Patients with autism spectrum disorder are characterized by high anxiety when facing social situations and dealing with interpersonal relationships on a daily basis. Although initially because of their rigid personality with the norm, and their tendency to social distancing, we do not have in mind this pathology as the most likely to develop a substance use disorder. However, it is observed in the literature a remarkable percentage of patients who resort to consumption, mainly alcohol, as an anxiolytic to be able to interact in society.

To show the case of a 19-year-old adult with a diagnosis of ASD who resorts to alcohol consumption in her daily life as a strategy to manage anxiety in social situations.

Case report and literatura review

This is a 19-year-old woman with a recent diagnosis of ASD. She is studying biotechnology and lives with her parents and 3 siblings. The patient reports difficulty in social relationships since early childhood, with experiences of school bullying. She expresses desire to relate with others, although she does it in an inadequate way, with difficulty in detecting nonverbal language, irony and anger when she does not understand a joke. The patient confesses that since she was 16 years old she has consumed alcohol to mitigate the anxiety caused by facing a group of people. She says that she feels that it relaxes her and facilitates interaction, making it more fluid and less tense. However, she recognizes that initially she used to drink 1 or 2 beers, but now she needs to drink up to 2 glasses of gin, recognizing this as something problematic.

The literature shows how patients with ASD can also present substance use disorder. It has been shown that about 10% of these patients have an abusive use of alcohol. Other samples show wider ranges (7-71%) of prevalence of alcohol consumption in patients with autism. In relation to cannabis, it is seen that around 3% of these patients consume it. These patients seek its anxiolytic effect and to reduce mental health symptoms. In addition, the purchase of alcohol does not involve high social interaction to obtain it, since it is a substance that can be purchased legally. It is important to explore alcohol consumption in consultation with patients with ASD to help them develop more functional anxiety management strategies.

Prevalence of psychiatric disorders in adults with autism spectrum disorder: A systematic review and meta-analysis. Lugo-Marín.J et al. 2019. Research in Autism Spectrum Disorders Volume 59, March 2019, Pages 22-33

None Declared

Infliximab is a tumor necrosis factor-alpha (TNF-α) inhibitor commonly used in the treatment of autoimmune disorders such as rheumatoid arthritis and ankylosing spondylitis. An increased risk of opportunistic infections, malignancy, and neurodegenerative diseases have been widely documented as adverse effects of IFX therapy. Few reports exist serving the notice of new-onset psychiatric symptoms linked to IFX treatment, such as suicidal behaviors in adults and elderly patients, as well as psychosis in an adolescent. Psychiatric side effects while under IFX treatment are reported to be rare.

Here, we present a case of a female with bipolar disorder who developed a long-standing depressive episode with suicidal thoughts after her fourth infusion of infliximab for her ankylosing spondylitis

Retrospective life chart was created, including infliximab infusion.

Montgomery Asberg Depression Scale was applied at time of hospitalisation and discharge.

The Naranjo Adverse Drug Reaction Probability Scale was applied.

A 55 year old female with ankylosing spondylitis and bipolar disorder was treated with IFX for 8 months. During this period, a total of 4 infusions were administered and AS symptoms were well responding to the treatment. Patient describes the onset of depressive symptoms such as anhedonia and insomnia after the infusion of third IFX infusion, gradually progressing to loss of function and suicidal thoughts and hospitalization in a psychiatry clinic.

The patient had a history of bipolar disorder for 10 years with recurrent manic and depressive episodes, 4 hospitalisations and 1 cure of ECT.

Patient was on sertraline, maprotiline and diazepam at the time of hospitalization. We started treatment with aripiprazole, quetiapine and valproate, followed for 4 weeks as an inpatient, consulted with rheumatology treatment options and neurology for demyelinating disorders, no pathology was discovered. Rheumatology suggested the continuation of IFX infusion under psychiatric control. Fifth dose of IFX infusion was administered and patient was discharged after euthymic mood was established and insomnia and suicidal thoughts were deteriorated. Upon follow up, depressive symptoms recurred and lamotrigine was added for augmentation.

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Although there is very scarce evidence that IFX causes psychiatric symptoms, there are few clinical trials too, showing evidence that TNF-alpha inhibitors may improve depressive symptoms. While we need more information and evidence to support the ideas of TNF alpha inhibitors effects on human neuropsychology, it is of great importance for especially patients with psychiatric history to be closely watched while administering the product, at least to minimize unintended adverse events.

None Declared

Polydrug use studies mention demographic and socioeconomic factors that may influence this problem. One of them is the existence of psychiatric comorbidity; Rentrop’s study (Rentrop et al., 2014) finds in a sample of 50 patients that all patients had at least one axis I disorder, 90% at least one axis II disorder, which may compromise the outcome of detoxification and dehabituation treatments (Rentrop et al., 2014). Another study found that 44.9% of patients admitted to a psychiatric unit are polydrug users (Karam et al., 2002).

To study the possible association of polydrug use with psychiatric comorbidity in patients admitted to a general hospital and presenting drug use.

We made a descriptive retrospective study through the use of electronic medical records. The drug use history was obtained for all patients admitted to the inpatient service of a general hospital during a 3-year period.

More cases of poly-consumption together with psychiatric comorbidity are found than expected in the χ² Test, with significant results (χ² = 27.2; p<0.001). The mean age of the patient with poly-consumption and psychiatric comorbidity is 34.9 years.

Psychiatric comorbidity in patients with polydrug use may be overlooked (Kruckow et al. 2016). Identifying patients with dual diagnosis is important given that these patients suffer decreased treatment compliance and life expectancy compared with single-diagnosis patients (Kruckow et al., 2016).

Rentrop, M., Zilker, T., Lederle, A., Birkhofer, A., & Hörz, S. (2014). Psychiatric comorbidity and personality structure in patients with polyvalent addiction. Psychopathology, 47(2), 133–140. https://doi.org/10.1159/000351784

Kruckow, L., Linnet, K., & Banner, J. (2016). Psychiatric disorders are overlooked in patients with drug abuse. Danish medical journal, 63(3), A5207.

None Declared

Depression has been recognized as a common comorbidity in patient with epilepsy and is associated with low quality of life. Regular screening for depression may aid in early detection and enhance quality of life.

To validate the Thai version of the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E).

The English version of NDDI-E was translated into Thai. Patients with epilepsy were enrolled at the outpatient neurology clinic from May 2019 to September 2019. Demographic data and clinical characteristics were collected. Participants underwent a psychiatric structured interview using the Mini-International Neuropsychiatric Interview (M.I.N.I.) as a gold standard for the diagnosis of major depressive disorder. Then, participants completed the NDDI-E. The internal consistency was measured by Cronbach’s alpha coefficient. The validity of the Thai version of the NDDI-E was assessed using the receiver operating characteristic (ROC) curve analysis. Youden’s index was used to determine the optimal cut-off score of the Thai version of the NDDI-E.

A total of 115 patients with epilepsy completed the evaluation. Twenty-three patients (20%) had major depressive disorder according to M.I.N.I. criteria. The Cronbach’s alpha coefficient of the Thai version of the NDDI-E was 0.826. The area under the ROC curve was 0.995. A cut-off score greater than 17 provided a sensitivity of 95.65%, a specificity of 97.83%, a positive predictive value of 91.67% ,and a negative predictive value of 98.90%.Table 1:

Demographic and clinical characteristics of the study population.

The Thai version of the NDDI-E is a valid screening tool for major depressive disorder in patients with epilepsy.

None Declared

Creating appropriate and sustainable treatment plans for patients with concurrent disorders presents a challenge to psychiatrists and addiction medicine specialists alike. Although varenicline has been found to be one of the most effective medications for smoking cessation and abstinence, caution is needed when starting patients on this medication. In this case, a young female provisionally diagnosed with bipolar I disorder was hospitalized for a manic episode in the context of substance abuse and medical noncompliance. She also endorsed a long history of smoking, alcohol, cocaine, cannabis and ketamine use. In addition to being stabilized for bipolar disorder, the patient was started on varenicline for smoking cessation on Day 14 of admission.

This case report highlights the potential risk of de-stabilization in a vulnerable youth with newly diagnosed bipolar I disorder and precarious social circumstances, in attempts to further concurrent approaches to psychiatric care.

In addition to qualitative observations, the main objective exam used to track patient progress through the duration of her hospitalization was the mental status exam (MSE). This is standard practice for psychiatric care and qualitatively assessed factors related to a patient’s behavioral and cognitive functioning. Important factors assessed for this patient include appearance and behavior, speech, affect and mood, thought form, thought content, perceptual abnormalities, insight and cognition.

Perceptual abnormalities, including auditory hallucinations, were not recorded at admission and the patient’s symptoms of mania were resolving clinically on Day 18. Two days after starting varenicline, the patient developed auditory hallucinations, paranoia and referential beliefs. However, her insight was intact, and she had minimal thought-form disorganization. The patient also reported hearing auditory hallucinations of a derogatory nature, with her mood appearing more distressed during varenicline use. Symptoms were found to be resolved shortly after the discontinuation of varenicline on Day 18 and the patient appeared to be less distressed on following days. In this case, these symptoms were not in keeping with her bipolar diagnosis and thought to be secondary to varenicline after the consideration of potential alternative contributors.

The occurrence of side effects as a result of varenicline use in patients with diagnosed mental health conditions is rare and underlying psychiatric illness is not labeled as an absolute contraindication in the prescription of varenicline. However, it is important to advocate for increased guidance and research on the treatment of substance use disorders in patients with bipolar I disorder.

None Declared

Autoimmune diseases are chronic and disabling conditions, especially because of the chronic pain they cause. Substance use disorders are on the rise in these patients, especially the problematic use of prescribed and over-the-counter analgesics.

to study the socio-demographic profile of patients with comorbidity between substance use disorders and autoimmune diseases, to assess the reasons for admission, the length of hospitalization, and the main psychoactive substances found in these patients

A retrospective cross-sectional study of the medical records of patients with substance use disorders co-morbid with autoimmune diseases who were hospitalized in the addictology department of the ar-Razi University Psychiatric Hospital in Salé between January 2014 and December 2021.

10 patients were included in our study, the median age was 42, 76% were male, 41.3% were single, 63% had an average socio-economic level. 43.5% of the patients had a medical history, the main reason for admission was depressive syndrome (50%), the most common autoimmune disease was insulin-dependent diabetes, followed by IBD

the comorbidity of autoimmune diseases and substance use disorders suggests the existence of common etiopathogenic mechanisms, the management of this comorbidity requires multidisciplinary collaboration

None Declared

Eating disorders are potentially severe, complex, and life-threatening. Therefore, it is crucial to identify and treat all the comorbidities that could worsen the prognosis.

The aims of this work are to assess if substance use disorders are frequently comorbid in patients suffering from eating disorders, what are the problems associated with drug consumption among these individuals, and what are the best therapeutic strategies in this dual psychiatric diagnosis.

We carried out a narrative review, by searching on PubMed and Google Scholar databases, using the expression “eating disorders and substance use disorders”. We included all types of scientific articles published between 2018 and 2022, and information was extracted regarding the objectives of this review.

The prevalence rates of substance use in eating disorders are higher than in general population. For eating disorders in general, substance use disorder (SUD) is the third most prevalent psychiatric comorbidity. According to a meta-analysis published in 2019, the lifetime prevalence rate of a comorbid SUD was 21.9% (95% CI 16.7-28.0). SUDs were more frequently comorbid among individuals with the binge/purge type, which has a specific phenotype characterized by greater impulsivity, emotional dysregulation, and problems with executive control. Individuals with this dual diagnosis had a higher number of psychiatric comorbidities, were more likely to be prescribed mood stabilizers, and were more sensitive to reward.

Research suggests that eating disorders patients with co-occurring SUDs experience lower rates of treatment response, higher relapse rates, more severe medical complications, greater impairment, poorer long-term outcome, and are at higher risk of early mortality.

To date, there is limited information guiding the concurrent treatment of eating disorders and SUDs. Dialectical Behavior Therapy for SUDs seems to be a promising treatment, but more research on its efficacy will be essential for establishing treatment protocols for these patients.

SUDs have an impact on treatment response and increase mortality among people with eating disorders. The prevention and treatment of SUDs in this patient group is thus imperative to reduce mortality and increase the quality of life of these patients.

None Declared

Postictal Psychosis of Epilepsy (PIPE), part of the group collectively known as Psychosis of Epilepsy, is characterized by an onset of confusion or psychotic symptoms within one week of apparent normal mental function. PIPE has been argued to be underdiagnosed in the clinical population, perhaps due to a failure to recognize the temporal relation between the seizure and the psychotic episode.

To explore the concept and management of post ictal psychosis.

We present a clinical case and a review of the literature concerning post ictal psychosis.

We report the case of a 36 year old woman with focal refractory epilepsy after a likely episode of limbic encephalitis in 2015. Cognitive and psychiatric sequelae in the form of depressive symptoms, in treatment with neurology and psychiatry since 2021. One previous episode of psychotic symptoms during seizures. Worsening of seizure frequency since march of 2022 with apparent normalization (absence of seizures after dose reduction of eslicarbamazepine and introduction oflamotrigine) for about four days before being hospitalized in the neurology unit due tobehavioral abnormalities. During psychiatric exploration, the patient showed signs of partial clouding of consciousness with manierisms, ecopraxias and ecolalias; verbigerance in the form of the neurologist’s name and bizarre movements like looking behind suggestive of sensoroperceptive disturbances. The symptomatology resolved itself during the following week after treatment with diazepam.

Finally, a narrative review concerning the case was also performed; with particular emphasis on antipsychotic drugs with low risk of lowering seizure threshold (such as risperidone or aripiprazole) as the recommended treatment.

Our findings point to the relevance of Postictal Psychosis of Epilepsy as a clinical entity. Further studies on pathogenic mechanisms and therapeutic management are required.

None Declared

Posterior Cerebral Artery (PCA) strokes cause the restriction of blood flow to multiple areas of the brain including the occipital lobe, the thalamus, the inferomedial temporal lobe, the upper part of the brainstem and the midbrain. This results in a panoply of possible symptomatology (including psychiatric manifestations) that increases the difficulty in diagnosis.

We aimed to present and discuss atypical presentations of cerebrovascular disease that often results in misdiagnosis in an emergency context.

A non-systematic review of the topic was conducted, and a case report is presented.

An 86-year-old male patient, previously autonomous and cognitively intact, presents with periods of confusion and incoherent speech, visual hallucinations, incongruity of affect with pathological laughter, insomnia and increased aggressive behaviour, which began suddenly and worsened in the period of a week. The symptoms motivated several recurrences to the emergency department and numerous diagnostic exams performed, including CT scans and an EEG. Neurological examination showed no focal neurological deficits. The patient was admitted to a psychiatric ward for further diagnostics work-up. Due to increasingly altered status of consciousness, an MRI was performed, which found ischemic left occipital lesions compatible with PCA stroke. The patient was afterwards transferred to a neurology ward for continuing medical care.

This case exemplifies how atypical symptoms such as visual hallucinations and changes in behaviour can be the only clues to diagnosing a PCA infarction, particularly in the absence of other focal neurological deficits. PCA strokes most commonly present with homonymous hemianopia, unilateral limb weakness, gait ataxia and vertigo. However, several other studies and case reports have found that this is not always the case and a minutious approach should be preferred in patients with a sudden onset of sensory and perceptual alterations and oscillating state of consciousness and disorientation, especially when discussing elderly people. Often these patients are admitted in psychiatric wards which may hinder the appropriate care they must receive.

None Declared

The increasing prevalence of cannabis use in the world requires awareness of cannabis-related disorders such as cannabinoid hyperemesis syndrome (CHS). CHS is characterized by cyclic episodes of nausea, vomiting and abdominal pain, affecting chronic cannabis users, who usually recur to hot showers to relief the symptoms. The pathophysiology underlying this syndrome is still unclear. Despite the well-established anti-emetic properties of cannabis, there is increasing evidence of its paradoxical effects on the gastrointestinal tract and central nervous system.

The authors pretend to inform the readers about the rare Cannabinoid Hyperemesis Syndrome (CHS).

The authors describe a case of a 22 years old patient with chronic cannabis use, cyclic and intractable nausea and vomiting, to bring to the attention that this condition exists and is underdiagnosed.

CHS should be strongly considered in the differential diagnosis of persistent vomiting in patients who reports relief with hot showers. In the acute setting, supportive care with intravenous fluids, dopamine antagonists, topical capsaicin cream, and avoidance of narcotic medications has shown some benefit. However, cannabis cessation appears to be the best treatment.

CHS prevalence will continue to rise in parallel with increasing worldwide cannabis use and potency. So, health professionals must be aware of this syndrome, its diagnosis, and treatment, to provide better care and avoid overlooking CHS. Further research is required to elicit the exact mechanism and additional therapies for this condition.

None Declared

Knowing mental representations about the phenomenon of illness and medical care allows the clinical team to have better emotional handling of their patients, with gains in greater adherence to treatments. Graves’ Ophthalmopathy is an inflammatory disease with primary involvement of the extraocular muscles and orbit, being the most frequent extrathyroidal manifestation of Graves’ Disease. Many patients have psychological status changes even after successful treatment of hyperthyroidism, especially when the disfiguring signs of ophthalmopathy are predominant. An understanding of the symbolic aspects linked to this condition help doctors and nurses to have a relationship more harmonious with them.

To interpret emotional meanings in reports of patients with euthyroidism and with ophthalmopathy under follow-up at a specialized university endocrinology outpatient follow-up, discussing contradictions perceived between a stigmatized body and clinical-laboratory euthyroidism.

Clinical-Qualitative design of Turato. Data was collected using Semi-directed interviews with open-ended questions in-depth, carried out with patients at a university hospital specialized outpatient service in South-eastern Brazil. The interview material was audio-recorded and fully transcribed. The interviews were treated by Clinical-Qualitative Content Analysis described by Seven Steps’ Faria-Schützer. It is based on psychodynamic concepts from the Medical Psychology theoretical framework, whose main author is Michael Balint. The sample was closed by the Theoretical Saturation of Information studied by Fontanella and cols. The finding validation has occurred by peers at the Laboratory of Clinical-Qualitative Research, State University of Campinas, San Paolo.

The sample was composed by 10 patients. From the search of nuclei of meanings in the reports, four categories of analysis were constructed: 1) “No, this is not normal, I must have cancer”: psychodynamics of the doctor-patient relationship in Graves’ Disease; 2) Types of illness according to their manifestations and auto-perception: silent illness and non-silent ones; 3) “The eyes are everything”: the impacts of the disfiguring alterations of ophthalmopathy; 4) The contradiction perception between clinical and laboratory normality the stigmas of ophthalmopathy.

The patients with severe exophthalmos, maintained emotional distress despite being euthyroid, manifested by various emotional meanings reported in the interviews. The clinical-laboratory diagnosis of Graves’ Disease alone is not sufficiently capable of responding to the psychological demands of the patients. Proper listening to emotional symbolic meanings attributed by patients can help physicians and nurses in handling this setting

None Declared

Knowing what “kind of patient” search the doctor is relevant to handle his/her treatment and care. What emotional meanings do people attach to their diagnosis, therapy, and care in general? Graves’ Disease has an impact on the metabolism, which directly affects behavior. Patients can be affected by Graves’ Ophthalmopathy at any stage of the disease. This usually leads to greater changes in facial physiognomy which may or may not be accompanied by typical symptoms of hyperthyroidism. Changes in appearance and visual symptoms often lead to a rapid search for treatment. Understanding the symbolic aspects of the condition can help clinicians to manage emotionally, leading to substantial improvements such as the adhesion to the treatment.

To understand and interpret psychodynamically the perceptions and emotional meanings related to Graves’ Disease with Ophthalmopathy and hyperthyroidism as reported by patients at an endocrinology-specialized outpatient service.

Clinical-qualitative design of Turato. Data is collected using Semi-directed interviews with open-ended questions in-depth carried out with patients at an specialized outpatient service. Interview material was audio-recorded and fully transcribed. The material was treated by Clinical-Qualitative Content Analysis of Faria-Schützer. It is based on psychodynamic concepts from the Medical Psychology theoretical framework, and which main author is Michael Balint. The sample will be closed by the Theoretical Saturation of Information criterion according Fontanella. The interviewer was a male psychologist and doctoral student in the Health Mental Area. The finding validation has occurred by peers at the Laboratory of Clinical-Qualitative Research, State University of Campinas.

This presentation refers to partial findings from a sample of a total of three participants as part of the doctoral project by the first author. The analysis of data collected so far indicates three designed categories of analysis: 1) “I wasn’t like that before”: impacts on physiognomy - the perception of social stigma and the difficulty of managing the illness. 2) “This disease is a mess”: the symptoms affect all aspects of the patient’s life. 3) Problematic emotions management: double anxiety in hyperthyroidism - hormonally based anxiety and psychological anxiety related to the impact of the medical diagnosis.

The findings shall aid medical personnel in better grasping patients’ emotional perceptions of their illness and medical care. The level of communication between the professional and the patient can be improved by involving the patient as an active protagonist in the well-being process. This could also lead to more effective management and greater adherence to the therapeutic process.

None Declared

Nausea is a very common symptom related to multiple physical illnesses. In the same way, nausea and other gastrointestinal symptoms are frequently associated with the symptomatology presented at the onset of anxiety or depression. These symptoms can significantly affect the patient’s functionality, reduce school or work attendance and lead to consultation with multiple medical specialties. Therefore, it is important that in addition to a good organic screening, psychiatric pathology should be considered in the differential diagnosis. We will present the case of a 22-year-old male with nausea as the main symptom referred to Psychiatry after having seen several specialists and having undergone multiple diagnostic tests without significant findings.

To review the association of psychosomatic symptoms with anxiety disorders and/or depression, as well as their management.

Presentation of a case and review of the available literature on the presence of psychosomatic symptoms, specifically nausea, in patients with anxiety and/or depression.

In patients in whom anxiety and depression were assessed by the Hospital Anxiety and Depression Scale (HADS), 48% reported gastrointestinal symptomatology during the previous year, of whom 12% reported nausea. It has been observed that anxiety had a higher risk for the presence of nausea (OR 3.42) than depression, although the latter also increased the risk of nausea (OR 1.47). The literature shows that interventions such as cognitive-behavioral therapy or pharmacological treatment with selective serotonin reuptake inhibitor (SSRI) drugs independently or in combination are strategies that have demonstrated therapeutic success.

The multidimensional nature of symptomatology such as nausea and other types of psychosomatic symptoms forces us to take a broad view of the symptom. The association of gastrointestinal symptoms and pathologies such as anxiety and/or depression has been demonstrated, so that, after a correct organic screening, mental health professionals should be considered to evaluate the possible management of symptoms that can become so disabling in the life of these patients.

None Declared

Headache is associated with a wide spectrum of comorbid, statistically and biologically related pathological processes. A person with headache is more likely to have a psychological disorder than the rest of the general population, even more so if the headache is chronic. Psychiatric comorbidity has been shown to act as a risk factor in the chronification of headache and may contribute to increased disability. Anxiety and mood disorders are the psychiatric comorbidities that most influence aspects of the disease such as prognosis, response to treatment and even quality of life.

To analyse the results of the implementation of a joint consultation between the headache unit and the liaison psychiatry programme.

To evaluate the efficacy of interdisciplinary intervention in patients diagnosed with resistant headache.

We performed a descriptive analysis of the database of patients included in the headache programme including data on neurological diagnosis, psychiatric diagnosis, type of intervention, referral to psychiatric consultation and number of subsequent revisions.

Diagnoses related to anxious and depressive symptomatology are the most common diagnoses in patients diagnosed with treatment-resistant headache.

In most of the patients analysed in the database a single joint intervention was necessary.

Referral to mental health consultations from the programme did not lead to an increase in urgent demands with a clinical correlation in terms of diagnostic orientation

Joint intervention in the management of these patients has been found to be beneficial in the reinterpretation of symptoms and progressive desensitisation to fear of chronic illness.

Training in symptom detection at the psychopathological level is important for professionals from other areas as well as training in interviewing skills.

More studies are needed to analyse the outcome of joint interventions in patients with difficult-to-manage chronic diseases and their comorbidities.

None Declared

Paraneoplastic syndromes (PNS) can be expressed with a wide variety of neurological and psychiatric symptoms: alterations in consciousness, cognition, behaviour, mood or perception. Testicular tumours have been related to different expressions of PNS, but, to date, no relationship with bipolar disorder has been described.

On the other hand, the relationship between SARS-CoV2 infection and subsequent affective conditions has also been recently described. Between 30-40% of people affected by the infection present symptoms of depression in the following months.

To describe a case of a 17-year-old patient with an atypical onset of bipolar disorder a few months after a SARS-CoV2 infection and a few months before a testicular germ cell tumour was detected.

Description of a clinical case, its differential diagnosis and the literature review associated.

This is a 17-year-old adolescent with no previous psychiatric history, who is referred to a day centre after committing a suicide attempt. The patient presented an average premorbid functioning. Stands out, a SARS-CoV2 infection 3 months before the onset of symptoms. He presents repeated and self-limited episodes (maximum 3 weeks) of major depressive symptoms: autolytic ideation, hypothymia, asthenia, clinophilia, isolation, anhedonia, mutism, psychomotor retardation, lack of hygiene, hyporexia, hypersomnia; that alternates with periods of stability and with others of symptoms of hypomania (sudden improvement in mood, increased activity and plans), also lasting a few days. Paradoxic response to treatment with antidepressants, presenting irritability and exacerbation of suicide ideas. Good tolerance and response to treatment with low doses of aripiprazole and quetiapine. The patient was diagnosed as type II bipolar disorder with rapid cycling.

A few days after definitive diagnosis, a testicular germ cell tumour was detected, for which he had to undergo surgical intervention and chemotherapy treatment. At this point, it is suggested that the symptoms could be included in a paraneoplastic condition prior to the tumour. Months after the remission of the cancer, the patient does not present symptoms of relapse or metastasis, but mood swings persist, of lesser intensity, every few weeks. Treatment with lamotrigine was started at increasing doses, with good response and tolerance from the start.

The onset of mental health disorders in adolescents can be complicated by the non-specific or atypical early or prodromal symptoms. This degree of complexity increases when somatic pathologies coexist and even more if those pathologies have yet to be fully understood and studied, such as paraneoplastic syndromes or SARS-CoV2 infections. It is necessary to continue investigating the interrelationship between somatic and psychiatric conditions in order to provide more specific and rapid clinical responses.

None Declared

Organizing pneumonia (OP) is a clinical, radiological and histological entity that is classified as an Interstitial Lung Disease. It can be either cryptogenic (of unknown cause) or secondary to a lung injury such as infection, drug toxicity, inhalation of a pathogen or toxic gas, gastroesophageal reflux, collagenosis, organ transplant, or radiotherapy (B.J. Roberton, D.M. Hansell. Organizing pneumonia: a kaleidoscope of concepts and morphologies. Eur Radiol, 21 (2011), pp. 2244-2254). We were called for a psychiatric consultation for a 50 years old male patient who presented to Emergency service of our hospital with symptoms of acute respiratory failure and bilateral pneumonia. This was his fourth hospital admission within two months with the same symptoms. In previous stays, he was given four different antiobiotics.

The objective of our psychiatric consult was to determine whether the clinical presentation of bilateral pneumonia could in fact be a side effect of one of the psychiatric drugs he was taking.

We reviewed the patients prescribed medication and their side-effect profile. Additionally, the patient underwent a series of diagnostic tests, with the most important one being histology analysis of the biopsy samples.

Upon reviewing the available medical sources, we were able to find a few articles that link organizing pneumonia and use of Na-valproate (Nanau RM, Neuman MG. Adverse drug reactions induced by valproic acid. Clin Biochem. 2013;46:1323–1338). The said medication was discontinued and the patient started receiving corticostroids. After only a few days, his condition improved drastically and was discharged to home care.

The mutual cooperation between internal medicine specialists and liaison psychiatrists is vital in cases like this when there is a psychiatric patient presenting with unspecific somatic symptoms or is responding poorly to standard treatment. We must sensitize the staff to the specifics of care for a psychiatric patient and at the same time provide him with adequate medical assistance.

None Declared

Fahr’s disease (FD) is a rare disorder consisting of bilateral and symmetrical calcium deposits in basal ganglia and cerebral cortex. These lesions are associated with neurological and psychiatric symptoms such as a rigid hypokinetic syndrome, mood disorders and memory and concentration abnormalities. It can be idiopathic or secondary to endocrine disorders, infectious diseases or mitochondrial myopathies.

To highlight the importance of considering organic causes when evaluating patients presenting atypical psychiatric symptoms and claim the role of neuroimaging.

Case report and non-systematic review of literature: sources obtained from Pubmed database.

A 69-year-old man, native of Syracuse (Italy), was admitted to the Psychiatry Unit in February 2022 presenting behavioural disturbances and irritability. In July 2021 he presented the same symptoms, being mistakenly diagnosed with Bipolar Disease type I. He has no previous psychiatric history. He started with changes in his personality, short-term memory loss, aggressiveness and disorganized behaviour at the age of 66. At admission he was talkative and hyperfamiliar, presenting delusions of grandiosity, exalted affectivity and insomnia. Neurological examination showed short-term memory problems, signs of frontal disinhibition and abnormal glabellar tap sign. Blood tests, CT brain and MRI were performed to rule out organic underlying causes. Neuro-imaging found bilateral and symmetric calcifications in globus pallidus, thalamus and corpus striatum, in favour of FD. Secondary causes (abnormalities in the PTH, vitamin disorders and infectious diseases such as HIV, brucellosis or neurosyphilis) where discarded, allowing us to conclude it was probably a primary case of FD. Valproate was started as a mood stabilizer and anticonvulsant. Genetic tests were indicated.

FD should be considered as a differential diagnosis in the evaluation of psychiatric symptoms, especially when atypical and/or presented with neurological symptoms. The role of neuro-imaging is essential.

None Declared

Diagnostic overshadowing is established as a mechanism by which physical symptoms are misattributed to mental disorder, hence under-diagnosing and under-treating medical pathology. We report a case series of adult males with established neurological disorders who presented to the ED with visual hallucinations in the postictal period. The phenomena of postictal psychosis is long established in neuropsychiatric literature, with reported rates of postictal psychosis in epilepsy of 2%. Patients vsual hallucinations resolve with anticonvulsant stabilisation and rarely require antipsychotic augmentation.

To illustrate diagnostic overshadowing in a case series of postictal psychosis

Retrospective case series

Case 1:

A 36year old man self-presented to the ED 24hrs post tonic-clonic seizure of 15minutes duration. Medical history was significant for hydrocephalus as an infant with 29 surgical revisions of in-situ ventriculoperitoneal shunt since initial placement. Secondary epilepsy was reported to be poorly controlled with an estimated 50 ED attendances in the past year for management of seizure activity. On assessment new symptomatology of non-threatening visual hallucinations with associated low mood was elicited. A diagnosis of postictal psychosis was advised following psychiatric assessment and medical admission with anticonvulsant titration recommended. Despite this characteristic presentation there were repeated requests to admit this patient to the psychiatric unit and a perceived lack of understanding of his acute medical needs.

Case 2:

A 45year old man self-presented to the ED <24hours post discharge following medical admission for management of seizure. Medical history was significant for a right parieto-temporal infarct one year prior, with acceptable return to functioning following rehabilitation. The man had recently been diagnosed with secondary epilepsy and titration of sodium valproate commenced. The patient presented as distressed in the context of new onset visual hallucinations and palinopsia. Medical admission with urgent neurology input and anticonvulsant titration was advised following psychiatric assessment. ED physician repeatedly stated this patients presentation was stress related and requested psychiatric admission. Following medical admission the patient was managed by neurology. Sodium valproate was augmented with clobazam and the patients psychopathology resolved in full.

Diagnostic overshadowing is prevalent in the ED. Despite established medical diagnoses there may be a reluctance for medical teams to acknowledge or treat organic psychopathology. Psychiatrists must keep abreast of medical comorbidities and physical treatment guidelines of neuropsychiatric disorders in order to advocate appropriately for due medical input. Postictal psychosis is effectively managed by neurological input for effective seizure control with collaborative neuropsychiatry input.

None Declared

Self-harm (SH) is common, in particular among young people. It can be seen in a wide range of psychiatric disorders, ranging from anti-social personality disorders to schizophrenia and mood disorders. In the extreme, self-harm can be functionally life-threatening. Such is the case of phlebotomy, emasculations and self-amputation. The severity of certain damage and the urgency of an initial somatic treatment contribute to make self-harm one of the most frequent reasons for intervention in liaison psychiatry.

Through our case series and a literature review, we tried to describe the socio-demographic and psychopathological characteristics of the self-harmers and to identify the specificities of their management in liaison psychiatry.

It is a descriptive cross-sectional study, in the psychiatric department of a general hospital in Rabat, concerning patients evaluated for SH with or without other psychiatric manifestations. The data collected are analysed using the statistical software ‘JAMOVI’. Patients seen in psychiatric consultations, in medical-surgical emergencies or in liaison psychiatry for SH were included. Patients already hospitalized in psychiatry were excluded.

35 patients were recruted of who 65.7% were male. 68.6% were single. 51.4% had a low socio-economic level and 42.9% had an average level. 48.6% had a psychiatric history of which 22.9% had attempted suicide. Abuse was present in 34.3%, family separation in 22.9%, death of a parent in 20% while no patient reported sexual abuse. The most common method used was a razor blade in 57.1% of cases. The most mutilated site was the forearms in 65.7%, following a frustration in 60% and a conflict situation in 25.7%. 48.6% were hospitalised (34.5% in psychiatry, 5.6% in intensive care and 5.6% in otorhinolaryngology).

Self-harm is a frequent pathological behaviour whose incidence is increasing. Understanding the psychological and biological basis of self-harm will help to improve the management of these patients and prevent the recurrence of this dangerous behavior and its complication by suicide.

None Declared

Hyperthyroidism due to Graves-Basedow disease is a common cause of neuropsychiatric manifestations, such as anxiety, psychomotor restlessness, mood disturbances, insomnia and psychosis. Hashimoto’s encephalopathy rarely occurs in so-called autoimmune thyroiditis, which can present with hyperthyroidism and neuropsychiatric symptoms similar to Graves’ disease. We add that the mystical-religious beliefs, present in all human cultures, and decisive in the case at hand, make us propose an evolutionary origin of them.

Clinical case description

A clinical case based on medical reports is described

We present the case of a 72-year-old woman, a member of the Seventh-day Adventist Church, well adapted to the Community. Known history of elevated antithyroid antibodies since 2019, brought to the emergency room involuntarily due to a mystical-religious delusional condition associated with behavioral disturbance. On examination, cachectic appearance, distal tremor, emotional exaltation and megalomanic speech were highlighted. Laboratory tests revealed primary hyperthyroidism with elevated antibodies. During admission, the differential diagnosis between Graves-Basedow disease and Hashimoto’s encephalopathy was considered. Thyroid scintigraphy oriented the diagnosis to Graves-Basedow disease, not requiring lumbar puncture or corticosteroid treatment. Treatment was based on high-dose antithyroid and antipsychotic drugs, with clinical and analytical remission at 3 weeks. The patient was referred to a Social Health Center for functional recovery. The family refers to a similar episode in 2014, of less intensity and self-limited, which is proposed to be a hashitoxicosis.

Differential diagnosis between Graves-Basedow and Hashimoto disease is essential as they differ in treatment and prognosis. The continuity that the delusion presents with the previous beliefs of the patient, differing mainly in the affective-behavioral implication, makes us consider a predisposition to psychosis in our patient. Religiosity can be adaptive in certain environments, since mystical beliefs have existed throughout the history of the human species and seem to be part of our nature.

None Declared