Frontal lobe lesions are associated with a range of behavioral and cognitive changes that vary according to location, extent, depth and laterality of the lesion. Behavior disturbances are usually divided into positive (related to disinhibition) and negative (related to apathy), while cognitive deficits mainly involve prefrontal functions, including executive functions and social cognition.

In 2009, a 42-year-old man was admitted to the Emergency Department with a cerebrospinal fluid (CSF) rhinorrhea, 2 days after elective endonasal sinus surgery. The fistula was surgically corrected. Three years later, he developed frontal epileptic seizures. A CT scan was performed and revealed multiple right frontobasal cysts and bifrontal inflammation with extensive edema. In 2013, he underwent surgical drainage of the cysts and repair of the anterior cranial fossa. Family members reported that his personality had changed progressively over the 5 years since the endonasal intervention, and he had become reckless, impulsive, sexually disinhibited and aggressive towards his family, showing lack of insight and difficulty in accepting his limitations. He became unable to manage his finances or carry tasks like paying bills, dealing with paperwork and keeping important documents. He also started consuming large amounts of alcohol, which worsened his epilepsy. Because of these behaviors, he was referred to a Psychiatric consultation, where he started medication and underwent a neuropsychological evaluation.

This case demonstrates the neuropsychiatric changes associated with a frontal lobe syndrome, and the clinical manifestations of frontal lobe epilepsy. Moreover, it encourages the reflection that no surgery is risk-free.

Conversion disorder is a diagnosis that can cause a lot of stigma in patients and their families as well as feelings of helplessness in medical care professionals. Patients with conversion disorder usually present to a hospital in despair, with acute motor or sensory deficits, with symptoms closely mimicking a cerebrovascular accident, seizures, or other frightening diagnosis. After a thorough noncontributory medical and neurological work up, when patients hear that “nothing is wrong with them and it's all in their head” they may further develop decompensation or lack of symptom resolution.

1. 1. Develop a strong therapeutic alliance.

2. 2. Educate the primary team, patients and their families about conversion disorder.

3. 3. Bio-psycho-social assessment.

4. 4. Identify the risk factors and the traumatic event that lead to the symptoms.

1. 1. Decrease the stigma of conversion disorder among patients and staff.

2. 2. Identify the triggers.

3. 3. Rapid resolution of symptoms.

4. 4. Decrease the risk of future episodes.

We are reporting a case series consisting on nine cases and the review of relevant literature. All the patients were initially seen in the general medical hospital.

By increasing patient's insight into their condition, their compliance with the diagnostic interview and treatment plan improved, which lead to rapid resolution of their symptoms.

More education needs to be provided to the primary medical team regarding a therapeutic approach towards a patient with suspected functional disorders. Rapid involvement of a well trained psychiatrist in working with patients with conversion disorder is crucial.

Psychosocial and psychiatric aspects influence adherence to treatment and, consequently, the prognosis of liver transplantation. Psychosocial and psychiatric pretransplant assessment helps physicians to make clinical and therapeutic decisions.

To describe psychosocial and psychiatric aspects of patients awaiting liver transplant at the Coimbra University Hospital Centre.

A psychosocial and clinical evaluation questionnaire developed for our study was responded by 31 patients referred for psychological/psychiatric assessment to the Liaison Psychiatry Consultation at Coimbra University Hospital Centre, during the year of 2012.

Mean age was 48 years. 52% of them were females and 71% were married. Mean years of shooling was 7 years. At the time of the evaluation 35% were working, 19% were not actively working due to their hepatic disease and 23% were unemployed. The main causes for transplant were alcoholic liver disease (55%) and familial amyloidotic polyneuropathy (26%). More than half of patients (58%) had psychiatric history, mostly alcoholism and depression. At the time of evaluation, 42% presented depressive and/or anxiety symptoms. 19% did not reveal full understanding about their liver disease, mainly related to transplant surgical complications and medication side effects. Social and medical satisfaction was reported by 58% and non and poor satisfaction was identified in 3% and 26%,respectively.

Results indicate that psychosocial and psychiatric risk factors of nonadherence behavior after transplant are frequent on patients awaiting liver transplant. Psychological/psychiatric assessment is very important for selection and orientation of these patients.

the relationship between hypothyroidism and mood disorder espacially depressive disorder is well described. However, there are few studies reporting psychotic symptoms (such as delusions, auditory or/and visual hallucination) in the setting of thyroid hormone defeciency.

this study highlights psychosis as a possible presenting symptom in hypothyroidism.

case report and review

we report the case of a female patient aged 36 years old with no family or personal psychiatric history, who presented with delusion, depressive disorder and auditory hallucination . the CT scan was without abnormality . the thyroid screening finds a severe hypothyroidism after 3 months of radiotherapy witn Iodine131 [FT4 = 2.49 ρmol/l, TSH 135.28 μUI/ml]

psychotic symptoms are an uncommun presentation of hypothyroidism and treatement choices are contreversial.

Organic disorders can mimic all kinds of psychiatric illnesses. Some neurological diseases including front location are misleading when psychiatric manifestations represent the beginning shape or dominate the clinical. It may be dementia, mental confusion, mood disorders and psychotic disorders.

the aim of this study was to point out through the study of a clinic observation, discuss the importance of the importance of organicity to psychiatric disorders and the resulting difficulties of diagnostic and therapeutic order.

We report the case of a 72 year old man without chronic disease identified, consulted in February 2013 emergency following a head injury with loss of initial knowledge . The brain scanner (TDM) was normal. In July 2013, the patient began to exhibit behavioral problems in such wandering, memory problems, slow ideation, delusions of persecution with audiovisual hallucinations. This table psychotic moved in a very insidious and fluctuating intensity. The patient was seen in psychiatry at the worsening of symptoms. Exploration has confirmed the diagnosis of chronic subdural hematoma (HSDC) without signs of compression. The surgery consisted of an enlarged trepanation and evolution was favorable.

It appears from this case and review of the literature that various psychiatric manifestations may reveal an HSDC and that, in the elderly, neuroimaging should be systematic, even for minor symptoms. The total resorption led to the disappearance of psychiatric symptoms in most patients, but this remains a topic of discussion for patients who retain residual symptoms, even after resorption of the mass.

blepharospasm is a focal dystonia of the orbicularis oculi muscles, provoking intermittent or sustained eye closure, sometimes severe enough to cause functional blindness. Basal ganglia connections seem to have a major role in its still largely unknown physiopathology. Though usually idiopathic, in the last decades many authors have been linking it to neuropsychiatric diseases, such as obsessive-compulsive disorder. Hemifacial spasm (HFS) consists in unilateral, sudden and intermittent contraction of muscles innervated by the facial nerve. Unlike blepharospasm, an identifiable etiology is frequent. Current best treatment for both diseases consists in botulinum neurotoxin type A application (BoNT/A).

to characterize psychological profile of patients with idiopathic blepharospasm or HFS and analyze significant differences.

consecutive patients diagnosed with one of the above mentioned diseases, visiting an outpatient clinic of BoNT/A application, were evaluated regarding the existence of stress, depression, and obsessive-compulsive behavior. Personality traits, quality of sleep and quality of life were also analyzed. Validated scales were used to assess these domains.

eighty patients were included, 43 with HFS and 37 with idiopathic blepharospasm. After explanation and agreement, demographic, social and clinical data was collected, in addition to questionnaires. Statistical analysis focuses on group differences and correlation with clinical and psychological parameters.

the proposed involvement of basal ganglia in motor and affective domains of blepharospasm must lead to a comprehensive approach of these patients, including a psychological evaluation and pharmacological treatment directed not only to motor spectrum, as it is currently usual, but also matching coincident psychopathology.

Anxiety may be associated with diverse medical conditions, among which joint hypermobility syndrome. Joint hypermobility (JHM) is characterized by increased elasticity and can be advantageous in specific activities, such as dance or gymnastics. On the other hand, joint hypermobility syndrome (JHS) is a more complex condition including other clinical symptoms, especially a history of injuries, skin signs, instability and pain.

To investigate the prevalence of JHM and JHS throughout ballet career and the association between anxiety and joint hypermobility in a sample consisting of ballet dancers.

study included 145 dancers, divided into three groups: students (n=59), teachers (n=37) and professional ballerinas (n=49). Participants completed self-rating instruments assessing JHM (five-part questionnaire), anxiety (BAI), social anxiety (SPIN), panic (Patient Health Questionnaire – Brief PHQ) and pain (Brief Pain Inventory [BPI]; Self-Estimated Functional Inability because of Pain [SEFIP]). Ballet dancers also underwent a clinical evaluation based on Beighton score and Brighton criteria.

Participants with JHM had higher scores in neurophysiological subscale of the BAI, but less social anxiety symptomatology. JHS correlated with the subjective and panic subscales of the BAI and with SPIN. Participants with JHS also presented higher scores in specific items of BAI as in specific items of SPIN.

our data suggest that JHS seems to be more consistently associated with anxiety than the 'isolated hypermobility” (JHM). Nevertheless, the strenght of the correlation between anxiety and JHS was moderate. Data also provided elements to discuss important features of JHM, JHS and pain throughout the ballet career.

Alcohol dependence is seen in approximately 15-20% of hospitalized patients. Delirium tremens is a serious manifestation of alcohol withdrawal. Understanding physicians' knowledge, attitudes and practices is vital to facilitate early recognition and timely management.

Assess knowledge, attitudes and practices of managing alcohol withdrawal in physicians in Tan Tock Seng Hospital, Singapore.

An anonymous self-administered survey assessing demographics, training experience, department of service, knowledge and attitudes was distributed between July to September 2014 to all registered medical practitioners in fifteen departments within the general hospital.

Six hundred and fourty surveys were distributed and 259 responses received with a response rate of 40.5%. Medical disciplines comprised of 55.1% of the responses and surgical 20.9%. Among the physicians surveyed, 61% were male, 39.8% were less than 30 years old, most were junior doctors/trainees (56%) and 71% saw 0-1 case of alcohol withdrawal/delirium tremens per month.

Overall, physicians felt they had been exposed to management of alcohol withdrawal, there was value in learning how to manage (71%) and learning how to manage should be part of core training (73.4%). Only 40.5% felt they were competent in managing and most felt it was not difficult to learn (43.7%). A majority (58.6%) felt they would be more comfortable if there was a protocol available and 36.6% hoped for more education in this area.

There are positive attitudes towards learning how to manage alcohol withdrawal and a protocol driven approach coupled with education as part of core training will be of value.

The end stage of a disease is a critical condition of the human life. This state is dominated by suffering, physical impairment and by activities that are aimed to satisfying the basic necessities of everyday (relief of pain, alimentation, personal hygiene etc.). The lives of patients change dramatically and occur a number of attempts to the adaptation that precede the exitus. This situation causes intense feelings and emotional reactions in physicians.

The purpose of this study is to analyze the reactions of physicians to terminally ill patients.

The consultative psychiatry in University Hospital of Sassari has allowed us to observe specific physician’s reactions to patients with terminal illnesses.

The thought of death generates fear, global depression and suffering in patients. Consequently, the specter of death, because of its seriousness, causes a psychological rejection in the physician also. Frequently there is a difficulty to accept the patient's pain, to communicate with him clearly and with empathy. The emotional reactions of the physicians are denial, avoidance and splitting as defence mechanisms.

In the light of these considerations we believe that it is necessary an appropriate training of health staff about this type of patients and a special attention of the psychiatrist to the discomfort of physicians.

With the introduction of antiretroviral treatment, the survival rates of Human Immunodeficiency virus (HIV) patients have improved significantly. However, the incidence of HIV- associated neurocognitive disorders (HAND) gained importance and represents actually a significant public health problem.

Neurological soft signs (NSS) refers to subtle neurological abnormalities in motor and sensory performance. The presence of these symptoms has been widely described in patients with mental diseases like Schizophrenia or Alzheimer’s Disease, but have not been studied in HAND despite its known subcortical physiopathology.

To study the prevalence HAND in a Chilean cohort of HIV patients and describe its association to NSS.

HIV patients without history of head injury trauma or opportunistic infections of the CNS were recruited from the HIV clinic, underwent a thorough clinical interview and neuropsychological testing. Healthy controls were recruited from the community. All participants were assessed with the Heidelberger NSS scale. HAND was diagnosed using NIMH and NINDS criteria.

Until now, 35 HIV+ patients and 18 controls completed the described assessment. 11 patients were cognitive healthy, 11 with Asymptomatic Neurocognitive Impairment (ANI) and 13 with Mild Neurocognitive Disorder (MND). NSS total score differed significantly between groups (F= 2,92 (DF=3), p<0.05), with MND and ANI patients showing the highest score. Duncan post hoc test showed group differences in NSS total scores with Controls >ANI, MND and Cognitive healthy HIV>MND.

Our data supports the use of NSS as a marker of HAND. It should be considered in the clinical examination of HIV patients.

Antidepressants can induce SIADH and it can be a serious complication. It is frecuently asociated with SSRIs (Selective Serotonin Reuptake Inhibitors) but this syndrome can be caused by another antidepressants, drugs and another causes can be involved.

We report the clinical course of an antidepressants induced SIADH with SSRIs and Mirtazapine and propose psychopharmacologic alternatives.

We describe the case of a 25 years old man, hypertensive in treatment with thiazides, polytraumatized as a result of a suicide attempt. The patient was treated with Sertraline and a SIADH occurred. Stopped Sertraline and diuretics and then, the patient was treated with Mirtazapine and Bisoprolol but hyponatremia was persistent. Then we use Trazodone and the sodium levels were normalized.

Hyponatremia is a potentially dangerous side effect of antidepressants and is not exclusive to SSRIs. Current evidence suggests a relatively higher risk of hyponatremia with SSRIs and venlafaxine, especially when combined with patient risk factors. In our case, the risk was increased by the polytrauma and thiazide diuretics. Although, according to the literature, the risk associated with mirtazapine is moderate, in our case, hyponatremia was persistent and sodium levels were normalized when stopped Mirtazapine and started Trazodone.

We have to take into account risk factors associated with SIADH and modify them as far as possible. Trazodone could be an alternative treatment for patients with SIADH.

Primary or secondary delusional parasitosis is a phenomenon that often has a clear and memorable presentation. Stimulants and cocaine in particular, have a long history of producing psychotic episodes. A famous example of these is the 'cocaine bugs”. It has been noted that this is part-delusion and part-hallucination. There have been reports of delusions of parasitic infestation occurring in psychotic disorders as well. We are reporting a case of one patient with delusions of parasitic infestation who self inflicted a trauma to his ear by attempting to remove “a bug”.

1. 1. Obtain a thorough substance, psychiatric and medical history.

2. 2. A close collaboration between dermatologist, medical team and psychiatrist involved in the case is recommended.

3. 3. Antipsychotic and substance use treatment when stimulant use disorder is identified is identified.

1. 1 Identify the etiology of delusional parasitosis.

2. 2 Prompt diagnosis.

3. 3 Implement adequate treatment.

We are reporting a case of a patient with delusions of parasitic infestation and the review of relevant literature.

On admission patient’s urine drug screen was positive for amphetamines and cocaine. He had a questionable history of Schizoaffective disorder. Parasitic infestation was rulled out by the medical team. Pt achieved symptoms resolution during psychiatric hospitalization and treatment with antipsychotics.

Patients with delusions of parasitic infestation can at times present significant danger to self during the attempts to remove 'a parasite”,

therefore a prompt diagnosis and adequate treatment are of great value.

Systemized research on the social representations of mental health in minority groups is scarce and it is even scarcer with Roma communities.

This paper describes a research conducted from the perspective of social representations theory exploring the understanding of mental ill-health amongst Roma communities residing in the center region of Portugal (Coimbra).

A qualitative ethnographic study was conducted. Data from observations, interviews with key informants, field notes and Focus groups were analyzed

Findings suggest that the culturally-based conceptions of mental health and emotional well-being in these Roma participants have a holistic approach, without a clear separation between the concept of 'physical health” and 'mental health”.

In this study, the notion of mental health and emotional well-being was strongly associated with the family’s well-being, including the extended family, and not only with the individual well-being

Mental health promoting programs in Roma communities should integrate families in structural interventions and, an ecological approach.

An audit was designed to compare 3 ethnic groups(White British(WB), South Asian(SA) and Other (Black and others) to identify trends in Diagnosis, Length of admission, No. of admissions, Status on admission, Services on Discharge. The initial cycle was commenced in 2009,data were collected for 1 year. More people from ethnic minorities were detained, had longer hospitalstay,were diagnosed with psychosis more than WB.

Observe outcome of assessment and treatment of patients from different ethnic background,after recommendations of the 2009 audit were implemented (better use of intrepreting services, educational events for carers and patients, effective discharge planning)

repeat the auditcycle to close the loop

data were collected, covering a period of 1 year (1/4/12-31/3/13). Number of patients:241

Diagnosis: 47% of SA were diagnosed with psychotic disorder compared to 18% of WB,more depressive disorders recorded in SA(16%) compared to previous audit(3%)

Length of admission: similar length of stay in SA(69%) and WB(71%)for admission < 28 days, similar results for admission >28 days

Number of admissions: 18% of WB have > 2 admissions compared to 9% of SA

Status on admission: 41% of SA are detained compared to 21% of WB.

Services on discharge: More SA(13%) are now referred to IHBT (Intensive Home Base treatment) compared to previously(2%) and is comparable to WB(12%)

Better use of interpreting services improved communication, timely assessment and lead to reduced length of stay. Better liasion with community/crisis services lead to effective discharge planning, reduced length of stay. In-depth audit of pathway leading to MHA admission is needed.