Rosário Curral

A case of choking phobia: towards a conceptual approach

Choking phobia, also known as phagophobia or swallowing phobia is an uncommon clinical entity that has been underappreciated and is included in the new DSM-5 and upcoming ICD-11 diagnostic category of avoidant/restrictive food intake disorder. Phenomenologically distinct from other eating disorders, it is characterized by the phobic stimulus of swallowing that results in the avoidance of food or drinks, and ultimately to low weight, social withdrawal, anxiety and depression states. Its prevalence and long-term course on the general population still needs to be determined, probably reflecting years of indefiniteness regarding its nosology and by the absence of a clear set of diagnostic criteria. We present a clinical case of choking phobia in a 32-year-old male patient after an episode of choke when eating chicken. An early diagnosis and distinction from other eating disorders is important for proper treatment and fundamental for prognosis. We also make a thorough revision on literature in clinical features, differential diagnosis and treatment approaches, suggesting a conceptual approach for choking phobia as a clinical spectrum settled by different degrees of phobic subtypes, which may depend on a varied number of clinical variables.

Stigmatizing attitudes in relatives of people with schizophrenia: a study using the Attribution Questionnaire AQ-27 = Atitudes estigmatizantes em familiares de pessoas com esquizofrenia: um estudo utilizando o Attribution Questionnaire AQ-27

BACKGROUND Family members of people with mental disorders can contribute to stigmatization. Because of the lack of adequate information and resources, and the fatigue resulting from daily care, the family can reinforce social exclusion of the mentally ill and disbelieve recovery. Furthermore, family members may also suffer from self-stigma, experiencing a decrease in their own self-esteem and self-worth. OBJECTIVE To evaluate the presence of stigmatizing attitudes towards patients diagnosed with schizophrenia in a group of relatives of patients with this disorder. METHODS In this exploratory study, we surveyed 40 family members of patients with schizophrenia seen at the Community Psychiatry Unit of the Psychiatry Department at Centro Hospitalar de São João (CHSJ), in Porto, Portugal, using a preliminary version of the Attribution Questionnaire AQ-27 in Portuguese. RESULTS The questionnaire dimensions with the highest mean scores were help, pity, and coercion, followed by segregation, anger, avoidance, dangerousness, responsibility, and fear. These results suggest that relatives do not see people with schizophrenia as responsible for their illness and that they show concern and willingness to help. They avoid but do not fear people with schizophrenia and neither consider them dangerous. CONCLUSION The participants expressed positive, little stigmatizing attitudes towards people with schizophrenia, probably as a result of their familiarity with severe mental disorder, an adequate attribution process, and low levels of perceived dangerousness. However, the high scores of coercion, pity, and segregation may reflect concealed stigmas that may influence the self-determination of the mentally ill, suggesting the need for psychoeducational interventions aimed at family members.

Dementia in multiple sclerosis: Report of a case with cortical gray matter involvement and frontotemporal-like clinical features

Multiple sclerosis (MS) is primarily a white matter disease, but may also involve the gray matter, a feature not often demonstrated in vivo. This report presents the case of a patient with MS and clinical features mimicking frontotemporal dementia due to clear-cut cortical gray matter involvement in the left frontal lobe.

Clozapine-induced palilalia?.

Introduction: Palilalia is an acquired speech disorder characterised by involuntary and spontaneous repetition of words or phrases two or more times in a row. It can occur in a variety of disorders including postencephalic parkinsonism, pseudobulbar palsy, schizophrenia, Gilles de la Tourette syndrome and others. Clinical Case: We describe a case of a 28-year-old man with refractory schizophrenia that developed palilalia with 300 mg of clozapine. In the patient evaluation we found unspecific alterations in the electroencephalogram, with normal blood tests and cerebral magnetic resonance imaging. Palilalia disappeared with lowering doses of clozapine. Discussion: The appearance of palilalia induced by clozapine is a rare pharmacologic side-effect which physicians should be familiarised with when evaluating this symptom presentation.

Organic psychosis due to hypoparathyroidism in an older adult: a case report

with attention-deficit/hyperactivity disorder: meta-analysis of subjective and objective studies. J Am Acad Child Adolesc Psychiatry. 2009;48: 894-908. 3 Brasil HHA. Desenvolvimento da versäo brasileira da K-SADS-PL (Schedule for Affective Disorders and Schizophrenia for Scholl Aged Children Present and Lifetime Version) e estudo de suas propriedades psicométricas [thesis]. São Paulo: Universidade Federal de São Paulo; 2003. 4 Cortese S, Brown TE, Corkum P, Gruber R, O’Brien LM, Stein M, et al. Assessment and management of sleep problems in youths with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2013;52:784-96. 5 Lauderdale DS, Knutson KL, Yan LL, Liu K, Rathouz PJ. Sleep duration: how well do self-reports reflect objective measures? The CARDIA Sleep Study. Epidemiology. 2008;19:838-45. 6 Hiscock H, Sciberras E, Mensah F, Gerner B, Efron D, Khano S, et al. Impact of a behavioural sleep intervention on symptoms and sleep in children with attention deficit hyperactivity disorder, and parental mental health: randomised controlled trial. BMJ. 2015; 350:h68.

Forty years of a psychiatric day hospital

INTRODUCTION Day hospitals in psychiatry are a major alternative to inpatient care today, acting as key components of community and social psychiatry. OBJECTIVE To study trends in the use of psychiatric day hospitals over the last decades of the 20th century and the first decade of the 21st century, focusing on patient age, sex, and diagnostic group, using data from Centro Hospitalar São João, Porto, Portugal. METHODS Data corresponding to years 1970 to 2009 were collected from patient files. Patients were classified into seven diagnostic groups considering their primary diagnoses only. RESULTS Mean age upon admission rose from 32.7±12.1 years in the second half of the 1970s to 43.5±12.2 years in 2005-2009 (p for trend < 0.001). Most patients were female (63.2%), however their proportion decreased from nearly 70% in the 1970s to 60% in the first decade of the 21st century. In males, until the late 1980s, neurotic disorders (E) were the most common diagnosis, accounting for more than one third of admissions. In the subsequent years, this proportion decreased, and the number of admissions for schizophrenia (C) exceeded 50% in 2004- 2009. In females, until the late 1980s, affective disorders (D) and neurotic disorders (E), similarly distributed, accounted for most admissions. From the 1990s on, the proportion of neurotic disorders (E) substantially decreased, and affective disorders (D) came to represent more than 50% of all admissions. CONCLUSIONS Mean age upon admission rose with time, as did the percentage of female admissions, even though the latter tendency weakened in the last 10 years assessed. There was also an increase in the proportion of patients with schizophrenia.

The utility of intravenous clomipramine in a case of Cotard's syndrome

Dear Editor, Cotard’s syndrome is a rare clinical event, characterized by negation delusion (individuals feel major changes in their bodies and deny the existence of one or several parts of their organs or bodies) and nihilistic delusion (individuals believe that they or all people are dead). First described in 1880 by Jules Cotard as negation delirium, the term Cotard’s syndrome was proposed in 1893 by Emil Regis. We describe the case of a patient admitted to the psychiatric ward of Hospital Ulysses Pernambucano, in Recife, northeastern Brazil and diagnosed with Cotard’s syndrome. M., 59 years old, male, was brought to the psychiatric emergency service of the hospital with complaints of insomnia, soliloquy, attempts to escape from home, suicide attempts by throwing himself in front of moving cars, and nonsense talk. He had dropped out of drug treatment two months earlier. The patient reported hearing voices making comments about him and giving him commands, as well as the existence of animals eating his body. He informed that he no longer had a body, but rather only a spirit, as he was already dead. He did not fear anything, as no one could kill him again (sic). Upon clinical examination, he was barefoot, wearing only shorts (no shirt), showed an unkempt beard and poor hygiene. He also showed alert consciousness, partial disorientation to time, a suspicious attitude, worn-out appearance, personal self-reference, deeply depressed mood, psychomotor retardation, insisting that he was not worth anything, that nobody wanted him there for 60 days already, and that he was paying for what he had done wrong. He also reported not having blood pressure, or blood, and that his body was broken, and that something very bad was about to happen. The patient was diagnosed with Cotard’s syndrome secondary to major depression with psychotic symptoms. He was treated with imipramine 150 mg/day and risperidone 4 mg/day for 60 days, and was discharged asymptomatic afterwards. Even though this disorder was first described by Cotard as a new type of depression, Regis later proposed that this syndrome could be associated with several medical conditions, e.g., psychotic depression, schizophrenia, neurosyphilis, and multiple sclerosis. Comorbidity between Cotard’s syndrome and Capgrass syndrome (individuals believe that family members have been replaced with doubles) is also common. Currently, Cotard’s syndrome is no longer classified as an independent disorder in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR) or in the International Classification of Diseases, Tenth Revision (ICD-10). Rather, in the DSM-IV-TR, nihilistic delusion is classified as a mood-congruent delusion within a depressive episode with psychotic features. It is important to emphasize that our case was absolutely compatible with the different descriptions available in the literature for Cotard’s syndrome, with features such as a depressed mood, nihilistic delusion, and delusions of guilt and immortality. Treatment of Cotard’s syndrome should focus on the underlying condition. Even though electroconvulsive therapy has been the treatment most frequently indicated in the literature, some reports of the combined use of psychotic and antidepressant drugs can also be found when psychotic depression is the underlying illness. Despite the absence of reports describing the combined use of imipramine and risperidone, the therapy was effective in remitting psychotic depression symptoms in our patient.

With regard to a case of unipolar mania

MFS, mulher de 52 anos, professora primaria, recorreu a urgencia por causa de insonia total, excesso de autoconfianca e envolvimento em multiplas atividades com duracao de uma semana. Apresentava-se com irritabilidade, agitacao, elacao do humor, verborreia, desinibicao sexual, atividade delirante persecutoria, ausencia de . Tinha

P03-27 - Multiple sclerosis: psychological and psychopathological study

Multiple Sclerosis (MS) is the most common demyelinating disease of the central nervous system and one that presents more neuropsychiatric manifestations. The authors of this paper proposes to characterize psychological and psychopathologically a group of patients sent from Neurology to Psychiatry at St. Joao Hospital - Porto. The initial group consisted of 48 patients (35 women and 13 men). Data collection was done through a semi-formant interview to obtain socio-demographic and clinical data. The psychological and psychopathological evaluation was made with the following tools: MMSE (Mini Mental State Examination), Raven, MOS SF-36 (Medical Outcomes Study 36-Item Short Form Health Survey), SCL-90 (Hopkins Symptoms Distress Checklist 90), HADS (Hospital Anxiety and Depression Scale), scale and EDSS (Expanded Disability Status Scale). On this sample the median duration of disease was 11 years and the value of EDSS has an average of 2.49. The sample does not show significant levels of psychopathology. However the results suggest that the worse is the overall severity of MS (EDSS) and the greater the duration of illness, the worst seems to be general physical and emotional functioning. In this study, no associations were found between variables of MS and psychopathological findings. However cognitive dysfunction appears to worsen with the greatest severity of MS, as in other works.

P01-481 - Dementia in multiple sclerosis: report of a case with cortical grey matter involvement and frontal-type-like clinical features

Background/introduction Although multiple sclerosis (MS), a demyelinating disease of unknown aetiology, is primarily a white matter disease, it may also involve the grey matter, a feature not often demonstrated in vivo by means of magnetic resonance imaging (MRI). The involvement of cortical grey matter in MS may account for cognitive dysfunction and behavioural abnormalities. Objective The purpose of this report is to present the case of a patient with MS and clinical features mimicking dementia of the frontal type due to clear-cut cortical grey matter involvement in the left frontal lobe. Case report A 55-year-old woman with relapsing remitting MS developed a clinical picture characterized by frontal deficits (e.g. attention, verbal fluency, and speed processing), disinhibition, loss of insight, perseveration, abnormal eating behaviour, agitation, insomnia, and depersonalization phenomena. Neuropsychological evaluation also revealed abnormal performance on the Trail Making and the Stroop tests. Besides typical demyelinating lesions and “black holes”, MRI showed a striking pattern of left frontal opercular involvement including cortical thinning, focal knife-edge appearance of the gyri, and marked gliosis in the adjacent white matter. Discussion Cognitive deficits in MS are typically subcortical, due to the expected predominance of white matter lesions. Nonetheless, the involvement of grey matter structures may contribute to a different pattern of cognitive dysfunction. For example, hippocampal involvement has been linked to memory impairment. This particular case report additionally illustrates how cortical grey matter involvement in the frontal lobe may lead (not unexpectedly) to a clinical condition mostly characterised by frontal deficits and psychiatric symptoms.