M. Lobo

P01-349 - Apathy in the spectrum dementia-depression

Objectives To alert to apathy as a sub-syndrome in the spectrum dementia-depression. Methods Review of literature relevant in medline database. Results The modern concept of apathy implies a reduced volition. Apathy may occur in depression and dementia and the differential diagnosis is difficult. Symptoms of apathy may constitute a sub-syndrome in the spectrum depression-dementia, that are characterized by lack of interest, psychomotor retardation, loss of energy and loss of appetite. Apathy may occur in dementia without depression and is significantly associated with more severe cognitive deficits. In dementia, depression may primarily result from a combination of symptoms of anxiety and apathy. Most patients with dementia and apathy had concomitant depression, but less depressed patients had concomitant apathy. The key to diagnosis may be the mood symptoms: dysthymia could be a negative emotional reaction to the progressive cognitive decline in dementia, whereas major depression could more strongly related to biological factors. Conclusions The nosological position of apathy remains obscure, with some studies suggesting that apathy and depression are independent constructs, and other studies showing a significant overlap between apathy and depression. The major interest to the type of syndrome has therapeutics implications.

P-1020 - Delirium in old age

Introduction The concept of delirium has developed historically from the prototype of acute confusion with psychomotor agitation. While the modern view of delirium recognizes four core features (disturbance of consciousness, disturbance of cognition, limited course and external causation), their operationalization can produce a misleading picture of the most common manifestations of delirium in elderly people. Objectives and Aims Alert to the diagnosis of delirium in elderly patients. Methods Review of relevant literature. Results Delirium is a multifactorial syndrome, involving the interrelationship between patient vulnerability, predisposing factors at admission, and the noxious insults and aggravating factors during hospitalization. A significant proportion of elderly patients are either delirious on admission to hospital, or develop delirium at some point during their hospital stay. The clinic needs to be alert to the predisposing and precipitating factors, which have the potential to identify those at risk of delirium and to prevent it occurring, like age, sex, dementia, psychiatric disorders and physical illness. Another important phase of assessment is the differential diagnosis that includes most other organic and functional psychiatric disorders (but its necessary to remember that their presence does not exclude the possibility that the subject is delirious as well), especially depression, dementia or dysphasia due to a cerebrovascular accident. Conclusions Complications arising from the delirious state in elderly patients prolong hospital admission and contribute to adverse functional outcomes, notably increased dependency and higher rates of institutionalization.

P-745 - Excited delirium: a clinical case

Introduction Delirium involves an acute, transient disturbance in consciousness and cognition. When the delirium involves aggressive behavior its termed excited delirium; when this is followed by sudden death, its termed excited delirium syndrome. Typically, patients presented fever, a rapid pulse, agitation and anxiety, with increasing confusion, and a progressive deterioration over a course of weeks before dying. Objectives and Aims Alert to the poor prognosis of excited delirium syndrome. Methods Review of relevant literature after the description of a clinical case. Results Description of a clinical case: A.R. is a man of 69 years, without psychiatric background, under neoadjuvant chemotherapy for metastatic bone disease. He has multiple comorbidity: chronic obstructive pulmonary disease, hypertension, diabetes and stomach cancer treated 15 years ago. Three days before the hospitalization the patient began incoherent speech, and physically he was dehydrated; it was requested observation liaison psychiatry for psychomotor agitation. In the course of the interview, the patient was aggressive, very anxious, with jealousy and paranoid delusions, visual and auditory hallucinations, disoriented and with dispersed attention. Its placed the hypothesis of delirium by multiple etiologies and he was medicated with neuroleptics. It was necessary increased doses and physical restraint to control of agitation, which was not complete and lasted two weeks; meanwhile, he developed a respiratory infection. The patient eventually died of cardiopulmonary arrest. Conclusions Its described a typical case of excited delirium syndrome in a patient with psychomotor agitation that was difficult to control and lasted weeks, which culminated in cardiopulmonary arrest.

P-744 - “Organic” mania in latter life

Introduction Bipolar disorder is commonly associated with early adulthood, although a substantial proportion of patients develops the condition in later life. The results of early investigations suggested that cases of bipolar disorder with onset in later life were more often associated with organic causeś, and could potentially justify the distinction between early and late onset bipolar disorder. Objectives and Aims Alert for organic causes of mania. Methods Review of relevant literature after the description of a clinical case. Results Description of clinical case: J.C. is a man of 80 years without psychiatric history that is admitted in a Oncology Service for dehydration. He has breast cancer since 2005, treated with neoadjuvant-chemotherapy, mastectomy and hormone-therapy with remission. In 2010 there was progression of the disease and he restart chemotherapy. He started odd behaviors and refusal to take medication and it was made the request for observation of liaison psychiatry. In the psychopathological observation is notorious a psychomotor agitation with sexual deshinibition, grandiosity ideas and dysphoric mood. It was placed the diagnostic hypothesis of mood disturbance due to cancer progression with manic characteristics that was supported by evidence in neuroimaging of metastization in frontal-parietal-occipital cranial bones. He started medication with halopheridol with remission of the psychiatric symptoms. Conclusions It is described a case of an old-age patient, without psychiatric background, with progression of his cancer disease, that suddenly starts manic symptoms. The manic states due to organic causes are more rare then other affective disorders and the clinician has to be alert.

P03-441 - Psychiatrist's reactions to patient suicide

Introduction The suicide of a patient in ongoing treatment is surely among the most traumatic events in the professional life of a psychiatrist. Objectives Alert to the psychiatrists reactions to patient suicide. Methods Review of literature relevant in medline database. Results A substantial proportion, estimated to range from 15% to 68%, of psychiatrists has experienced a patient suicide. A significant proportion of psychiatrists show strong negative reactions, affecting professional and personal lives at levels of distress that are frequently comparable with those seen in clinical populations. Psychiatrists develop rather classic symptoms of anxiety, depression, or acute or posttraumatic stress symptoms, and their responses are typical: in the beginning occurs shock, disbelief, denial and depersonalization; and in the second phase takes place: grief, shame and guilt (“did I listen to him?”), anger (toward the patient who did not honor a therapeutic contract), relief (for example, after the suicide of a chronically suicidal patient), and the finding of omens that the psychiatrist considered signs of the coming suicide. But they are predictors of increased distress among psychiatrists who experienced a patient suicide, and the more consistent are age, experience, individual personality and psychiatric history. Recognition of all this combined with an avoidance of isolation is an effective coping mechanism that prevents the structuring of a pathological response to the patients suicide. Conclusions Psychiatrists reactions to patient suicide are specific but not noted; its recognition is important to help them find appropriate coping mechanisms.

P01-197 - Euthymic bipolar disorder: Are there cognitive dysfunctions?

Introduction The presence of cognitive dysfunction in bipolar disorder is well established, but in the euthymic phase appear a few studies that point to the absence of cognitive deficits. Objectives Alert to cases of euthymic bipolar disorder with no cognitive dysfunction. Methods Review of relevant literature and description of a clinical case with psychological tests that assess memory and executive functions. Results Description of a clinical case: FP is a middle age woman, early retired, with a bipolar disorder type 2, which begins at age 30. Her disease has several depressive episodes, and in the last 10 years, she spent most of the days lying in bed and repeatedly resorted to the emergency department for excessive voluntary drug intoxication or simply because she “wanted” to be hospitalized; her husband could not stand this situation. In September of 2009, in addition to the medical and psychological consultations, she starts attending group therapy; over the next 6 months her medication was changed and finally her disease goes into remission. The psychological tests, made at euthymic phase, show’s no significant deficits in verbal memory and executive functions. Conclusions This patient has a disease with prolonged course and multiple hospitalizations and drug treatments, but don’t present relevant cognitive deficits, which may point to the fact that cognitive impairment is determined by biological factors.

P01-447 - Is religion really important?

Introduction Knowing the impact that religious beliefs can have on the etiology, diagnosis and course of psychiatric disorders will help psychiatrists better understand their patients, assessing when the religious or spiritual beliefs are used to cope with mental illness and when they may be exacerbating this disease. Objectives Alert to the importance of religion in clinical practice. Methods Relevant literature review. Results Several studies have demonstrated the influence of spirituality on physical, mental and health. In 1988, the World Health Organization (WHO) has given rise to the interest in further investigations in this area, with the inclusion of a spiritual aspect of the multidimensional concept of health. The spiritual well-being can be considered a protective factor for psychiatric disorders. Although it is not possible to determine with accuracy, the mechanisms of interaction of spirituality on health, especially mental health, several studies suggest that exercise can influence the spiritual activities, psychodynamically, through positive emotions. Furthermore, these emotions may be important for mental health in terms of possible psychophysiological and psychoneuroimmunological mechanisms. Anthropological sources suggest that beliefs in demons, black magic and evil spirits as cause of mental illness and distress are common. They may be less prevalent in western countries but even in Europe its possible to see patients thought that their condition have been caused by evil and occult possession. Conclusions Clinicians should understand the negative and positive roles that religion plays in those with mental disorders and use this in clinical practice.

P01-350 - Mania like symptoms in frontotemporal dementia

Objectives To alert to manic like symptoms in frontotemporal dementia (FTD). Methods Review of literature relevant in medline database. Results Frontotemporal dementia (FTD) is a behavioural syndrome caused by generation of the frontal and anterior temporal lobes. Bipolar disorder in dementia and the temporal relation between the two conditions have rarely been studied. There is a increased probability of developing a manic episode in patients with dementia. Those with temporal FTD have impairments in emotional processing and hypomania like behavior. Moria (childish excitement or tendency to joke) or frivolous excitement are common presenting symptoms, and is difficult to distinguish to features in bipolar disease. The correlation between mania like symptoms and FTD can be make with the help of informations of the family and computed tomography imaging. Those with temporal involvement are particularly at risk of developing deficits in emotional processing secondary to atrophy in the amygdale, anterior temporal cortex, and adjacent orbitofrontal cortex. Conclusions Early temporal involvement in FTD is associated with frivolous behavior and right temporal involvement is associated with emotional disturbances. Moria or frivolous behavior are common presenting symptoms of FTD and the differential diagnosis is made with the help of informants reports and computed tomography imaging.