Substance Use During Pregnancy.

Pregnancy is a period of transition with physical changes in the maternal body but also mental and psychological ones. This phase may be accompanied by symptoms of anxiety, depression or irritability, which are part of non-pathological adaptation mechanisms. These symptoms can, however, be intense and constitute real psychiatric syndromes, particularly when the woman presents vulnerability factors. While fetal exposure to alcohol and other drugs is one of the leading preventable causes of developmental delay and birth defects in newborns, substance use during pregnancy is common, particularly in Europe. There is no amount and no time during pregnancy where consuming alcohol and other substances of abuse is safe. This narrative review reflects the point of view of the obstetrician, the constraints of his therapeutic framework with its limitations of time, training and tools to detect and manage substance-related disorders. Validated detection questionnaires are poorly adapted to obstetric practice; detection and first brief interventions can be delegated to save time but at the risk of reducing the involvement of the obstetrician. The combined management of pregnancy and addictions by a psychiatrist and an obstetrician comes up against different frameworks and working deadlines in the two disciplines.

Awake Bruxism Treated with Pregabaline in a Patient with Generalized Anxiety Disorder.

BACKGROUND: Bruxism is excessive teeth grinding or jaw clenching. Several symptoms are commonly associated with bruxism, including hypersensitive teeth, aching jaw muscles, headaches, tooth wear, and damage to dental restorations. There are two types of bruxism, awake bruxism and sleep bruxism. Awake bruxism is generally treated by dentists and maxilla-facial surgeons through several treatment modalities such as, counselling about triggers, relaxation, occlusal splints and botulinum toxin type A injections. METHODS: We will present the case of a 21-year-old woman presenting mood swings with a high level of anxiety and concentration difficulties since childhood. She also complained of awake bruxism. Intelligence was evaluated using The Wechsler Adult Intelligence Scale - Fourth Edition (WAIS-IV). Attention-deficit hyperactivity disorder (ADHD) was investigated through a neuropsychology test. RESULTS: Intelligence evaluation showed normal intellectual function. Neuropsychology test showed a profile corresponding to ADHD. Bupropion XR 300 mg was initiated for ADHD. Pregabalin was prescribed for general anxiety syndrome. The patient reported a complete disappearance of awake bruxism at a daily dose of 375 mg, with no occlusal appliances. Following the improvement of the anxiety symptoms, the attempt to reduce the dose twice leading to the recurrence of bruxism. CONCLUSIONS: A 21 years old female treated with 375 mg daily doses of pregabalin for generalized anxiety disorder experienced a significant reduction of daytime bruxism. More studies are needed to determine whether pregabalin has a long term effect against awake bruxism.

Neuroleptic malignant syndrome in a patient treated with clotiapine.

BACKGROUND: Neuroleptic malignant syndrome (NMS), which is linked to the use of antipsychotic medication, is a potentially lethal neurological emergency. The interest of our study is that NMS induced by the use of clotiapine has never previously been described. SUBJECTS AND METHODS: We present the case of a 61-year old man whose sleep disorders were treated with clotiapine 40 mg/day. After 7 days of taking 40 mg clotiapine, the patient presented with a deterioration of his general health which had gradually taken hold, with altered consciousness accompanied by generalised muscle rigidity and hypersalivation. Laboratory blood tests revealed elevated levels of Creatine Phosphokinase (CPK) at 812 U/l. The patient was diagnosed with NMS and treated accordingly. RESULTS: The mechanism that underlies the appearance of NMS remains largely unknown. Clotiapine is a second-generation antipsychotic, first released onto the market in the 1970s, and is available in a few countries, including Belgium. NMS is treated as a medical emergency due to the possibility of morbidity and death. The first step in the treatment of NMS consists in withholding the agent suspected of provoking the symptoms. CONCLUSIONS: NMS is difficult to diagnose due to a great variability in clinical presentations and the absence of specific tests and laboratory results. The use of clotiapine in treating sleep disorders can provoke NMS as a life-threatening side-effect. To our knowledge, this is the first time a case of clotiapine-induced NMS has been published.

Incidence and prevention of deep vein thrombosis in restrained psychiatric patients.

BACKGROUND: Although physical restraint is still used in psychiatric inpatient settings, it sometimes causes serious side effects, including deep vein thrombosis (DVT) and resulting pulmonary embolism. The aim of this study was to review the literature investigating the incidence of the DVT in restrained psychiatric patients, to identify the risk factors of this condition and the effectiveness of routine prophylaxis. SUBJECTS AND METHODS: Studies investigating associations between deep vein thrombosis and restrained psychiatric patients were searched in the Pubmed database. More than 700 articles were sorted independently by two of the authors using predefined criteria. Only research articles, reviews and meta-analyses were selected for this review. RESULTS: 5 articles published between 2010 and 2016 were selected. Although antipsychotics and restrain are known to be thrombogenenic, in all retrospective studies, with anticoagulant prophylaxis for those restrained for more than 12 or 24 h, incidence of DVT in restrained psychiatric patients was almost not existent. Controversially, in a comparative study by Ishida, although deep sedation and physical comorbidities were associated with the occurrence of DVT, not using of anticoagulants was not associated with any increased incidence of DVT. DVT may be overlooked because psychiatric patients are often unaware of leg symptoms because of their psychiatric disease and induced sedation. Furthermore most DVT, in particular distal DVT are asymptomatic. When screened and assessed with more appropriate methods such as plasma D Dimer and ultrasound scanning the incidence of DVT reaches 11.6%. CONCLUSION: The incidence of DVT in restrained psychiatric patients was not low in spite of prophylaxis. These findings emphasize the importance of regular screening of and thorough assessments of DVT, especially in restrained psychiatric patients.

A transient personality disorder induced by football matches.

BACKGROUND: Personality disorders are a class of mental diseases characterized by inflexible and maladaptive patterns of behavior, cognition, and inner experience, involving several areas of functioning, such as affectivity, impulse control, ways of perceiving and thinking and reaction to stress factors. In the literature, personality disorders have always been described as stable patterns of long duration, and their onset can be found during adolescence or early adulthood. These patterns are associated with significant distress or impairment in a patient's life in which a main element affects every aspect of living, and in which no biological or other pathologies exist to assist in its identification. Therefore, they often lead to comorbidities such as dysfunctional anxiety, drug abuse, major depression and suicide. SUBJECTS AND METHODS: We present a case of a 37-year-old man, who came to the outpatient department needing support to quit smoking. During the follow up, he described some transitory changes in his personality while watching football (soccer) games. These episodes were characterized by inappropriate anger crises, rapid and dramatic shifts in emotional tone, dysphoria and superstitious and magical beliefs with paranoid elements; connecting himself, his family and friends to players in the match and to the unfolding of the game. Every manifestation was induced by the football match, and there were no signs of difficulty in handling impulses and in managing relationships, or any superstitious beliefs, outside of it. RESULTS: The combination of all the symptoms led us to think about a diagnosis of the borderline personality disorder. There was a lack of managing impulsivity, intense uncontrollable emotional reactions, and episodes of psychotic decompensation with unreal and paranoid connections made between the patient's entourage and the results of the match. CONCLUSIONS: With this case, we propose to consider the personality disorder, not just as a stable and inflexible pattern, but also as a transitory dysfunction induced by stress factors, as in this case, a football match, introducing therefore a new entity: transient personality disorder.

Admitting or Discharging Patients with Opiate or Alcohol Related Problems? Psychiatrist Uncertainty and Welfare Losses.

BACKGROUND: Much attention has focused on variations in therapeutic strategies across catchment areas and the related question of whether the differences in attitudes are due to socio-economic variables in the studied population or to physician uncertainty about making a specific therapeutic recommendation. SUBJECTS AND METHOD: We monitored the emergency admission rate for patients with alcohol or opiate related problems of 9 resident psychiatrists for a year. To rule out differences in population characteristics, the study took place in only one hospital: Brugmann University Hospital, whose catchment area is the north of Brussels. RESULTS: Our results show 3 distinctive practice styles. We suggest that variation in urgent admission rates for patients with alcohol and opiate related problems can be due not only to the socio-economic variables of the population, but also to medical uncertainty about the effectiveness of admission for the treatment of these disorders. CONCLUSION: The extent of uncertainty about appropriate standards of care and the plausible related inappropriate care and welfare losses are discussed.

Bipolar Disorder and Early Affective Trauma.

BACKGROUND: Bipolar disorder is a chronic psychiatric disease with a high prevalence and is a major psychosocial and medical burden. The exact etiological pathways of bipolar disorder are not fully understood. Genetic factors are known to play an important role in the etiology of bipolar disorder. However, high rates of discordance among identical twins and a growing body of evidence that environmental factors such as early stress can influence the onset and course of psychiatric diseases underline the importance of additional etiological mechanisms of bipolar disorders. There has been little investigation about early trauma in bipolar disorder. The aim of this study was to review the literature on the association between early traumatic interactions like child neglect, mistreatment, abuse or early parental separation and the occurrence of bipolar disorder in adulthood or impact on the course of the disease. METHODS: Studies investigating associations between child neglect, mistreatment, abuse or early parental separation and occurrence of bipolar disorder in adulthood or impact on the course of the disease were searched in the Pubmed database. More than 700 articles were sorted independently by two of the authors using predefined criteria. Only research articles, reviews and meta-analyses were selected for this review. RESULTS: 53 articles met the inclusion criteria. To date, four systematic reviews partially addressed our research question. Early trauma is more frequently found in the past of bipolar patients than in the general population. Studies support a harmful effect of childhood trauma on the course of bipolar disease, with more anxious, depressive or psychotic symptoms, an early age of onset and a worse prognosis. CONCLUSIONS: Early trauma is more often found in the past of bipolar adult patients than the general population and studies support a harmful effect of childhood trauma on the course of bipolar disease, with more anxious, depressive or psychotic symptoms, an early age of onset and a worse prognosis. In further studies attention should be paid to the age of trauma occurrence and the definition of trauma. The findings also support the importance of additional psychoanalytic oriented psychotherapy for the treatment of bipolar disorder.

Megadose bromazepam dependence.

BACKGROUND: Benzodiazepines (BZDs) are among the most widely prescribed drugs in developed countries. Since BZDs can produce tolerance and dependence even in a short time, their use is recommended for a very limited time. However, these recommendations have been largely disregarded. The chronic use of BZDs causes a number of serious side effects, i.e. cognitive impairment, falls, traffic accidents, dependence and tolerance. METHODS: We present the case of a 37 years old woman taking daily doses of 220 mg of bromazepam. The patient's anxiety, depression and cognitive status were evaluated with a battery of questionnaires. A sleep laboratory test was performed in search of sleep apneas and sleepiness during the day. A Cerebral PET SCAN was executed in search of altered cerebral metabolism. RESULTS: Blood concentrations of bromazepam reached 7800 µg/L. Questionnaire evaluations showed significant depression and anxiety but only moderate cognitive impairment. Oxygen saturation was normal throughout the Sleep lab test, respiratory events were very few and sleepiness was moderate with an average latency of 9 minutes. Brain cortical glucose consumption was homogeneously slightly reduced. CONCLUSIONS: With doses of bromazepan reaching 15 times the toxic dose, anxiety remained high. Cognition, sleepiness, respiratory sleep events and brain metabolism remained remarkably close to normal.

Management of Demented Patients with Urinary Incontinence: A Case Study.

OBJECTIVE: To assess whether a demented patient with urinary incontinence (UI) could learn to use an adapted version of timed voiding (i.e., instead of being led by a caregiver, the patient learns to perform timed voiding by herself). Indeed, UI affects a large number of patients with dementia and creates a substantial burden to the caregiver. UI is the most common complaint at the time of institutionalization and it is often the cause of premature institutionalization. Timed voiding is a promising intervention, but one whose effectiveness remains to be demonstrated. Additionally, timed voiding has the disadvantage of being constraining for caregivers, requiring them to be present to stimulate the patient to urinate at each of the scheduled occasions. METHOD: The present intervention required the patient to learn (1) to associate an auditory signal from a timer to the action of urination, (2) to reprogram the timer, using the spaced retrieval technique. An ABAB paradigm was used to assess the effectiveness of this program to eliminate urinary accidents. RESULTS: The results of the intervention showed that the use of the timer was effective in helping the patient to reduce her urinary leaks from 1.5 diurnal accidents per week to zero during four months. CONCLUSION: UI in patients with dementia seems treatable. Such intervention could contribute to delay institutionalization of patients with dementia through maintaining their autonomy and reducing the burden of caregivers.

Theory of mind difficulties in patients with alcohol dependence: beyond the prefrontal cortex dysfunction hypothesis.

BACKGROUND: Previous studies have shown that alcohol-dependent (AD) individuals have difficulties inferring other people's emotion, understanding humor, and detecting a faux pas. This study aimed at further understanding the nature of such "Theory of Mind" (ToM) difficulties. METHODS: A total of 34 recently detoxified AD and 34 paired controls were compared based on 2 nonverbal and video-based false belief tasks. These tasks were designed to identify 3 different types of deficits: (i) a deficit in dealing with the general task demands, (ii) a selective deficit in self-perspective inhibition, and (iii) a deficit in tracking the other person's mental state. (i) and (ii) are compatible with the hypothesis of a prefrontal cortex dysfunction being at the origin of AD individuals' social difficulties, while (iii) would suggest the possible contribution of a dysfunction of the temporo-parietal junction in explaining the social difficulties. RESULTS: Group analyses highlighted that AD individuals performed worse on the 2 false belief tasks than controls. Individual analyses showed, however, that just under half of the AD individuals were impaired compared to controls. Moreover, most of the AD individuals who were impaired showed a deficit in tracking the other person's belief. This deficit was linked to disease-related factors such as illness duration, average alcohol consumption, and craving but not to general reasoning abilities, depression, anxiety, or demographic variables. CONCLUSIONS: Just under half of the AD individuals tested showed a ToM deficit, and in most cases, the deficit concerned the tracking of other people's mental states. Such a type of deficit has previously been associated with lesions to the temporo-parietal brain areas, indicating that a prefrontal cortex dysfunction may not be the sole origin of the social cognition deficits observed in alcohol dependence.