Ironically, the correlation between systemic pathologies and caries/ periodontal diseases is commonly accepted by the scientific and medical community, but the fact that severe mental illnesses may affect one’s physical health, and thus lead to poor oral health is less well-known.

This clinical case report’s aim is to raise awareness among medical staff about the relevance of appropriate management of patients with severe mental illnesses in terms of dental care.

Illustration of integrative management through the description of the oral rehabilitation of a 63-year-old female whose bipolar disorder had been diagnosed 20 years ago. This patient came in May 2020 to the Cliniques Universitaires Saint-Luc (Brussels, Belgium) for painless mobility of the lower central incisors. Her diagnosis later revealed more than 20 advanced carious lesions as well as chronic severe periodontitis. Since then, despite numerous dental treatments and regular follow-up appointments, an important degradation of her oral health could be noted over time, characterized by a recurrent carious phenomenon (called “rampant” caries) and a failure in the stabilization of her periodontitis.

The literature review revealed that bipolarity was a major risk factor leading to tooth decay and aggravation of periodontal disease; when bipolar disorders’ inherent symptoms are coupled with medication’s side effects, they work in synergy towards a deterioration of oral health. Following the results obtained after this etiological research, the management of this patient was pursued in accordance with specific recommendations proposed in the literature. A stabilization of her oral condition was then observed at the 3-6-9-12 month check-ups, without the appearance of any new lesion.

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The positive effect obtained on this patient’s oral health following the implementation of bipolar disorders specific measures opens the discussion on the relevance of integrating individual strategies within the therapeutic management of patients with severe mental illnesses.

None Declared

Bipolar disorder (BD) and borderline personality disorder (BPD) appear as prevalent psychiatric conditions, with both being associated with increased morbidity and elevated suicide rates.

Borderline personality disorder is characterized by emotional instability and impulsivity, and patients are susceptible to dangerous behaviors such as unsafe sexual behavior, eating disorders and substance abuse. On the other hand, mania in BD patients contributes to impulsivity, hypersexuality and poor judgment, as well as a lack of inhibition. In both cases, individuals are at a higher risk of committing suicide due to emotional dysregulation and impulsive behaviours.

The symptomatic overlap in BPD and BD is prone to discussion and may lead to misdiagnosis. Some studies suggest that BPD and BD may lie on a spectrum, while others advocate them as separate entities that may coexist.

To explore the clinical challenges associated with both the differential diagnosis and the comorbidity of BD and BPD.

We performed a non-systematic review of the literature using the database PubMed and the following keywords: bipolar disorder borderline personality disorder comorbidity

Patients with borderline personality disorder seem to have significantly greater odds of a previous bipolar misdiagnosis, but no specific borderline criterion was shown unique in predicting this outcome.

Nonetheless, research studies have reported that approximately 20% of BPD were also diagnosed with BD and, similarly, 10% of people with BD I and 20% with BD II were diagnosed with BPD.

Comorbid BPD and BD are associated with marked psychosocial disability, with patients being more impulsive and aggressive than those with BPD and BD alone. They are also highly susceptible to anxiety disorders like obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and somatoform disorders. Studies have shown that comorbid BPD has a negative impact on the clinical course of Bipolar Disorder, as the patients have an unfavorable illness trajectory, with earlier onset of mood symptoms,higher likelihood of hospitalization, longer treatment duration and worse response to treatment. They are also at higher risk for depression and persistent unemployment, increased risk drug abuse, higher suicide risk, and greater utilization of ECT, compared to patients with BPD or BD alone.

A careful review of the patient’s history must be done to properly distinguish between BPD and BD and to make the right diagnosis. Further studies are needed to clarify the risk factors associated with the comorbidity between these two disorders, in order to develop effective clinical strategies for optimal outcomes for patients with both disorders, improve their clinical course and prevent the increased risk of suicidality.

None Declared

Bipolar disorder is one of the top 10 medical causes of disability according to the WHO and despite this, its diagnosis can be delayed up to 10 years after the appearance of the first symptoms of the disease. A major reason for the difficult diagnosis is the challenge of differentiating bipolar disorder type II from unipolar depression and borderline personality disorder, especially in those patients with no clear history of hypomania.

To present a case report of a bipolar disorder undiagnosed for years to remark the importance of recognizing premorbid symptoms of the disease in order to implement an early intervention that potentially improves the prognosis of patients.

We compiled the patient’s complete medical history and we carried out a non-systematic review of literature containing the key-words “bipolar disorder type II” and “diagnosis”.

We present the case of a 48-year-old woman going through a depressive episode, multiple suicide attempts and more than 10 admissions in the Acute Inpatient Psychiatric Unit. For 3 years, the evolution was torpid with a significant multidomain cognitive impairment in a previously functional patient. Different antidepressant treatments were tested, however they were not tolerated due to adverse effects such as anxiety, insomnia and nervousness. After considering multiple differential diagnoses, bipolar disorder type II was finally diagnosed. A hypomanic episode that took place after 3 sessions of electroconvulsive therapy during an admission for depression, allowed to guide the diagnosis and after the introduction of Lithium and Quetiapine as treatment, the patient experienced a complete remission of the symptoms.

1. 1. It is important to consider the differential diagnosis of bipolar disorder type II due to its impact on the patient´s life.

2. 2. An early diagnosis improves the course and prognosis of the disease.

3. 3. Patients resistant or intolerant to antidepressant treatment could have undiagnosed bipolar disorder.

None Declared

Lithium is one of the main drugs used in Bipolar Affective Disorder. However, it has a narrow therapeutic window, which requires close monitoring and progressive dose adjustment, according to serum levels, clinical response and the appearance of side effects. The term ‘SILENT’ explains descriptively persistent neurological sequelae related to lithium salt intoxication when symptoms persist for more than 2 months after stopping treatment.

SILENT Syndrome is more common in females, at ages ranging from 21 to 77 years and is characterized mainly by avermian-type cerebellar disorder, persistent extrapyramidal syndrome, brainstem dysfunction and dementia of varying severity. It can also result in apraxia of the body, changes in the coordination and balance, dysarthria, as well as intentional and kinetic cerebellar tremor, involuntary movements of orofacial dyskinesias or resting tremor.

The authors intend to review the relevant and current literature in order to extend the knowledge about this condition and find the best conducts for clinical practice.

Non-systematic literature review.

Complications from the use of lithium known in the medical literature include mainly nephrotoxicity, endocrine alterations and neurotoxicity.

The neurotoxic effects of lithium usually occur at high serum concentrations. However, they can also occur with lithium in the therapeutic range, and memory, attention and ataxia impairment may be some of the permanent sequelae.

The etiopathogenesis is unclear, but demyelination has been detected in multiple brain regions, mainly in the cerebellum. The mechanism of lithium-induced cerebellar injury is believed to be mediated by the entry of calcium into the cells of this organ.

The main factors that predispose to greater side effects and risk of toxicity are patients with decreased renal function, advanced age, use of diuretics, dementia, pregnancy, low sodium intake and physical illness with vomiting and/or diarrhea.

Lithium is a drug used mostly in affective disorders and given the narrow therapeutic window, it requires close monitoring in order to avoid side effects that can be permanent. In this way, it is important to review the factors that increase the lithium toxicity and make recommendations about it.

None Declared

Bipolar Disorder (BD) is considered a serious mental disorder characterized by a changing mood that fluctuates between two completely opposite poles. It causes pathological and recurrent mood swings, alternating periods of exaltation and grandiosity with periods of depression. We talk about rapid cyclers when four or more manic, hypomanic or depressive episodes have occurred within a twelve-month period. Mood swings can appear rapidly. Approximately half of the people with bipolar disorder may develop rapid cycling at some point.

Presentation of a clinical case about a patient with Bipolar Disorder with rapid cycling and poor response to treatment.

Review of the scientific literature based on a clinical case.

33-year-old male, single, living with his mother, under follow-up by mental health team since 2012. First debut of manic episode in 2010. The patient has filed multiple decompensations related to consumption of toxics (alcohol and cannabis). Currently unemployed. He attended to the emergency service in June 2022 accompanied by his mother, who reported that he was restless. The patient refers that he has interrupted the treatment during the vacations, having sleep rhythm disorder with abuse of caffeine drinks. Currently the patient does not recognize any consumption.The patient reports that during the village festivals he felt very energetic, occasionally consuming drinks rich in taurine and sugars, even having conflicts with people of the village. Finally, the patient was stabilized with Lithium 400 mg and Olanzapine. In September, the patient returned to the emergency service on the recommendation of his referral psychiatrist due to therapeutic failure. The only relevant finding we observed in the analytical determinations were low lithium levels (0.4 mEq/L). The transgression of sleep rhythms and the abuse of psychoactive substances required the admission of the patient to optimize the treatment (Clozapine, Lithium, Valproic Acid). At discharge, he is euthymic, has not presented behavioral alterations and is resting well. Finally, it was decided that the patient should go to the Convalescent Center to continue treatment and achieve psychopathological stability.

Bipolar disorder is an important mental illness, having an incidence of 1.2%, being responsible for 20% of all mood disorders. Therefore, it is important to perform an adequate and individualized follow-up of each patient. Treatment with mood stabilizers tries to improve and prevent manic and depressive episodes, improving chronicity and trying to make the long-term evolution as good as possible, being important psychoeducation and psychotherapy.

None Declared

We present the case of a 49-year-old woman who was diagnosed with multiple sclerosis at the age of 19 and suffers from an affective disorder that has been evolving for years. This condition, for which she has been followed by psychiatry and psychology for more than ten years, consists of alternating periods of hypomania lasting weeks and phases in which frank depressive symptomatology predominates, with no phases of euthymia in between and with a predominance of severe deterioration of her functionality at both poles.

(1) We will review the term cyclothymia and explore the concept of “cyclothymic temperament” advocated by some authors, in order to be able to understand the dimension of the present case and reformulate its approach.

(2) The relationship between multiple sclerosis and bipolar spectrum disorders will be covered, reviewing the current knowledge in this regard and relating it to the patient’s symptomatology.

A review of the patient’s clinical history will be carried out, taking into account her life history, the complementary tests performed as well as the multiple therapeutic approaches tried over the last few years.

Likewise, a bibliographic review of the available scientific literature will be carried out in relation to the diagnosis of cyclothymia or bipolar disorder type II, the controversial term “cyclothymic temperament”, and the relationship that these diagnoses have with the diagnosis of Multiple Sclerosis.

(1) Our patient could fit into what many authors define as a cyclothymic temperament, fulfilling, in certain episodes, the criteria that the manuals propose for bipolar disorder type II.

(2) 2.1 The prevalence of bipolar affective disorder in MS is approximately twice as high as in the general population (rates of 0.3-2.4%). 2.2 Patients with MS have higher scores in cyclothymic and hyperthymic temperament than the control group. 2.3 Certain drugs generally used in BD also seem to have a beneficial effect on MS.

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The reformulation of the concept of cyclothymia would allow us to recognize in our patient a basic temperament of long evolution that would be the substrate on which different factors have subsequently influenced, such as antidepressant drugs or multiple sclerosis. In addition, it is necessary to know the association between BD and MS, in order to be able to offer an adequate treatment, contemplating some pharmacological options such as Lithium or some Atypical Antipsychotics, given the beneficial effect both for the affective disorder and for the neurological process.

None Declared

Bipolar disorder comorbidity rates are the highest among the major mental disorders. In addition to other intoxicants, alcohol is the most abused substance because it is socially accepted and can be legally bought and consumed. Estimates are between 40-70% with male predominance, which further influences the severity with a more complicated course of both disorders.

The objective of this article is to highlight the impact of substance use on the course and prognosis of bipolar disorder, as well as to make a differential diagnosis of a manic episode in this context.

Bibliographic review of scientific literature based on a relevant clinical case.

We present the case of a 45-year-old male patient. Single with no children. Unemployed. History of drug use since he was young: alcohol, cannabis and amphetamines. Diagnosed with bipolar disorder in 2012 after a manic episode that required hospital admission. During his evolution he presented two depressive episodes that required psychopharmacological treatment and follow-up by his psychiatrist of reference. Since then, he has been consuming alcohol and amphetamines occasionally, with a gradual increase until it became daily in the last month. He went to the emergency department for psychomotor agitation after being found in the street. He reported feeling threatened by a racial group presenting accelerated speech, insomnia and increased activity.

The presence of substance abuse complicates the clinical presentation, treatment and development of bipolar disorder. It is associated with a worse prognosis with multiple negative consequences including worsening symptom severity, increased risk of suicide and hospitalization, increased medical morbidity and complication of social problems. In addition, this comorbidity delays both the diagnosis and treatment, by masking the symptoms, and making more difficult an adequate differential diagnosis.

None Declared

Numerous guidelines are bending the rule of monotherapy as initial treatment of acute manic episodes and suggest the importance of polytherapy in maximising the treatment efficacy.

To assess the polytherapy used in the management of acute manic episodes and the degree of conformity of our prescriptions with international guidelines.

A retrospective study was carried out for descriptive purposes, targeting the drugs prescribed among patients admitted for the first time for a manic episode within the psychiatry « C » department of Sfax, Tunisia between 2019 and 2022. Patients who received ambulatory care prior to the current episode were excluded.

Our study included 50 male inpatients, with a median age of 31.8 years (min=18, max=62) at the moment of their hospitalisation. Nearly two thirds were single, 82% didn’t get postsecondary education and 65.3% had a profession. The majority (73.5%) belonged to upper-middle class and 67.3% had social security. A quarter of the patients suffered from substance abuse and 14% had a criminal record. Around 89.8% individuals presented a manic episode with psychotic features. The symptoms included mainly heteroaggressiveness in three quarters of cases, agitation in 77.1% and insomnia 76.1%. Insight was good in 79.6% of cases. Polytherapy was preferred to monotherapy in 86% of cases. Bitherapy was used in 74% of cases and tritherapy in only 12%. The most frequent combination was a mood stabilizer plus a second-generation antipsychotic (46%), risperidone plus sodium valproate being used in 34% of cases.

Overall, our prescriptions were in line with the international guidelines and the choice of polytherapy was well argued. Combination therapy is the suggested way to increase treatment efficacy, however, vigilance is required because of the increased risk of side effects.

None Declared

Mania is a serious psychiatric condition, characterized by high rates of relapse and significant dysfunction. An early understanding of the factors involved with the manifestations of this disease is critical as to help estimate impact and plan appropriate treatment modalities.

To assess demographic and clinical characteristics in a first bipolar mania and describe the associations between these factors.

A retrospective study was carried out for descriptive and analytical purposes targeting the demographic and clinical characteristics of patients admitted for the first time for a mania within the psychiatry « C » department of Sfax, Tunisia between 2019 and 2022.

Our study included 50 male inpatients, with a median age of 31.8 years (min=18, max=62) at the moment of their hospitalisation. One third of the patients was married. Only 18% got postsecondary education and 65.3% had a profession. A total of 26.5% had a low socioeconomic status. Twenty-four percent suffered from substance abuse and 14% had a criminal record. Personal psychiatric history was noted in 32% of cases and a personal medical history in 16% of cases. Psychotic features were found in 89.8% of patients. Heteroaggressiveness was present in three quarters of cases, whereas an expansive mood was found in half the population. Twenty percent of patients had a poor insight. A statistically significant association was found between being employed and the absence of personal psychiatric history (p=0.017), whereas personal medical history was associated with a poor insight (p=0.049). Substance abuse was correlated with having a criminal record (p=0.006) and heteroagressiveness (p=0.012). The presence of psychotic features was positively associated with expansive mood (p=0.022).

This study confirms that some epidemiological factors are strongly associated with clinical characteristics of the bipolar mania. Early interventions over these factors may contribute to a potential reduction in morbidity and mortality of this disease.

None Declared

Bipolar disorder (BD) is a common psychiatric condition. However, it is underdiagnosed. Electroencephalography (EEG) has been proposed as a neurophysiological biomarker to delineate psychotic disorders.

To compare the EEG tracings of patients with BD with those of normal subjects to aid in diagnosis.

This was a cross-sectional, descriptive, and analytical case-control study conducted with patients followed for BD in the psychiatry "C" department at the Hedi Chaker hospital in Sfax. Patients were assessed by the Young Mania Scale (YMRS), the Hamilton HDRS-17 Scale, and the Medication Adherence Report Scale (MARS). Healthy controls were included. All participants benefited from an EEG. It was undertaken in resting eyes closed testing conditions at the service of the functional exploration at the Habib Bourguiba hospital in Sfax. The powers of each band were measured using the power spectral density method called absolute power (AP). Statistical analyses were carried out.

Fifteen bipolar patients and 15 healthy controls, all male, were included. The average age of bipolar was 36.07 ± 10.50 years. The one of health control was 47.93 ± 15.61 years. There were no significant differences in age between bipolar patients and healthy controls. The mean scores on the HDRS-17 and YMRS and MARS scales were 2.73±2.08, 1.67±3.53 and 5.8±2.83 respectively.

At the quantitative EEG, differences appeared to be insignificant. There was an overall decrease in AP for alpha band particularly in the parietal and occipital lobes in bipolar patients (158,84 ± 447,71 μV2 and 188,21 ± 415,55 μV2 respectively) compared to controls (335,15 ± 994,73 μV2 and 400,24 ± 1109,95 μV2 respectively). An overall increase in AP for delta and beta was found for bipolar patients compared to controls.

Our main finding was a higher delta and beta frequency activity, and lower alpha frequency activity in bipolar patients compared to controls, which may aid in the diagnosis of this disorder.

None Declared

Despite the potential for EEG abnormalities to provide insight into the neurophysiology of disease processes, studies that measure EEG power and coherence in bipolar disorder (BD) are rare.

We investigated whether the resting electroencephalogram (EEG) in patients with BD showed altered synchronization

This was a cross-sectional, descriptive, and analytical case-control study, conducted with patients followed for BD in the psychiatry department "C" at the Hedi Chaker hospital in Sfax compared to healthy controls. Patients were assessed by the Hamilton Depression Scale (HDRS-17), and the Young Mania Scale (YMRS). EEG was also recorded at the service of the functional exploration at the Habib Bourguiba hospital in Sfax. Functional connectivity between pairs of EEG channels was measured for 4 frequency bands delta [0.5 – 3.5 Hz], theta [4 – 7.5 Hz], alpha [8 – 12.5 Hz], and beta [13 – 30 Hz]. Statistical analyses were carried out.

Thirty subjects including 15 patients with BD and 15 age- and sex-matched controls were included. The mean age of bipolar and control was 36.07 ± 10.50 and 47.93 ± 15.61 years, respectively. The mean scores on the HDRS-17 and YMRS were 2.73±2.08, and 1.67±3.53 respectively.

Bipolar patients showed a decrease of connectivity in the delta band, and the decreases were greatest between the left frontal lobe and the right frontal, parietal and temporal lobes on the one hand and between the left temporal and right parietal lobes on the other hand. For the theta band, there was poor connectivity between the left frontal lobe and the right frontal and temporal lobes on the one hand and between the right central area and the left parietal, temporal and occipital lobes.

Bipolar patients had poorer intra and interhemispheric connectivity, which may be a key feature of BD.

None Declared

Psychotherapy is a treatment of proven efficacy in bipolar disorder (BD), but little is known about the molecular and cellular mechanisms that it produces in the brain. Brain-derived neurotrophic factor (BDNF) is thought to be important in neuroplasticity and could be increased by psychopharmaceuticals and psychotherapy in BD patients, but evidence in the literature is limited.

To analyze the scientific studies that relate psychotherapies with the increase in BNDF levels in patients with BD.

Systematic review with PRISMA recommendations in PUBMED and Web of Science in July 2022. The search was performed using the combination of keywords “bipolar disorder” AND (“BDNF” OR “Brain Derived Neurotrophic Factor”) AND “psychotherapy”.

With the initial search, 839 studies were obtained, finally 8 articles were analyzed. The available literature supports the role of psychotherapy in increasing BNDF in patients with BD.

BDNF could be a biomarker of therapeutic efficacy in BD. Psychotherapy increases BDNF levels. No differences were found between the different types of psychotherapies. More studies are needed to determine the mechanisms by which psychotherapies produce molecular changes in the brain.

None Declared

The clinical presentation and the course and outcome in Early-Onset Bipolar Disorder (EOBD) patients are found to be atypical compared to adult bipolar patients. Lithium and valproate are among the first-line maintenance treatments for bipolar disorder. Because of atypical features, in many patients, valproate is preferred over lithium. However, recent studies have shown that valproate results in more neurocognitive deficits than lithium. There have been very few Indian studies that assessed the prophylactic response to mood stabilizers in patients with early-onset bipolar disorder. BDNF has an important role in neurodevelopment, and it is shown that peripheral levels of BDNF are reduced in early-onset bipolar disorder.

To compare the effectiveness of lithium and valproate in attenuating manic, depressive, and mixed episodes in early-onset bipolar disorder.

This study was an observational (cross-sectional analytical) study conducted in the Affective Disorder clinic of a tertiary care hospital. We have recruited a total of 50 adult patients with a history of early-onset, i.e., onset at <18 years of age and in remission. Patients were divided into two groups based on the mood stabilizer drug they were receiving. There were 25 patients each in the lithium and valproate group. Montreal Cognitive Assessment (MoCA) scale was applied to assess cognitive functions.

The overall functioning was found to be significantly better in the patients receiving lithium than valproate, which was found by higher scores on the Global Assessment of Functioning (GAF) scale.We have found a statistically significant negative correlation between the number of episodes before starting a mood stabilizer and the time to recurrence after starting a mood stabilizer. However, the former cannot predict the latter. The age, educational status of the patient, total duration of illness and number of episodes before starting mood stabilizer correlated significantly with the MoCA score. Of all, the educational status could also predict the patient’s performance on the MoCA scale.

There were no significant differences between lithium and valproate in attenuating further episodes, the frequency of neurocognitive deficits and other adverse effects. Both drugs were equally effective and tolerable. The severity of illness was more in valproate-treated patients, and overall functioning was better in lithium-treated patients. BDNF levels did not correlate with neurocognitive deficits significantly. Future studies comprehensively assessing neurocognitive measures with a larger sample size in the early-onset bipolar disorder population would shed more light on the role of biomarkers in cognition in subjects with early-onset bipolar disorder.

None Declared

Although mania is commonly associated with bipolar disorder, it can have many etiologies. Thus, “primary mania” results from bipolar disorder, whereas “secondary mania” results from pharmacological, metabolic, or neurologic causes. Older adults are at risk for secondary mania because of increased medical comorbidities and neurological changes. In one retrospective study of 50 patients with mania who were older than 65 years, it was the first manic episode for 28% of the patients and 71% had a comorbid neurological disorder.

The etiology of mania is important because although acute symptomatic treatment of both primary and secondary mania may be similar, appropriate treatment of secondary mania includes addressing the cause. We present here two case histories of secondary mania in older adults, discuss their presentations and differential diagnosis in turn, and discuss treatment.

We will present a clinical case of a patient. Ms. A, a 63-year-old divorced woman with no prior medical or psychiatric history, was seen for an acute manic episode with mixed features. She was in her usual state of health until 2 weeks before admission, when she presented with a status epilepticus requiring a one-week hospitalization in the neurology département and treated by Carbamazepine. She then developed an abnormally excited and labile mood, motor excitability accompanied by rapid thoughts, with a total loss of desire and pleasure and thoughts of death.

In our study, the patient presented a manic episode with mixed characteristics secondary to a status epilepticus.

The patient was treated both somatically and psychologically, and the evolution was positive. The patient was stabilised after being put on an antiepileptic drug associated with an antipsychotic drug.

In our study, the patient presented with a manic attack with mixed characteristics secondary to a status epilepticus.The patient was treated both somatically and psychologically, and the evolution was favourable. The patient was stabilised after being put on an antiepileptic drug associated with an antipsychotic drug.

Late onset psychiatric disorders often represent a challenge for the psychiatrists as far as the diagnosis and management issues are concerned. The elderly patients have generally been reported to have associated medical, especially neurological illnesses and are also prone to side effects of various psychotropic medications.

None Declared

Both organic and psychiatric comorbidities are frequently detected in bipolar disorders (BD) and this phenomenon has a significant impact on case management in these patients. The most reported general medical conditions in patients with BD are migraine, thyroid illness, obesity, diabetes mellitus, and cardiovascular disease. The screening for comorbidities detection in BD patients is important from multiple perspectives, including the need to construct an adequate therapeutic plan, the need to increase treatment adherence, and to improve these patients’ quality of life.

To assess the prevalence of comorbid organic diseases in a clinical sample of BD patients.

A chart- and register-based analysis of BD patients (i.e., type I and II BD) evaluated in our department during a period of three years (January 2019- January 2022) was conducted in order to detect the prevalence rate of organic diseases. All patients aged over 65 years were evaluated either for acute mood episodes or presented to their treating psychiatrists for follow-up visits.

A number of 87 patients were included in this analysis, 45 male and 42 female, with a mean age of 70.5 years. The most frequently detected organic comorbidities were metabolic disorders (obesity, dyslipidemia, diabetes mellitus- 36.8%), cardiovascular (arterial hypertension, arrhythmias, myocardial ischemia, deep/superficial venous thrombosis- 26.4%), digestive system-related (hepatic, gastric, intestinal diseases- 21.8%), neurologic (i.e., stroke, migraine, Parkinson’s disease) (18.3%), endocrine (mainly thyroid diseases) (17.2%), and other (19.5%). A relatively high rate of organic diseases (38%) were newly diagnosed (in the last 3 months), suggesting there is a certain need to screen for organic pathology in this population, but most of the BD patients presented a long history of investigated and treated comorbid conditions.

Organic diseases are very common in elderly BD patients. Even where no history of somatic conditions exists, comprehensive investigations are granted in order to detect such health problems with important prognostic impact.

None Declared

Bipolar disorders (BD) associate impairments in cognitive functioning not restricted to acute mood episodes. The functional impact of these cognitive dysfunctions is significant in many cases, therefore, an extensive evaluation is granted for BD patients from this perspective. Executive dysfunction in BD has been reported, especially during mania and was associated with formal thought disorder, but multiple cognitive deficits may reflect an underlying pathologic process related to the mood disorder itself.

To assess the level of executive dysfunction in a sample of patients with type I BD (BDI) using structured measurement methods.

Five patients diagnosed with BDI (two patients during manic episodes, one during the euthymic phase, and 2 during depressive episodes) were evaluated for working memory (n-back test), verbal fluency (Controlled Oral Word Association Test, COWAT) and verbal learning (Verbal Learning and Memory test, VLMT). All patients were adults, mean age of 35.5 years, and all were undergoing psychotropic treatment with antipsychotics and/or mood stabilizers. Also, five normal healthy controls, matched for age, were evaluated using the same test battery.

All five BDI patients presented dysfunctions (three at a trend level, and one at a significant level, p<0. 01) in at least one cognitive domain, with three patients presenting modifications in all three tests that were administered vs. normal controls. The most affected domain was verbal learning, followed by working memory and verbal fluency. No individual in the control group had significant cognitive deterioration, on any outcome assessed.

Cognitive domains are altered in BDI patients, therefore, a test battery destined to quantify executive dysfunctions, independent of the presence of an acute mood episode or during the euthymic phase, may be useful for case management.

None Declared

The pathophysiology of bipolar disorder (BD) is complex and remains uncertain to this day.

Several hypotheses have been suggested, including the involvement of inflammatory mechanisms in its pathogenesis and in eventual cognitive impairment. C-reactive protein (CRP) is one of the most commonly used inflammatory markers. High-sensitivity CRP (hs- CRP) is a more sensitive marker.

We aimed to examine hs-CRP levels in patients with BD, and to investigate its relationship with cognitive functions.

We conducted a cross-sectional study between June 2016 and July 2018 on drug-free BD patients. These participants were hospitalized at the “C” Psychiatry department of HediChaker University Hospital in Sfax-Tunisia which accepts only male patients. The diagnosis of BP disorder was established according to DSM-5 criteria.

We used the Montreal Cognitive Assessment (MoCA) scale to assess cognitive functions in our patients, and blood samples were collected to analyze hs-CRP levels.

Our study included 33 patients whose median age was 33 years, with an interquartile range of 27.5-44 years. The majority (90.3%) were diagnosed with type I of bipolar disorder and 9.7% were diagnosed with type II. At the time of the study, 82.4% had a maniac episode and 17.6% had a depressive one.

The median MOCA scale score was 24 with an interquartile range of 19-26, and the analysis of hs-CRP values revealed a median level of 2.1 (interquartile range: 1.2-7.3).

There was no significant correlation between hs-CRP levels and MOCA scores nor its domains. Table 1 shows the results of this correlation analysis.Table1:correlation results between hs-CRP levels and MOCA domains

We also did not find any significant difference in hs-CRP levels between patients with depressive and maniac episodes.

Our study showed no significant relationship between inflammation and cognitive impairment in bipolar disorder. Further research is needed to better investigate the role of inflammatory processes in this disorder.

None Declared

There are manic episodes to involve a challenge in treatment due to finding resistance or secondary effects with the drugs of choice, this situation oblige forcing us to seek alternatives in the data sheet.

To describe the complicated evolution of a case of acute mania difficult to threat with stabilizer drugs and antipsychotics of choice. We discuss the psychopharmacological approach.

Case summary. We have conduced a systematic review of the descriptions published to date, regarding this case.We presented a case, in a 48-year-old female, admitted to our hospital due to psychopathological descompensation of bipolar affective disorder, where we observed manic and psychotic symtoms.

In the first instance, we started treatment with Lithium and Olanzapine, in increasing doses, along with benzodiazepine support.

During more than four months of follow-up , multiple drugs have been tested sequentially: olanzapine, aripiprazole and quetiapine. We observed a good response but low tolerance issue to secondary effects consisting of severe akathisia, in progressive stiffness (spasticity) and hands tremor, it was very disabling problem for patient, even though the use of biperiden.

This situation forced us to search another option of treatment, different from non-pharmacological therapies (ECT). After checking the literature and publications about it, we decided to start treatment with Caripracine 3mg/24h, for which the therapeutic indication is the treatment of manic with mixed symtoms.

We propose, through a clinical case, the use of cariprazine as a first choice in the acute decompensation of bipolar affective disorder, without symptoms of mixed mania.

During the treatment, the patient presente multiple difficulties and finally, a good response is was obtained with the use of Cariprazine, althought this patient continued showing slight akathisia well tolerated, she was able to leave after four months of hospitalization in the acude mental health unit.

None Declared

Mood disorders have been reported in the literature as a risk factor for developing cognitive deficits. Bipolar disorder (BD) and Frontotemporal Dementia (FTD) share many common features, often presenting as a differential diagnostic challenge to the clinician. The clinical features of mania, such as euphoria, hyper-sexuality and difficulties in impulse control can mimic the impaired judgment and loss of inhibition seen in FTD. Depressive features such as anhedonia and social isolation can mimic apathy associated with FTD. Of the various subtypes, the behavioural-variant of FTD (bvFTD) is most similar to a manic episode.

The authors aim to explore the relationship between BD and FTD, and the implications in differential diagnosis, treatment and prognosis with recourse to a clinical case example.

A non-systematized review of pertinent literature on the topic with focus on that which is most relevant to the theme was included. The authors present a clinical case of 55 year-old female with history of BD who was hospitalized in the context of a depressive episode with suicidal ideation and disorganized behaviour.

It is not uncommon for patients with bvFTD to be initially diagnosed with BD, whereas on the other hand, patients presenting in late with an inaugural manic episode are considered to have dementia. The literature also reports that patients with BD appear to be at increased risk of a later FTD diagnosis, further contributing the diagnostic difficulties. Core symptoms that present in mood disorders, also make-up the clinical picture of FTD, and vice versa. Correct diagnosis is imperative as early-intervention may have significant impact on prognosis of the clinical pictures. The patient underwent complementary diagnostic imaging testing with magnetic resonance imaging, which documented atrophy in the fronto-temporal regions which were not detected on previous exams, thus strongly suggesting a FTD diagnosis in a patient with history of BD.

The literature establishes, especially through various case reports, an apparent clinical overlap between FTD and mood disorders. A multifaceted connection between BD and FTD appears to exist, with clinical and genetic similarities having been described, although further studies are merited demonstrating this relationship. The clinical case highlights the challenges in FTD diagnosis in a patient with prior history of a mood disorder, especially BD, as well as demonstrating the difficult task in establishing a differential diagnosis between the two conditions when the mood disorder presents late in life. The clinician is alerted to the mimicry between the two conditions, taking into account the possibility of a FTD diagnosis in patients with history of BD presenting with unexpected cognitive and behavioural decline.

None Declared

Bipolar affective disorder type II is often misunderstood, neglected and rarely receives the attention it deserves and often remains undiagnosed. Despite its neglect and insufficient diagnosis, it is an important diagnostic entity because it causes significant suffering and functional impairment, a chronic course of the disease and a high suicide rate. Cognitive impairments and multiple comorbidities that significantly affect the course and outcome of the disease are common.

The purpose of this research was to determine the extent of the deficiency in diagnosing bipolar affective disorder type II in daily clinical work.

A total of 82 adult psychiatric inpatients diagnosed with affective disorders (depressive disorders and bipolar affective disorders) and borderline disorders participated in this study. They completed HCL-32, MDQ and PHQ-9 questionairres. The average age of the sample is 43.9 years. A total of 76.8% were women in the sample.

72.8% of respondents achieved a score above 14 on the HCL-32 questionnaire and thus met the criteria for possible hypomania. All three criteria for mania on the MDQ questionnaire were satisfied by 27.5% of respondents. 68% of respondents have moderate or severe symptoms of depression according to PHQ-9.

The results confirmed our assumption about the lack of recognition and diagnosis of bipolar affective disorder type II. Only 5 respondents (6.1%) were diagnosed with BAP II upon arrival. After the research, 73% of them met the criteria for diagnosing BAP II. As a correctly established diagnosis affects the selection of adequate therapy, we have tried to emphasize the importance of correct recognition of BAP II.

None Declared