Preoperative anxiety related to either anesthesia or surgery remains for many patients a major subject of concern.

Evaluation of preoperative anxiety in patients undergoing surgery.

Our study is transversal and analytical. It was conducted among 50 patients admitted to the surgical unit of CHU Habib Bourguiba in Sfax (Tunisia). The screening tool for the preoperative anxiety was the ‘Inventory self-assessment of State-Trait Anxiety” (STAI-Y) and the ‘Amesterdam Preoperative Anxiety and Information Scale” (APAIS).

Using the STAI scale reveal a moderate to severe level of anxiety “state” in 26% of cases and a moderate to severe level of anxiety “trait” in 18% of patients. While, by the application of the APAIS scale, preoperative anxiety was detected in 44% of our patients; it was fairly linked to surgery and anesthesia. In our sample, 40% had expressed a means to intense desire for information about anesthesia and surgery. A high score of anxiety was correlated with general anesthesia (p=0.016) and low level of information (p=0.006). A moderate to severe level of anxiety “state” was correlated with low socioeconomic level (p = 0.03), heaviness of the surgery (p = 0.02) and a moderate to severe level of anxiety ‘trait” (p = 0.026).

Our study confirms the concerns of patients regarding both anesthesia and the surgery and highlights the problem of lack of preparatory information. Thus, collaboration between the surgeon and the anesthetist during the preparatory stage is indispensable to decrease the level of preoperative anxiety.

Post-traumatic stress disorder (PTSD) is a debilitating condition, caused by exposure to an extremely traumatic, terrifying, or tragic event. Likelihood of some mental disorders increases among women during the postpartum period. In fact, women are potentially vulnerable to mental illnesses during and after pregnancy. This study aimed to determine the prevalence of PTSD among postpartum women in Zahedan city, Iran.

Data in this cross-sectional study were gathered from healthcare centers of Zahedan, located in Southeast of Iran. Four-hundred people were selected among women with previous childbirth experience over the past few months; almost 6-24 weeks had passed since their delivery. We used three questionnaires in order to evaluate demographic data, PTSD symptoms, and traumatic childbirth experience.

In total, 32% of the participants showed PTSD symptoms. Prevalence of PTSD was not significantly associated with parity, pain duration, education level, and employment status. In addition, PTSD was significantly correlated with the mode of delivery (p=0.013), curettage (p=0.005) and length of hospitalization. Also, prevalence of PTSD was substantially associated with the type of pregnancy (planned or unintended) (p=0.011).

As the results indicated, women with PTSD were not significantly different from those without PTSD in terms of parity, pain duration, education level, or employment status. Previous history of curettage, episiotomy, and vacuum evacuation increased the incidence of PTSD in postpartum women. Moreover, unwanted pregnancy was more common among women with PTSD, compared to normal subjects.

The treatment of anxiety disorders is subject to multiple factors (biological and environmental), this creates a complex situation while trying to achieve effective treatment of anxiety disorders.

This is the reason why in the current study, we decided to evaluate the effectiveness of specific relaxation techniques as an additional therapeutic measure.

To determine whether there is therapeutic benefit in the application of relaxation techniques among patients undergoing Pharmacological and psychological anxiety disorder treatment in comparison with patients with anxiety disorders receiving only the latter.

Firstly the process involved a pre and post intervention assessment using a psychometric equipment the Hamilton rating Scale for -HARS anxiety (HARS), the anxiety Inventory-STAI State (STAI-S) and Trait (STAI-T), which allowed us to perform an objective assessment of anxiety levels

Significant reductions in post intervention levels were obtained in comparison with pre anxiety levels, in HARS (30.56 and 22.75), in STAI-S (64.93 and 46.62) and in STAI-T (83.75 and 63.56).

Additionally the size effect (SE) was considerable, in the HARS (SE= 0,70), en STAI-S (SE=0.59) and STAI-T (SE =0.69).

From the obtained results, we can affirm there are benefits of introducing therapeutic relaxation techniques as a complement to pharmacological / psychological treatment in patients with anxiety disorders.

However more studies should be carried out to evaluate the maintenance of these results in the Long-term.

Treatment adherence is one of the main factors affecting the success of treatment and, secondarily, the quality of life and social adaptation of the patients. The aim of this study was to investigate the association between self-stigmatization, treatment adherence and history of discontinuation of drug treatment.

The cross-sectional study was conducted on 120 (98 completed all the questionnaires) neurotic outpatients treated in the University Hospital Olomouc. The following variables were evaluated: the objective and subjective Clinical Global Impression (CGI) scale, Drug Attitude Inventory (DAI-10) questionnaire measuring adherence, Internalized Stigma of Mental Illness (ISMI) scale measuring self-stigma, and a demographic data questionnaire.

Data analysis showed no correlation between self-stigmatization and age, age of onset or length of the post-hospitalization phase. However, there were significant correlations between self-stigmatization and the severity of the disorder (assessed by both objective and subjective CGI), number of previous hospitalizations, total number of psychiatrists visited by the patient, the arbitrary discontinuation of medication in the past, and the dose of an antidepressant. Furthermore, self-stigma was significantly negatively correlated with the current treatment adherence. The rate of adherence was negatively correlated with both objective and subjective CGI only.

Self-stigma significantly affects the current adherence to the treatment of neurotic spectrum disorders.

76 neurotic inpatients undergoing a six week hospitalization in the psychotherapeutic department attended the study. The probands completed these psychodiagnostic methods at the start of the treatment – ISMI (Internalized Stigma of Mental Illness Scale), TCI-R (Temperament and Character Inventory, revised version), ADHS (Adult Dispositional Hope Scale), DES (Dissociative Experiences Scale), BAI (Beck Anxiety Scale), BDI-II (Beck Depression Scale, second edition), and CGI (Clinical Global Impression, both the subjective and objective versions). The scores of the scales and the inventory were processed by descriptive statistics, t-tests, correlations, linear regression, and backward stepwise regression.

The overall level of self-stigma in the patients with a neurosis and possible comorbid depression significantly correlated with several psychological features. Self-stigma was significantly positively connected to the harm avoidance trait, the symptoms of dissociation, anxiety, and depression, and the overall level of psychopathology measured by objCGI and sucjCGI. It also correlated significantly negatively with the persistence and self-directedness traits and hope and its subscales – pathway thinking and agency. After applying backward stepwise regression, only three of the mentioned factors predicted the level of self-stigma – self-directedness, hope, and the subjective evaluation of own mental state. Other factors were suppressed during the analysis.

Patients with more severe psychopathology show larger tendencies to stigmatize themselves. Low self-directedness and lack of hope are also typical for individuals with higher levels of self-stigma.

Choking phobia was described by Chorpita, Vitali and Barlow as a condition characterized by intense fear of choking along with avoidance of swallowing solid food, drinking and taking pills in the absence of anatomical or physiological abnormalities. Patients may present a significant weight loss, on which they usually feel uncomfortable

Report a patient with choking phobia who was admitted to the Neurology service of Santa Maria Hospital and conduct a brief literature review on the subject.

Analyse the patient’s clinical records and perform a PubMed database review, using ‘chocking phobia” as keywords.

A 31 years old woman with no history of psychiatric care was admitted to the Neurology service after presenting progressive dysphagia with excessive weight loss. It was possible to determine the sudden onset with progressive worsening (initially the patient was fed only in the presence of other people – due to fear of choking – and lately refused solid food intake). Changes in diagnostic procedures (endoscopy, electromyography and barium meal) were not found. The patient was observed by the Psychiatry service and initiated a treatment with sertraline, supported with cognitive behavioural therapy, which revealed a clear improvement from the resistance to swallowing point of view (currently the patient is able to have lunch / dinner in less than 1 hour).

Choking phobia is a rare and poorly understood disorder, whereby future studies should contribute to a deeper knowledge of these events and their treatment.

Complications of anxiety disorders can be serious and even life-threatening in some cases.

The aim of our study was to identify the complications related to anxiety disorders.

This is a cross-sectional study of 40 patients suffering from anxiety disorders and followed to the outpatient psychiatry Hedi Chaker University Hospital in Sfax Tunisia during the month of August 2014. The subjects who participated in the survey responded to an anonymous questionnaire to collect socio-economic and demographic data, the type of anxiety disorders and the presence of psychiatric complications related disorders.

Diagnoses of anxiety disorders were selected according to DSM-IV-TR.

The rate of each anxiety disorder was as follows in our patients:

Obsessive Compulsive Disorder (OCD) 31.6%, Generalized Anxiety Disorder (GAD) 15.8%, Panic Disorder(PD) without agoraphobia 21.1%, PD with agoraphobia 5.3%, Post Traumatic Stress Disorder (PTSD) 13.2%, Acute Stress Disorder(ESD) 10.5%, agoraphobia 2.6%.

55.3% of the patients were female.

The mean age was 41.55 years, ranging from 18 to 67 years.

71% of patients were young people between 25 years and 45 years.

55.3% of patients lived in urban areas. 63.1% were married.

50% of the patients had, along the evolutionary course of their illness, psychiatric complications including: depression 57.9%, suicide attempts 31.6%, alcohol abuse 10.5%.

The findings underline the importance of the proper management of any anxiety disorder to reduce its complications and improve the quality of life of these patients.

The presence of panic disorder (PD) [1,2,3] is associated with numerous of cardiovascular, respiratory, gastroenterologic and neuro-otologic symptoms. PD is an anxiety disorder with a good outcome and prognosis, but if it isn't recognized cause a worse quality of life and a reduction of global functioning. The aim of our study is to put the attention on this delayed form of PD that are very good treated with duloxetine.

GV, a 29-year-old caucasian woman affected by PD with agoraphobia referred for recurrent gastroenteric symptoms (heartburn, chest tightness). PA, a 64-year-old caucasian woman affected by PD without agoraphobia referred for recurrent gastroenteric symptoms (heartburn). TB, a 45-year-old caucasian man affected by PD without agoraphobia referred for recurrent gastroenteric symptoms (heartburn, tightness, eructation). All patients are evaluated by gastroenterologist to excluded fisical gastroenterological problems. After 6 months all patients treated with duloxetine 60 mg/day, showed a complete remission of gastric and panic related symptoms.

Three case report positive treated with duloxetine, without particular adverse effects and litterature review.

Others authors hypothesized the duloxetine, a serotonin-norepinephrine inhibitor that has greater initial noradrenergic effects than venlafaxine, would have broad efficacy for individuals with PD. Descending serotonin and norepinephrine pathways are modulators of pain perception, and duloxetine have an analgesic effect on painful physical symptoms. Further research is warranted to replicate our clinical observations.

Prognostic staging is one of the most important current psychiatrical challenges.

Bipolar prognostic factors must be identified to assist in staging.

To assess prognostic factors, to describe any correlation with the disease outcome and to recommend that psychiatrists assess bipolar patients, determining their stage of disease in order to identify possible high-risk groups of patients.

We collected data from the clinical notes of 70 bipolar outpatients seen at the initial psychiatric assessment clinic about socio-demographic and clinical factors.

The sample comprised 16 bipolar I (22.9%) and 54 bipolar II (77.1%) outpatients; 60.9% reported anxiety, 71.7 % mixed state features and 72.7% rapid cycling. A comparison between 12 prognostic factors found that only the correlations between current illicit drug use/previous illicit drug use, current alcohol use/previous alcohol use, and current illicit drug use/anxiety were statistically significant; the correlation between previous illicit drug use/previous alcohol use, previous alcohol use/family history and mixed state features/anxiety were almost significant.

17 patients were assigned to a care coordinator; we found no statistically significant differences between the patients with or without a care coordinator on the basis of the presence of 12 possible prognostic factors.

In our sample, some patients were found not to have information available so we suggest that a questionnaire to remind clinicians of potentially useful information would be helpful to aid in prognostication. Specific features of the disease (family history, age at onset, features of depressive episodes and mixed state, rapid cycling) may be highlighted.

Bipolar disorder is characterized by relapsing and remitting mood phases, such as manic or depressive episodes as well as periods of subsyndromal symptoms. Among the treatment options for acute manic episodes, most antipsychotics have a good level of evidence of effectiveness [1]. Asenapine is a new atypical antipsychotic which showed good effectiveness and tolerability [2] along with a reasonable cost-effectiveness [3] in placebo-controlled trials. However, few studies have tested this in real-world clinical settings so far.

The aim of this study was to evaluate the effectiveness and tolerability of asenapine in bipolar patients in a naturalistic clinical setting.

We retrospectively examined the clinical records of 94 systematically followed-up adult patients who received asenapine in four selected Spanish reference centers. We assessed sociodemographic variables, tolerability as well as clinical severity through routinely used evaluation scales.

Half of the patients reported at least one adverse effect related to the asenapine (51%), being somnolence the most frequent (30%). Although none of the side effects reported was a cause to discontinue it. Asenapine showed good levels of effectiveness with a 61% reduction of manic and 44% of the depressive symptoms. Concerning mixed states, there was reduction of 30% and 39%, for both manic and depressive symptoms respectively.

Though asenapine has an indication for acute manic episodes in bipolar disorder, the present study suggests that it can also have a role in treating depressive and mixed states in a real world setting. In addition, tolerability was consistent with clinical trial data.

Trazodone is a 5-HT(2) antagonist and 5-HT reuptake inhibitor (SARI), and an antidepressant with therapeutic effects on its target symptoms depressed mood, anxiety and insomnia [1,2]. The aim of our study is to present a possible line of treatment of a depressive episode in bipolar disorder type II with three case report.

BT is a 35-year-old Caucasian lady affected by bipolar disorder type II with a depressive episode. CA is a 40-year-old Caucasian lady affected by bipolar disorder type II with recurrent depressive episode with atypical symptoms. FR is a 38-year-old Caucasian gentleman affected by bipolar disorder type II with recurrent depressive episode. All patients are treated with trazodone immediate release subsequently increased up to 50-75 mg/day. After 6 months of treatment the patients showed a good outcome.

These case reports underscore the possibility of tailoring therapeutic strategies for the treatment of depressive episode in bipolar disorder type II. Our interest in trazodone lies in the possibility of treatment of depressive episode with the added benefit of resolution of affective symptoms, with fewer adverse effects and a well done effect in this patients. Moreover our opinions is that a therapy like trazodone with this particular profile of action, could represent a new strategy of tratment this patients. Further research is warranted to confirm the efficacy of this treatment.

Varenicline is an alpha 4 beta 2 nicotinic receptor partial agonist with dopaminergic effects, approved for smoking cessation. In May 2008, the FDA updated the previous Public Health Advisory and required that all patients should be observed and report to their physicians immediately for any mood or behavior changes, or worsening of preexisting psychiatric illness, during or upon discontinuation of varenicline therapy.

A 48 year old married woman with a history of major depression. She was in antidepressant treatment with 100 mg/day sertraline for 2 years and was euthymic for last 18 months. She never had symptoms of mania or hypomania. She had no family history of psychiatric illness. She was given a prescription by her doctor for varenicline, by dosing titrated to 1-mg BID by day 8. On day 14, she stopped smoking, with no withdrawal symptoms. She had no mood or behaviour changes during 12-week treatment period. At the end of 12 weeks, she was admitted to hospital with the diagnosis of mania with psychotic features.

There are case reports of mania in the context of initiating varenicline treatment, but this is the first case, to our knowledge, of a patient developing mania upon discontinuation of varenicline therapy. In this case we can suspect varenicline withdrawal may have contributed to the emergence of mania; however, this has not been reported in the literature. Also it's possible that antidepressant-like properties of varenicline, may have potentiated the effect of sertraline and a manic shift occurred.

The bipolar disorder, characterized by mania episodes, hypomania and depression is a serious recurring perturbation associated not only to severe sleep pattern disturbances but also to a significant circadian disruption. These fluctuations/changes have a great impact on quality of life and in the disease prognosis.

Review the main sleep pattern alterations/fluctuations observed in the bipolar disorder, their clinical impact and the involved pathophysiological mechanisms.

Complaints about sleep pattern changes may occur during any phase of the disease. These include frequent night-time awakenings, poor sleep quality, reduction of the total sleeping time (TST) and decreased latency and increased density of REM sleep. In the depressive phase, patients also reveal insomnia/hypersomnia, difficulty waking up and excessive daytime sleepiness.

Sleep pattern fluctuations are frequent in bipolar disorders and have a great clinic implication as a symptom. The corrections of sleep disturbances observed in bipolar disorder should be considered a therapeutic priority, since they prevent symptoms recurrence and smooth the socio-professional integration, thus providing greater success in patient’s rehabilitation and quality of life.

The substance use is common among people with a diagnosis of bipolar disorder. In addition, alcoholism and bipolar disorder coexist with a high frequency. This association is higher in men than in women, and this consumption is thefactor that most strongly influences the hospitalization.

To analyze the clinical, epidemiological, diagnostic approach and evolution of bipolar disorder andalcoholism.

Review of thesubject on recent articles of alcoholism in bipolar disorder.

The stages of mania associated with alcohol consumption up to 40% of casesand are more common at this stage that in depressive. This association isgreater than that which occurs between alcoholism and schizophrenia ordepression. Patients with bipolar disorder who have mixed and irritative statesand those with rapid cycling have a prevalence of alcohol consumption and sustanceuse higher than those who do not use substances. It has also been observed thatthe consumption of alcohol, and substance use can change the symptoms of maniaand turn them into a mixed state symptoms. It also states that rapid cycles canbe precipitated by increased alcohol consumption during rotation from mania todepression.

The associationof bipolar disorder with addictive behaviors is a factor that worsens theprognosis and comorbid alcohol itself is associated with a poor prognosis. Close monitoring of bipolar patients and especially in those who consumealcohol is very important.

Asenapine (ASE) is a second-generation antipsychotic with a unique pharmacological profile, that was recently approved for the treatment of moderate/severe manic episodes (ME). Real-world data on rapidity of action in inpatient settings are lacking.

1) rating scale variation after 7 days (T0-T1) of treatment with ASE in patients hospitalized for ME during Bipolar I Disorder or a Schizoaffective Disorder

2) follow-up on continuity of treatment at 6 months

Determination of short-term effects of ASE and continuity of treatment in an observational, real-world study.

All inpatients who met DSM-IV-TR criteria for ME treated with ASE were recruited in the 2 years after the drug was available. YMRS and BPRS were administered at T0 and T1. 6 months follow-up data were collected from patients taking ASE at discharge.

The mean total YMRS score decreased by 12.6 (SD ±10.3; t(17)=5.2, p<.005), implying a mean 37.8% improvement. A statistically significant reduction was observed for all YMRS items, except for 'sexual interest”.

The mean total BPRS score decreased by 17.2 (SD ±14.9; t(17)=4.9, p<.005). A statistically significant reduction was observed for several items, including 'conceptual disorganization”, 'grandiosity”, 'unusual thought content”, 'excitement”.

At hospital discharge, ASE was confirmed in 55% of patients, 18% of which were still taking the drug at 6 months: lack of efficacy and poor adherence were found to influence continuity of treatment rather than specific side effects.

ASE is rapidly effective in the first week of treatment, but is subject to a high discontinuation rate on the long term.

This review aimed to examine the impact of cannabis use on the incidence of manic symptoms and on their occurrence in those with pre-existing bipolar disorder

A systematic review of the scientific literature using the PRISMA guidelines. PsychINFO, Cochrane, Scopus, Embase and MEDLINE databases were searched for prospective studies.

Six articles met inclusion criteria. These sampled 2,391 individuals who had experienced mania symptoms. The mean length of follow up was 3.9 years. Studies support an association between cannabis use and the exacerbation of manic symptoms in those with previously diagnosed bipolar disorder. Furthermore, a meta-analysis of two studies suggests that cannabis use is associated with an approximately 3-fold (Odds Ratio: 2.97; 95% CI: 1.80 to 4.90) increased risk for the new onset of manic symptoms.

Our findings whilst tentative, suggest that cannabis use may worsen the occurrence of manic symptoms in those diagnosed with bipolar disorder and may also act as a causal risk factor in the incidence of manic symptoms. This underscores the importance of discouraging cannabis use among youth and those with bipolar disorder to help prevent chronic psychiatric morbidity. More high quality prospective studies are required to fully elucidate how cannabis use may contribute to the development of mania over time.