Borderline personality disorder (BPD) is characterized by impulsivity with emotional and behavioral dysregulation. Inappropriate anger becomes a central problem of these patients who underwent aggressive behavior against themselves or against other. Impulsive aggression has been consistently related with serotonergic dysfunction. Drug therapy with SSRIs has proven effective in treatment of impulsive aggression in varying amounts, but still there have not been described clinical predictors of good response to this treatment. Is known that neuroticism is a stable trait in BPD, also related to serotonergic dysfunction.

To investigate the relationship between neuroticism and clinical response to fluoxetine in impulsive aggression in BPD. We hypothesized that the level of neuroticism at baseline may predict aggression response to pharmacologic treatment.

59 patients were recruited, all meet DSM IV criteria for BPD according to IPDE. They did not fulfill criteria for axis I diagnoses or other personality disorders. Patients were treated with fluoxetine (Prozac®) for 12 weeks, in doses 20 to 60 mg. Aggression was measured with OAS-M.

Temperament was evaluated with NEO-PI-R.

Multiple regression analysis of OAS-M reduction at endpoint as dependent variable, and temperament as independent variables shown a significant predictive model with neuroticism as an inverse predictor factor (ß = −0.36, p = 0.005). We discusses that high levels of neuroticism at baseline can predict lower aggression response to fluoxetine, perhaps due to the relationship of both disorders with serotonergic dysfunction.

We can conclude that neuroticism is a relevant predictor of impulsive aggression response to treatment with SSRIs in BPD.

Suicide prediction is a clinical challenge in psychiatry, especially in borderline personality disorder (BPD) which presents a wide range of self injurious behaviors including consummated suicide. Interviews based on biographical and clinical factors are insufficient in suicide prevention. Treatment with ISSRs is accepted as effective to reduce ideation and suicidal behavior in BPD and other diagnoses.

To evaluate the relation between neuroticism and suicide response to ISSRs in BPD.

59 patients were recruited, all meet DSM IV criteria for BPD according to IPDE. They did not fulfill criteria for axis I diagnoses or other personality disorders at the moment of the evaluation. Patients were treated with fluoxetine (Prozac®) for 12 weeks, in doses 20 to 60 mg. Suicidality was evaluated with OAS-M self aggression score (ideation and conduct measurement). Temperament was evaluated with NEO-PI-R.

Multiple regression analysis of OAS-M self aggression reduction at endpoint as dependent variable, and temperament as independent variables shown a significant predictive model with neuroticism as a direct predictor factor (ß = 0.32, p = 0.044).

ISSRs are a useful treatment for suicidal behavior in BPD. Neuroticism is a good predictor of suicide response to ISSRs treatment in BPD.

1. 1) Depression was associated with self-reports of increased impulsivity and rigidity of behavior.

2. 2) Depressed patients reported significantly lower physical energy, tempo of physical activity and plasticity of behavior. The presence of comorbid anxiety further worsened these effects.

3. 3) The ability to sustain attention on a mental task and to learn new information was lower in depressed patients than in other groups.

comorbid depression and anxiety might be associates, decreasing adaptivity and the self-regulatory balance of behavior, leading to the development of extremes in behavioral reactivity (impulsivity and rigidity).

To conduct a Cost-effectiveness evaluation of agomelatine, in the treatment of major depressive disorder (MDD) in adults in private hospitals setting in Saudi Arabia.

Using an economic model validated by European Health Authorities, data were collected from expert's opinion survey regarding MDD management and patients profile in Saudi Arabia. The perspective used was that of private hospitals. The comparators of agomelatine were venlafaxine, escitalopram, and a hybrid comparator which cost and effectiveness were those of the previous compounds weighted by their market share. The effectiveness data was extracted from published head-to-head clinical trials (e.g., venlafaxine) or derived from a meta-analysis when no publicly available direct comparison (e.g., escitalopram). The effectiveness included remission rates, time to remission and potential adverse events occurrence (sleep disorder and sexual dysfunction). Utilities, for QALY (quality adjusted life years) expression, were collected from international literature. The results are expressed in cost/life year in remission (cost/LYR) and in cost/QALY. Costs (SAR 2010) and effectiveness were discounted at 5%/year.

Agomelatine was dominant (i.e., cost saving with incremental effectiveness) versus venlafaxine, escitalopram and the hybrid comparator venlafaxine/escitalopram (21%/79%). In the sensitivity analysis, agomelatine was cost saving versus all comparators in 75%, 60%, and 61% of the cases respectively.

Agomelatine brings incremental effectiveness in MDD patients and reduces hospital expenditures compared to venlafaxine, escitalopram and the hybrid comparator. The sensitivity analyses confirmed the robustness of those results. Therefore, the choice of agomelatine is relevant for an optimization of resource allocation in private hospitals in Saudi Arabia.

In the U.S., Medicare Part D coverage gap poses concern for antidepressant adherence, but wide availability of generic antidepressants may mitigate the effect.

To assess the effects of coverage gap and generic prescribing on antidepressant adherence among a cohort of Medicare patients experiencing a new episode of depression.

We used 2007 Medicare Part D drug event file to examine antidepressant use over the 6 months following antidepressant initiation. We estimated Cox proportional hazard models to assess the effects of the two factors on the risk of antidepressant treatment disruption. We estimated mixed-effects linear models to assess the effects on monthly days of antidepressant possession. All analyses were stratified by Part D low-income subsidy (LIS) status and Medicare entitlement (aged vs. disabled).

Receiving a generic (vs. brand) antidepressant on the first script was associated with a significantly reduced risk of treatment disruption across all four populations: hazard ratios ranged from 0.66 (p = 0.006) among disabled patients not receiving LIS to 0.88 (p = 0.020) among aged patients receiving LIS. For patients not receiving LIS, experience of coverage gap was associated with increased risk of disruption only among the disabled (hazard ratio = 2.15, p = 0.006). Analysis of monthly antidepressant possession produced consistent results and indicated that the beneficial effect of generic first script was comparable with or outweighed the detrimental effect of coverage gap.

Part D coverage gap adversely affected antidepressant adherence by disabled patients not receiving LIS. Increased generic prescribing may help improve adherence among all patients.

Methadone, a Mu-opioid receptor agonist, is currently used as a maintenance treatment in opioid dependant patients. However, its therapeutic index is narrow, and side effects are life threatening. Non-optimal dosing results in withdrawal symptoms and further heroin craving and use. The optimal dose is defined as the dose necessary to obtain a stable substitution. This optimal maximal dose can then be decreased, the final goal being to stop substitution.

To identify factors to optimize the methadone optimal daily dose.

We aimed to identify genetic variants (SNP) associated with the methadone optimal dose. In a candidate gene approach, we focused on OPRM1, which encodes the opioid receptor Mu, and on DRD2/ANKK1 SNP's, implied in the reward dopaminergic signalling.

Caucasians patients (n = 98) followed for methadone maintenance treatment were included in this prospective study. Candidate SNPs were genotyped (ANKK1: TaqI A; DRD2: c.957C>T; OPRM1: c.A118G). The plasmatic methadone level was determined using mass spectrometry in 59 patients.

Two polymorphisms were significantly associated to the optimal methadone doses: OPRM1 c.A118G (p = 0.03) and DRD2 TaqI A (p = 0.035).

The TaqIA polymorphism is located within ANKK1, which encodes a serine threonine kinase which role remains elusive. Its molecular link to methadone pharmacodynamy remains to be established. None of these polymorphisms was associated neither to the current methadone doses, nor to the methadone plasmatic concentration.

This description is the first step to optimize the prescription of methadone in caucasian populations.

Pharmacokinetically important polymorphisms could guide dosing, ensuring adequate CNS bioavailability in a particular individual during a therapeutic trial. Hepatic enzyme (CYP450) polymorphisms have been extensively studied. Less work has been done on the permeability glycoprotein (P-gp) - the key efflux pump at the blood brain barrier (BBB).

An eight week prospective multi-centre candidate gene association study of 113 patients with psychiatrist diagnosed DSM-IV MDD was conducted. Subjects were treated with escitalopram (ESCIT) or venlafaxine (VEN) in a naturalistic clinical setting. Treatment outcome was assessed with the 17-item HDRS and Clinical Global Impression (CGI) Scales. Side effects were rated with a comprehensive adverse reactions scale (UKU). All response ratings were blinded to genotype. P-gp, CYP2D6, and CYP2C19 polymorphisms were assayed using microarray methodology.

BBB (P-gp) polymorphisms associated with less antidepressant CNS entry were associated with need for higher medication dosage and less overall clinical improvement. Patients with higher BBB block polymorphism need 1.45 (p = 0.018) times the dose of escitalopram than those with lower blood brain barrier block polymorphism. Patients with lower BBB block genotype had a 1.602 time greater reduction in depression compared to subjects with higher block polymorphisms (p = 0.043). Subjects with lower BBB block and poorer metaboliser status at cytochrome P450 2D6 and 2C19 genotype were significantly more likely to respond on the HDRS (RR = 1.60, 95%CI 1.095–2.339, p = 0.015).

This is the first study to demonstrated that P-gp polymorphisms predict antidepressant dose, and that combined P450 and P-gp polymorphisms predict antidepressant response.

The authors intend to analyse through a historical and philosophical perspective, the relationship between nihilistic delusions content and ideas expressed in remarkable literary works addressing the Nihilism theme.

Report of two clinical cases of patients with nihilistic delusions. Review of relevant literature collected from PubMed and other medical internet databases under key-words “nihilistic delusions”, “nihilism”, “Cotard syndrome” and “psychotic depression”. Review of relevant historical and philosophical literature.

First descriptions of nihilistic delusions were made by Jules Cotard, who described a syndrome with his name in middle nineteenth century. First references to the Nihilistic philosophy are contemporary to that, initially by Jacobi and later on by other philosophers, including Nietzsche, who was its main propeller. Some literature propose that Nietzsche suffered from migraine and mental illness, namely bipolar disorder.

Cotard's Syndrome refers to the delusional belief held by patients that they are dead, do not exist, are putrefying or have lost their blood or internal organs. Nihilistic philosophy posed great influence to world's thinking of XIX and XX centuries. Analysis of Nihilistic philosophy works show ideas that resemble the ones reported by patients with nihilistic delusions.

Cardinal ideas expressed by Nietzsche in some of his works, relating to the nihilistic thematic, may have been influenced by an altered mental state, with manifestations compatible with Cotard syndrome which can be associated with bipolar disorder, migraine or organic cerebral pathologies.

The exact spatio-temporal parameters are always included into a pilot's professional activity. Our investigation shows that space and time are the objects of reflection and the means of self-organization in activities of daily living in pilots with good psychological health.

Peculiarities of spatio-temporal relations mastered by the pilot (chronotopes) and the qualities of his psychological health were studied. The first included professional reflection, ability to self-organization in activities of daily living, age-related self-awareness, spatial orientation, mental processing, the second included resistance to stress, communicative abilities, anxiety, self-esteem, riskiness.

The aim of the study was to prove the occurrence of significant correlation between quantitative indicators of chronotopes and quantitative indicators of psychological health in pilots.

The battery of tests including general tests (like test of Leonhard-Schmischek) and special tests (e.g., test “Chronometer”) and also interviews and observations were used in the study.

The participants were 105 pilots of Civil aviation. They displayed a significant correlation (r = 0,73 by Pearson correlation coefficient) between 1) high resistance to stress, high communicative abilities, normal anxiety, adequate self-esteem, moderate riskiness and 2) high professional reflection, high ability to self-organization in activities of daily living, high age-related self-awareness, high spatial orientation, high mental processing.

If the pilot treats space and time as a value (philosophical level) and deliberately guides the chronotopes in his professional and private life (psychological level), he will demonstrate reliable indicators of psychological health which is treated as the most important quality of Human factor in aviation.

The methodological opposition between the categorical approach and the dimensional approach appears as the main issue for the reorganization of current psychiatric knowledge. After a period exclusively marked by the categorical approach, the dimensional method comes back today complementarily with spectral models, anticipating the development of the future DSM V, scheduled for 2013.

In this abstract, we browse the interaction between these two approaches in the construction of our nosographic from Pinel and Kraepelin to nowadays spectral classifications. Both approaches are compared in an epistemological way, with its pros and cons.

Historical perspective shows how psychiatry begins with categorical classification, which is later replace by dimension taxonomy, since second decade of XX century. Most symptoms are dimensional in nature, and can be transformed into a category by setting a cutoff point. Now, after excessive classification and clinical reductionism applied since DSM III, dimensional approach is emerging to propose a more sensible description about mental disorders. Dimensional approach advantages are a certain facility to explore interpersonal differences without artificial cut-offs, and clinical flexibility. A principal disadvantage is the multiplicity of proposed dimensions, without consensus between different theories. In the other hand, categorical method is familiar to us, and is based on solid clinical empirical data. By the way, clinicians say “the more they know their patients, the more they find it difficult to insert them into a category”, the map is not the territory.

Both approaches must coexist, being each one complementary to each order.

Sleep disturbance is a common complaint among patients diagnosed with post-traumatic stres disorder (PTSD). Polysomnography is one of objective methods used to better understand the pathophysiology of PTSD. But consistent results of polysomnography have not been obtained so far.

The aim of this study is to investigate sleep structure and the relationship between sleep variables and clinical symptoms in adult male PTSD patients with combat trauma, with or without comorbid psychiatric disorder and without any medication.

30 PTSD patients and 19 healthy subjects exhibit similar characteristics in terms of age and sex were included in the study. Two consecutive overnight polysomnographic sleep study were performed to investigate sleep patterns.

In this study we found that compared with normal controls, PTSD patients exhibited difficulty in starting sleep, reduced sleep efficiency, decreased total sleep time, prolonged sleep latency, increased Stage-1 sleep, increased REM density and REM sleep, increased phasic EMG activity percentage. Also, comorbid psychiatric disorders accompanying PTSD affected the structure of sleep and there was a significant relationships between symptom severity and sleep variables.

Althouh the relationship between symptom severity and sleep parameters was found significant, there was no relationship between the changes of sleep parameters and shape of the traumatic event, elapsed time after injury and deterioration in the integrity of the body. In the PTSD patients we observed disturbed sleep patterns (Sleep continuity, sleep structure, REM sleep) which support the finding that these patients are in an arousal state even at night.

To verify the association of various risk factors with Post Traumatic Stress Disorder in adults among Internally Displaced Persons of Bajour and Swat.

Case Control studyPlace and Duration of study: Conducted on adult males and females among internally displaced persons, selected from the IDPs Camp in Peshawer and the IDPs visiting Psychiatric setting at Hayatabad Medical Complex, Peshawer from 1st of May to 15th of June, 2009.

Cases selected among the respondents through a screening questionnaire, suffering from PTSD. The controls were those respondents which screened out negative from the questionnaire for PTSD but were from the same camp. A total of 208 cases & equal number of controls were enrolled in the study. The statistical analysis was done in a stepwise manner (Uni-variate analysis, bi variate analysis, Logistic regression) using SPSS version 17.

The results show that the factors significantly associated with PTSD were Exposure to Injury (OR = 19.181, 95% CI = 5.740-22.797, p = 0.000), Witnessing Death (OR = 21.113, 95% CI = 5.550-19.826, P = 0.000), Hopelessness (OR = 26.918, 95% CI = 3.403-13.101, p = 0.000), Torture (OR = 5.008, 95% CI = 1.795-3.962, p = 0.009) and Loss of relative (OR = 3.934, 95% CI = 1.077-4.893, p = 0.008).

The Posttraumatic stress disorder is highly prevalent in the vulnerable populations and various determinants are responsible for the morbidity associated with it. The degree that risk factors function to determine both the development and recovery from trauma, it is plausible that targeting risk factors may help both in the treatment of PTSD and in preventing recurrences of PTSD over time.

PTSD and post-traumatic spectrum symptoms represent the most frequently reported psychiatric sequelae of earthquakes and several studies have investigated the role of risk factors1,2. Aim of the present study was to explore PTSD and post-traumatic spectrum symptoms in L’Aquila (Italy) 2009 earthquake survivors and their correlations with age, gender and degree of exposure.

1488 subjects were investigated by means of the TALS-SR5. The total sample was divided, by random extraction, in 8 homogenous subgroups comparable for gender, age (≤40 vs >40 years) and direct/indirect exposure to the earthquake.

41.3% of exposed subjects presented PTSD vs 16.6% of not exposed. Women reported significantly higher PTSD prevalence rates and post-traumatic spectrum symptoms than men. Exposed subjects reported higher PTSD rates both in the whole sample and in all subgroups, with the only exception of younger men.

Our results confirm different vulnerability to PTSD after earthquake on the basis of gender, age and degree of exposure.