholipid, lupus anticoagulant, IgG immunoglobulin, and anti-nuclearand anti-double-stranded DNA autoantibodies were also all within the normal range. During her hospital stay, the patient’s psychotic symptoms gradually improved on haloperidol (5 mg/day); for progressive extrapyramidal symptoms, haloperidol was replaced with chlorpromazine (25 mg/day) after discharge a few weeks later, with a fair response. No exacerbation of the psychosis was noted during follow-ups over the next 3 years at our clinic. In our patient, idiopathic Sneddon syndrome was diagnosed. She had deafness and MRI showed multiple cerebral infarctions. The livedo reticularis was noted over her four limbs and the skin biopsy revealed thrombosis of subcutaneous arterioles. Systemic lupus erythematosus, polyarteritis nodosa, cryoglobulinemia, livedoid vasculitis, cold agglutinin disease, arteriosclerosis, and others were all excluded. During this hospitalization, her autoimmune factors were normal and Sneddon syndrome was still considered. Her psychotic symptoms were fully remitted under a low dose of antipsychotics (haloperidol at 5 mg/day in the ward, and subsequent chlorpromazine at 25 mg/day in the clinic), without recurrence of psychosis over the following 3 years. There may be some debate about whether the patient’s symptoms indicated a comorbid primary psychosis or were secondary to Sneddon syndrome. However, the evidence suggests that this is not a comorbid primary psychosis, because of the absence of a family history of psychiatric disorder, the relatively late onset of the psychotic symptoms, and a lack of concomitant delusions. We hypothesize that the psychotic symptoms were secondary to Sneddon syndrome. Suicide risk should be considered in cases where Sneddon syndrome is the diagnosis; a low dose of antipsychotics may be effective for controlling the symptoms and preventing side-effects. The protocol for the research project has been approved by TMU-JIRB (Taipei Medical University-Joint Institutional Review Board, No. N201604035, protocol version/date: version 1.0/2016/04/05, informed consent forms: waiver of informed consent), and it conforms to the provisions of the Declaration of Helsinki.

Mental health in Portugal in times of austerity

We read with interest the letter of our colleague Gonçalo Augusto, and therefore would like to congratulate the author and the editor for their interest in this subject. However, we confess some disappointment with Augusto’s citations. Although the World Mental Health (WMH) survey, was an impressive eff ort in the study of mental illness prevalence, it had serious limitations, because “schizophrenia and other nonaff ective psychoses...were not included in the core WMH assessment”. Regarding completed suicides, we remind readers that statistics have always been a problem in Portugal. There are important biases with doctors underdeclaring suicide as “unknown cause of death” in paper certifi cates, to avoid life insurance non-payment or religious stigma, especially in northern Catholic communities. To overcome this diffi culty, the Ministry of Health has implemented an online and obligatory Death Certifi cate Information System (SICO). Still, it is probably premature to affirm that “suicide rates have remained stable over the past few years in Portugal”. In fact, Augusto later cites a newspaper article regarding the disparity in offi cial numbers between those of the National Institute of Legal Medicine and the Institute of Medical Emergency, suggesting that both attempted suicides and deaths by suicide seem to have been increasing. The second reference (Rodrigues et al) leads to a broken link and nonexistent PubMed paper. Nevertheless, we found it, in Portuguese only, at the online repository of the Doutor Ricardo Jorge’s National Health Institute. In sum, we would agree with Dr Augusto’s statement that “unfortunately, no studies have been done on the effect of the country’s economic and social crisis on the mental health of its people”. In fact, the Spring 2014 report by the Portuguese Health Systems Observatory, made public on June 30, concludes that Portugal stands before a conjugation of unfavourable factors in the area of mental health, worsened by the insuffi cient response, and maintained by an “apparently mediocre” information system; therefore, we think it would be important to first have more accurate data on Portuguese mental health prevalence, and suicide statistics, before jumping to premature (and alarming) conclusions. Quality science is made with accurate numbers and citations.

Bleuler's Psychopathological Perspective on Schizophrenia Delusions: Towards New Tools in Psychotherapy Treatment

The authors begin by addressing the historical evolution of the delusion concept and its different approaches, focusing afterwards mainly on the work of Bleuler, who stressed the proximity between delusions and the emotional life of patients with schizophrenia. I Therefore, the present work intends to review the main aspects of the theory of delusion formation in schizophrenia according to Bleulers psychopathological perspective. For that purpose, first the role of delusions in the psychopathology of schizophrenia is explored in a close relation with the Bleulers fundamental symptoms (Alogia, Autism, Ambivalence, and Affect Blunting) nowadays known as negative symptoms. Then, persecutory, grandiosity and sexual delusions in schizophrenia are described according to the tension between logic and affects, as well as, internal conflict, schizoid features, and auto-erotism as key psychopathological pathways. Thus, with this subjective perspective, it is intended to highlight Bleulers psychopathological contribution to the affective and meaningful causality of delusions in schizophrenia. The former might be useful in the integration with other psychopathological phenomena (hallucinations and negative symptoms) and new forms of research and therapeutic approaches in this disorder that are complementary with the contemporary tendencies in psychopathology.

Letter to the Editor: Still About Delirium

Leonor CARNEIRO-LEÃO1, Natacha SANTOS2, Ângela GASPAR3; Grupo de interesse de “Anafilaxia e Doenças Imunoalérgicas Fatais” da SPAIC Sociedade Portuguesa de Alergologia e Imunologia Clínica. 1. Serviço de Imunoalergologia. Centro Hospitalar São João. Porto. Portugal. 2. Serviço de Imunoalergologia. Centro Hospitalar do Algarve. Portimão. Portugal. 3. Centro de Imunoalergologia. Hospital CUF Descobertas. Lisboa. Portugal. Autor correspondente: Leonor Carneiro-Leão. leonorcarneiroleao@gmail.com Recebido: 20 de janeiro de 2018 Aceite: 22 de janeiro de 2018 | Copyright

How to Write Discharge Notes and Referral Letters? A Simple but Effective Perspective

1. Hospital Júlio de Matos. Centro Hospitalar Psiquiátrico de Lisboa. Lisboa. Portugal. 2. Clínica Universitária de Psiquiatria e Psicologia Médica. Faculdade de Medicina. Universidade de Lisboa. Lisboa. Portugal.  Autor correspondente: João Gama Marques. joaogamamarques@gmail.com Recebido: 28 de janeiro de 2018 Aceite: 02 de fevereiro de 2018 | Copyright

Taijin kyofusho: A culture-bound diagnosis discussed by Japanese and international early career psychiatrists

F ROM THE 1930S, Japanese psychiatrist Morita characterized Taijin kyofusho (TKS) as phobia of blushing and being ashamed. Kasahara redefined TKS as a type of neurosis that includes excessive anxiety and tension in social situations and withdrawing from interpersonal relationships. He also reported that there can be severe, almost delusional cases. Nagata later developed diagnostic criteria for TKS differentiating the tension (fear of being looked at by others) and offensive (fear of offending or embarrassing others) subtypes. In 1980, the DSM-III adopted social phobia encompassing fear of scrutiny by others, fear of humiliation and embarrassment, and fear of offending others. The criteria were close to the classification of TKS, as social phobia is diagnosed in 66% of TKS cases. In 1994, under DSM-IV, social anxiety disorder (SAD) was listed as equivalent to social phobia, and TKS was added in ‘culture-bound syndromes.’ Fears of offending others in certain cultures (e.g., Japan and Korea) were first mentioned as associated features of SAD. DSM-5 recently included offending others as one of the main fears in SAD, although differences remain between TKS and SAD, as some symptoms of TKS, shubo-kyofu (similar to body dysmorphic disorder) and jikoshu-kyofu (similar to olfactory reference syndrome), are categorized as other specified obsessive– compulsive disorder and related disorders. Still, TKS appears to be changing under cross-border cultural influences. In the Fellowship Award Symposium at the 112th annual meeting of the Japanese Society of Psychiatry and Neurology (JSPN), a TKS case vignette was discussed. Awardees (including some of the co-authors of this letter) chose SAD as a diagnosis, while others suggested body dysmorphic disorder or delusional disorder. In the discussion, we were reminded that diagnostic practices may be culture-bound and may evolve over time, even though DSM is an internationally accepted diagnostic standard. Professor Malcolm John Hopwood of the Royal Australian and New Zealand College of Psychiatrists pointed out the importance of thinking about the purpose of diagnostics and the differences of prognosis and intervention for SAD, TKS, and other diagnoses. Reflection on the diagnostic principles and purposes is crucial for early career psychiatrists. The discussion among international colleagues at the JSPN fellowship award symposium was extremely valuable.

A "Sleeping Beauty" With a "Heart-Hand": Kleine-Levin Syndrome Treated With Buproprion and Carbamazepine in a Patient With Holt-Oram Syndrome.

To the Editor, A 41-year-old woman with congenital Holt-Oram syndrome, permanent pacemaker, neurogenic bladder with recurrent urinary infections, type 2 diabetes mellitus, and dyslipidemia developed recurrent episodes of somnolence, transient anterograde amnesia, irritability, anorexia, occasional changes in the eating habits (craving for French fries) and subtle derealization feelings (she felt her house and bedroom were different and strange). Her family history was positive for bipolar disorder in a first-degree relative. On the first episode, she was admitted to the neurology department, where the extensive blood work, cerebrospinal fluid analysis, brain computed tomography scan were normal and a urinary infection was diagnosed. Brain magnetic resonance imaging was not possible because of cardiac and vesical pacemakers. The visual evoked potentials showed bilateral optic tract disturbance. The electroencephalogram showed slightly slow background activity with occasional somnolent periods, with no sleep episodes. The neuropsychological evaluation showed subtle executive dysfunction. The hospital admittance occurred later in the episode (about 15 days after the beginning of the symptoms) and the hypersomnia complaint was not confirmed in a 24-hour polysomnography performed at that time. She also complained of paraparesis which could not be confirmed on the neurologic examination. Therefore, during this episode, she was diagnosed with dissociative conversion disorder and treated with supportive psychotherapy, plus medicated with escitalopram, olanzapine, and mexazolam. The hypersomnia episodes recurred once or twice per month during the next 8 months, lasting, on average, 1 week. At this time, she was seen in an outpatient psychiatric consultation. After this consultation, olanzapine was stopped to alleviate weight gain and escitalopram interrupted to improve urinary retention. She was started on buproprion. After starting this antidepressant, these hypersomnia episodes decreased significantly in duration, lasting on average 1 to 2 days, but continued to recur, on average, once or twice per month. During a recurrent urinary tract infection, a long-lasting hypersomnia episode recurred. During this episode, the electroencephalogram showed burst of delta activity on frontal leads and polysomnography reported a 13-hour total sleep time in 21 hours of recording. She also underwent an HMPAO-SPECT (Tc–hexamethylpropyleneamine oxime–single-photon emission computed tomography) scan that showed subtle thalamic hypoperfusion, bilaterally. After this episode, the diagnosis of Kleine-Levin syndrome was established. The patient was started on carbamazepine (400 mg/d) and buproprion was maintained. After this, there was fast remission of all symptoms and episodes. Over the past 34 months, there was only 1 brief episode. Holt-Oram syndrome is an autosomal dominant disorder (secondary to TBX5 gene mutation) presenting with upper limbs and cardiac dysplasia, classically described without having any typical neuropsychiatric or neurologic complications, apart from the ones induced by cardiac related complications (stroke, endocarditis). Kleine-Levin syndrome is a rare sleep disorder characterized by relapsing-remitting episodes of severe hypersomnia, cognitive impairment, apathy, derealization, and psychiatric and behavioral disturbances. Our case reports a new association of Kleine-Levin syndrome and HoltOram syndrome, and brings important contributes to treatment of Kleine-Levin syndrome. There is no consensus regarding the etiology of KleineLevin syndrome. It is triggered frequently by infections, as was the case in our patient, suggesting a possible immune mechanism. However, it is more frequently than expected in patients with congenital disorders. The reasons underlying this association are not understood. The congenital syndromes reported are very diverse and generally assumed to result from a casual association. Holt-Oram syndrome, although generally not associated with central nervous system changes, has recently been shown to induce retinal problems and the TBX5 gene is known to influence the retinotectal pathways. Our patient also showed changes in the optic tract. Kleine-Levin syndrome is also very frequently (>25% of the reported cases) observed with perinatal pathology, like strokes or birth complications, 644087 EEGXXX10.1177/1550059416644087Clinical EEG and NeuroscienceGama Marques et al letter2016

Melancholia before the twentieth century: fear and sorrow or partial insanity?

Throughout the history of psychopathology, several meanings have been assigned to the term melancholia. The main ones were related to affective disorders (fear and sadness) and abnormal beliefs. At the time of Hippocrates melancholia was regarded mainly in its affective component. Since that time, and until the eighteenth century, authors and opinions have been divided, with both aspects (affective disorders and abnormal beliefs), being valued. Finally, in the eighteenth to nineteenth centuries, with Pinel at its peak, melancholia becomes exclusively a synonym of abnormal beliefs. At the turn of the nineteenth to the twentieth century, the affective component returns as the main aspect characterizing melancholia.