[Neurocognitive and social cognition deficits in patients with anorexia nervosa]. / Deficyty neuropoznawcze i spolecznego poznania u pacjentów z jadlowstretem psychicznym.

In the first part of the article the authors present a set of the actual concepts explaining problems of cognitive functions and social cognition currently observed in patients with anorexia nervosa (AN). It is possible; through the neuroimaging research, to get better understanding of the brain specifics in these individuals. Even though, the AN remains a disease with very complex and multifactorial etiology which remains a huge medical challenge. Currently, popular is the view that takes into consideration the integrating role of the insula and subcortical structures (such as hippocampus, amygdala, thalamus) in the regulation of cognitive and emotional processes in people suffering from AN. There is still an open problem, however, of the selection of therapeutic interventions targeting these deficits. The second part of the article presents the attempt to describe deficits in neurocognitive and social cognition in people with AN occurring prior to illness, during and after the recovery. Particular attention has been paid to the most frequently described in the literature--neurocognitive deficits such as rigidity of thinking, weak central coherence, and deficits in social cognition, including mental processes of perception and expression of emotions, disorders of the theory of mind (ToM) and empathy. The results of previous studies, their scarcity in Poland, do not give a satisfactory answer to the question whether the above mentioned disorders are a feature of endophenotype or condition in an episode of the disease. Research point to the more permanent nature, which may be more resistant to therapeutic modifications.

[Functional polymorphism of genes inactivating biogenic amines and cognitive deficits in paranoid schizophrenia]. / Funkcjonalny polimorfizm genów enzymów inaktywujacych aminy biogenne a deficyty procesów poznawczych w schizofrenii paranoidalnej.

AIM: The aim of the work was to assess relationship between gene polymorphism of enzymes influencing dopaminergic-, serotoninergic, and noradrenergic transfer and cognitive functioning of paranoid schizophrenic inpatients (ICD-10). METHOD: The following methods have been used in the study: The Test of Everyday Attention (TEA) and The Visual Object and Space Perception Battery (VOSP), psychiatric scales (SAPS, SANS, BDI) and techniques of genetic engineering (PCR reaction, RFLP and VNTR techniques). Subject groups included 100 schizophrenic patients (57 male) and 50 healthy controls (20 male). RESULTS: The results revealed positive correlation between polymorphism of Vall 58MetCOMT and cognitive deficits in schizophrenic patients. No statistically significant relationship was elicited between gene polymorphism of Val158Met COMT and VNTR MAO-A in promoter area and schizophrenia onset. Allelic polymorphism ofVall58Met OMT and VNTR MAO-A in promoter area did not differ between the subject groups. The patients with genotype Val/ Val of polymorphism Val 158MetCOMT showed major cognitive deficits.

Attentional and emotional functioning in schizophrenia patients treated with conventional and atypical antipsychotic drugs.

BACKGROUND: Effectiveness of antipsychotics in treating emotional and cognitive deficits in schizophrenia still remains controversial. The aim of our study was to assess emotional and cognitive functioning in schizophrenic inpatients currently treated with typical antipsychotics (perphenazine, perazine, fluphenazine, and haloperidol) and in another group of schizophrenic inpatients currently on atypical antipsychotics (olanzapine, risperidone, amisulpride, and quetiapine). MATERIAL/METHODS: One hundred patients with DSM-IV schizophrenia or schizoaffective disorders (39 treated using typical antipsychotics and 61 treated with atypical antipsychotics) under naturalistic treatment conditions, and 50 healthy controls were given the following: Test of Everyday Attention, Facial Emotion Recognition Test, Facial Memory Recognition Test, and "Reading the mind in the eyes" Test. RESULTS: Patients with a diagnosis of schizophrenia revealed the following deficits: facial emotion perception, empathy /theory of mind, visual selective attention/speed, attentional switching, and auditory-verbal working memory. Our results show a significant difference between schizophrenic and healthy controls in all tasks, with schizophrenic patients performing worse than controls. Interestingly, our patients on atypical neuroleptics performed similarly compared to schizophrenic patients treated with conventional neuroleptics on all tasks provided. There were some significant relationships between emotional and cognitive deficits and clinical variables. CONCLUSIONS: Our findings remain consistent with other recent studies in which atypical antipsychotics did not show a clear advantage over typical antipsychotics on both emotional and cognitive functioning.

[Functional polymorphism of genes inactivating catecholamines and emotional deficits in paranoid schizophrenia]. / Funkcjonalny polimorfizm genów enzymów inaktywujacych katecholaminy a deficyty procesów emocjonalnych w schizofrenii paranoidalnej.

AIM: The aim of our work was to assess qualitatively and quantatively emotional deficits in patients diagnosed with schizophrenia following ICD-10 criteria in early and late stages of the schizophrenic process and the evaluation of the relationship between genes polymorphism of enzymes influencing dopaminergic, serotoninergic, and noradrenergic transfer and emotional functioning of the examined patients. METHOD: In our study the following methods have been used: Short Recognition Memory test for Faces (TPRT), Facial Expression Recognition Test (FERT), "Reading the mind in the eyes" Test and psychiatric scales (SAPS, SANS, BDI) and molecular techniques (PCR reaction, RFLP and VNTR techniques). 100 paranoid schizophrenia patients (43 female and 57 man) and 50 healthy controls (30 female and 20 man) were invited to participate in the study. RESULTS: Our results revealed an association between polymorphism of Val158Met COMT and emotional deficits in schizophrenic patients. Furthermore, the relationship between polymorphism of MAO-A and empathy/theory of mind deficit was found. No relationship was elicited between polymorphism of Val158Met COMT and VNTR MAO-A in the promoter area and schizophrenia onset. Allelic distribution of polymorphism of Val158Met COMT and VNTR MAO-A in the promoter area did not differ between the groups. The patients with genotype Val/Val of polymorphism Val158Met COMT showed major emotional deficits. The patients with genotype of 4/4 of polymorphism VNTR MAO-A showed deeper empathy/theory of mind deficits.

[Genetic polymorphism of a MAO in mental disorders]. / Polimorfizm genu MAO w zaburzeniach psychicznych.

Amin oxydase (monoaminoxydase, MAO) is an enzyme which catalyses chemical reactions of biogenic amines. It plays a crucial role in pathogenesis of mental disorders associated with the dysfunction of the central monoaminergic systems (schizophrenia, affective disorders, some forms of alcohol dependence, and personality disorders). MAO has got two isoforms such as MAO-A and MAO-B. The genes coding of MAO are localised at the short arm of chromosome Xp11. In each sequence of genes there is a probability of functional polymorphism occurrence which leads to a variable expression or a change of MAO activity and it exerts an impact on the onset of some mental disorders, such as: schizophrenia, affective disorders, some forms of alcohol dependence, and personality and behavioural disorders. Dynamic development of psychiatric genetics may have crucial impact on considerable progress in understanding molecular background of mental disorders.

[Genetic polymorphism of COMT in mental disorders]. / Polimorfizm genu COMT w zaburzeniach psychicznych.

Many neurobiochemical studies show abnormalities within dopaminergic neuropathways, particularly altered dopamine transmission in etiopathogenesis of mental disorders. Evaluation of genes associated with the dopaminergic system include five well known subtypes of dopaminergic receptors, dopamine transporter and enzymes associated with the synthesis and degradation of dopamine, such as tyrosine hydroxylase, dopa decarboxylase, monoamine oxidase (MAO) and catechol O-methyltransferase (COMT). None of these genes is 'a' pathognomonic factor of schizophrenia onset. In each sequence of the following genes 'a' functional polymorphism can occur. The polymorphisms of genes MAO-A and COMT have been described in relation to various expression or altered activity of these enzymes, their influence on cognitive functions, affective and anxiety disorders, learning disabilities, aggressive behaviour, eating disorders or gender differences.

A reversal of the normal pattern of parahippocampal response to neutral and fearful faces is associated with reality distortion in schizophrenia.

BACKGROUND: Individuals with schizophrenia demonstrate impaired recognition of facial expressions and may misattribute emotional salience to otherwise nonsalient stimuli. The neural mechanisms underlying this deficit and the relationship with different symptoms remain poorly understood. METHODS: We used event-related functional magnetic resonance imaging to measure neural responses to neutral, mildly fearful, and prototypically fearful facial expressions. The sample included 15 medicated individuals with chronic schizophrenia (SZ) and 11 healthy control individuals (CON), matched for gender (all male), age, and years of education. RESULTS: A repeated measures 3 x 2 analysis of variance (ANOVA) revealed a significant interaction between expression intensity and group in right parahippocampal gyrus (p < .01). Individuals with chronic schizophrenia demonstrated a decrease, whereas CON showed an increase, in right parahippocampal gyrus response to increasingly fearful expressions. Between-group comparison revealed greater activation in SZ than CON in right parahippocampal gyrus to neutral faces. The reality distortion dimension, but not neuroleptic medication dose, was positively associated with the right parahippocampal gyral and right amygdalar response to neutral faces in SZ. CONCLUSIONS: An abnormally increased parahippocampal response to neutral faces was positively associated with reality distortion in SZ. This may underlie the previously reported finding of a misattribution of emotional salience to nonsalient social stimuli in schizophrenia.

Disordered emotional processing in schizophrenia and one-sided brain damage.

The work concentrates on the problem of human emotions in healthy and pathologically changed brains, mainly in persons afflicted with schizophrenia or with organic impairments localized in one of the cerebral hemispheres. This chapter presents the state of current knowledge concerning the hemispheric lateralization of emotions among healthy people, psychiatric patients, and patients with one-sided brain lesion, on the basis of clinical observations, the results of experimental work, and the newest neuroimaging techniques. The numerous experiments and scientific methods used to assess the hemispheric lateralization of emotions and the discrepancies in their results point toward a lack of consistent theory in the field of hemispheric specialization in the regulation of emotional processes. Particular scientific interest was taken in the emotions of persons afflicted with schizophrenia, either in its early or late stages. This was inspired by the emotional behavior of schizophrenic patients on a psychiatric ward and their ability to perceive and express emotions during various stages of the schizophrenic process. In order to examine the cerebral manifestations of emotional deficits and the specialization of cerebral hemispheres for emotional processes, the author has described the emotional behavior of patients with unilateral cerebral stroke, i.e., patients with damage to the right or left cerebral hemisphere. Overall, the inferior performance of emotional tasks by right-hemisphere-damaged patients compared to other groups might support right-hemisphere superiority for affect perception despite variations in the stimuli used.

Impaired social cognition processes in Asperger syndrome and anorexia nervosa. In search for endophenotypes of social cognition. / Zaburzenia procesów spolecznego poznania w zespole Aspergera i jadlowstrecie psychicznym. W poszukiwaniu endofenotypów spolecznego poznania.

A growing number of publications indicates presence of significant deficits in social cognition in patients with anorexia nervosa (AN). These deficits appear to be comparable in qualitative and quantitative dimension with impairment of the same functions among people with Asperger syndrome (AS). The aim of this study is to identify subject areas in the field of impairment of social cognition processes among people with Asperger syndrome and anorexia nervosa taking into consideration the potential contribution of genetic pathways of oxytocin and vasopressin in the pathogenesis of these diseases. In the first part of the paper a systematic analysis of studies aimed at the evaluation of the processes of social cognition among patients with AN and AS has been carried out. The results of a significant number of studies confirm the presence of deficits in social cognition in AN and AS. In addition, among patients with AN and AS there exists a similar structure and distribution of the brain functions in regions responsible for social cognition. The second part of the paper describes the role of the oxytocin-vasopressin system (OT-AVP) in the processes of social cognition in AN and AS. Its genetic basis and the possible importance of single nucleotide polymorphisms within the genes: OXT, AVP, CD38, OXTR, AVPR1A and LNPEP have also been presented.

Perception of emotions from faces and voices following unilateral brain damage.

The importance of the right hemisphere in emotion perception in general has been well documented but its precise role is disputed. We compared the performance of 30 right hemisphere damaged (RHD) patients, 30 left hemisphere damaged (LHD) patients, and 50 healthy controls on both facial and vocal affect perception tasks of specific emotions. Brain damaged subjects had a single episode cerebrovascular accident localised to one hemisphere. The results showed that right hemisphere patients were markedly impaired relative to left hemisphere and healthy controls on test performance: labelling and recognition of facial expressions and recognition of emotions conveyed by prosody. This pertained at the level of individual basic emotions, positive versus negative, and emotional expressions in general. The impairment remained highly significant despite covarying for the group's poorer accuracy on a neutral facial perception test and identification of neutral vocal expressions. The LHD group were only impaired relative to controls on facial emotion tasks when their performance was summed over all the emotion categories and before age and other cognitive factors were taken into account. However, on the prosody test the LHD patients showed significant impairment, performing mid-way between the right hemisphere patients and healthy comparison group. Recognition of positive emotional expressions was better than negative in all subjects, and was not relatively poorer in the LHD patients. Recognition of individual emotions in one modality correlated weakly with recognition in another, in all three groups. These data confirm the primacy of the right hemisphere in processing all emotional expressions across modalities--both positive and negative--but suggest that left hemisphere emotion processing is modality specific. It is possible that the left hemisphere has a particular role in the perception of emotion conveyed through meaningful speech.

Ketamine alters neural processing of facial emotion recognition in healthy men: an fMRI study.

Disruption of facial emotion perception occurs in neuropsychiatric disorders where the expression of emotion is dulled or blunted, for example depersonalization disorder and schizophrenia. It has been suggested that, in the clinical context of emotional blunting, there is a shift in the relative contribution of brain regions subserving cognitive and emotional processing. The non-competitive glutamate receptor antagonist ketamine produces such emotional blunting in healthy subjects. Therefore, we hypothesised that in healthy subjects ketamine would elicit neural responses to emotional stimuli which mimicked those reported in depersonalization disorder and schizophrenia. Thus, we predicted that ketamine would produce reduced activity in limbic and visual brain regions involved in emotion processing, and increased activity in dorsal regions of the prefrontal cortex and cingulate gyrus, both associated with cognitive processing and, putatively, with emotion regulation. Measuring BOLD signal change in fMRI, we examined the neural correlates of ketamine-induced emotional blunting in eight young right-handed healthy men receiving an infusion of ketamine or saline placebo while viewing alternating 30 s blocks of faces displaying fear versus neutral expressions. The normal pattern of neural response occurred in limbic and visual cortex to fearful faces during the placebo infusion. Ketamine abolished this: significant BOLD signal change was demonstrated only in left visual cortex. However, with ketamine, neural responses were demonstrated to neutral expressions in visual cortex, cerebellum and left posterior cingulate gyrus. Emotional blunting may be associated with reduced limbic responses to emotional stimuli and a relative increase in the visual cortical response to neutral stimuli.

Perception of facial affect in chronic schizophrenia and right brain damage.

This study was designed to compare the performance of 50 chronic schizophrenics (CS) to that of 30 right brain-damaged patients (R), and 50 healthy controls (N) on several facial perception measures: Emotion Labelling and Recognition, and the Benton Facial Recognition Test. CSs were diagnosed according to DSM-IV criteria and their psychiatric state was assessed using the PANSS scale. All subjects were right handed. Their cognitive state was assessed using the MMSE. Subjects rated their current mood on a visual analogue scale. The results showed that the CSs and Rs were significantly impaired compared to Ns for the emotional tasks but did not differ from each other. Moreover, the patient groups were significantly less accurate in recognising emotionally neutral facial stimuli. Each subject group had more difficulty processing negative relative to positive affect. The deficit in schizophrenia was found to be stable, which may reflect a trait-like, rather than a state-dependent, characteristic. Moreover, some support is provided for the notion that facial affect perception in chronic schizophrenia is associated with right hemisphere dysfunction.

[The location of the deficits of emotional communication in dimensional models of schizophrenia]. / Miejsce deficytów komunikacji emocji w modelach wymiarowych schizofrenii.

Disordered communication of emotions belongs to the primary schizophrenia symptoms. The aim of this study was our attempt of the localisation of the deficits in emotional communication (its decoding and expression) in dimensional models of schizophrenia. The evaluation of emotionality in schizophrenia might be performed indirectly via negative dimension (for instance: apathy, diminished verbal fluency, flat or inappropriate emotional reactions), via excitement (elevated mood) and depression (decreased mood) or via cognitive dimension. Interpretation of emotional phenomena within the cognitive dimension remains an oversimplification. Brain emotional and cognitive systems act independently although they also reveal mutual interactions enabling the control of emotional behaviour via social learning of emotions. To conclude, to date emotional dimension in schizophrenia has not yet received satisfactory explanation which is in line with the complex nature of emotions. Thus the question regarding the location of emotions in dimensional models of schizophrenia still remains open.

[Emotional behavior in schizophrenia and one-sided brain damage. Cerebral hemispheric asymmetry. Part I]. / Zachowania emocjonalne w schizofrenii i w jednostronnych uszkodzeniach mózgu. Asymetria pólkul mózgowych. Czesc I.

Although, emotions play a crucial role in schizophrenia, the changes in emotional dimension in relation to brain asymmetry still remain controversial. The aim of our work was: 1) to compare the emotional behaviour between the examined groups: S--non-chronic schizophrenic patients (n = 50), CS--chronic schizophrenic patients (n = 50), N--healthy controls (n = 50), R--right brain-damaged patients (n = 30), and L--left brain-damaged patients (n = 30), 2) to assess the changes in attitude processes and in types of emotional reactions, its relation to lateralised hemisphere damage and chronicity of the schizophrenic process. All psychiatric subjects were diagnosed as paranoid schizophrenics according to DSM-IV criteria and were scored on the PANSS scale after four weeks of neuroleptic treatment. Brain-damaged patients were included if they experienced single-episode cerebrovascular accidents causing right or left hemisphere damage (confirmed in CT scan reports). The neurological patients were examined at least 3 weeks after the onset of the episode. Emotional behaviour was assessed using Observational Scale of Emotional Behaviour aimed at the evaluation of: A) attitude processes B) the emotional reactions. Our results revealed differentiated type of emotional behaviour in the examined population. Right brain-damaged patients significantly often revealed elevated mood, lack of adequacy of self-evaluation and active or negative attitude towards the environment. Left brain-damaged patients showed depressed mood, resignation, positive or seldom passive attitude to others and adequate self-evaluation. Schizophrenic patients mostly revealed indifferent mood and passive attitude to environment, their self-evaluation was rather adequate. Based on our data, the changes in emotional behaviour in schizophrenic patients might reflect frontal lobes dysfunction rather than dysfunction localised in one of cerebral hemispheres.

[Emotional behavior in schizophrenia and one-sided brain damage--expression and verbalization of emotions. Cerebral hemispheric asymmetry. Part II]. / Zachowania emocjonalne w schizofrenii i w jednostronnych uszkodzeniach mózgu--ekspresja i werbalizacja emocji. Asymetria pólkul mózgowych. Czesc II.

Emotional behaviour in non-chronic and chronic schizophrenic patients, right and left hemisphere-damaged patients and healthy people was observed. Similar type of emotional reactions have been recorded in schizophrenia and right hemisphere damage. This might suggest the similarity of localisation of the cerebral dysfunction in the two patient groups. The difficulties with catching verbal expressions and verbal humour might be associated with the frontal cortex dysfunction.

[Neural areas of emotions in normal and brain pathology assessed by functional neuroimaging methods]. / Neuronalne osrodki emocji w prawidlowym i patologicznie zmienionym mózgowiu badane metodami funkcjonalnego neuroobrazowania.

The investigation into neural back-ground of emotions in normal and brain pathology using functional brain imaging techniques (fMRI, PET, SPECT) remains one of the most interesting scientific challenges in the area of psychiatry. The aim of the current study is: 1) to present the recent neuroimaging findings concerning functioning of "emotional brain" in normal and brain pathology with particular emphasis on psychiatric disorders, 2) to consolidate knowledge of neuroimaging techniques and experimental designs used in the assessment of human affect.

[Informed consent for angiography and endovascular treatment]. / Informacje dla chorego i zgoda na badanie angiograficzne lub zabieg wewnatrznaczyniowy.

The aim of this paper was to evaluate the methods of passing information concerning angiography and endovascular treatment from doctors to patients. Patients undergoing modern procedures are especially prone to anxiety or even panic caused by the lack of sufficient information about the planned procedure. There are many reasons for such phenomena. One of them is extremely fast improvement of new, sophisticated technology and lack of humane attitude to patients. Authors examined 60 patients before and after angiography and endovascular treatment. Most of them (92%) knew nothing about the procedures. 30% of the patients gained information from other patients. After angiography and endovascular treatment most of patients assessed the procedures as less dangerous than expected. Our questionnaire is attached to this paper.

"Saba"--application of knowledge and state-of-the-art technologies in the field of psychiatry for development of new diagnostics prevention and therapeutic tools for schizophrenia.

The aim of project is to build a European network, which will integrate the research capabilities of a group of research institutes and university departments to provide an infrastructure for the highest quality research in psychiatric disorders, particularly in schizophrenia and schizoaffective disturbances. This network will integrate original computer expert advisory system called "Saba" with modern brain imaging techniques and neurophysiological methods, which allows for the delineation of specific subtypes and particular episodes of mental disorders and their neural bases will be studied by state-of-the art (high tech) imaging techniques. This approach will lead to new investigatory, diagnostic and therapeutic techniques. Together the members of this network will comprise an unmatched critical mass of human and other resources aimed at fundamental and applied research into a group of disorders, which impose a huge burden on social and material capital. The relationships and mutual responsibilities between neuroscience and the society it serves will be addressed specifically. Top brain research is performed at several locations in Europe. In particular, in the area of linking classical psychiatric and psychological assessment methods and the newest brain imaging techniques in mental disorders, major progress can only be made when various research groups join their efforts. Large-scale studies using different databases are critically required, which demands standardization of the description of mental disorders and of the applied techniques and methods of analysis. Imaging techniques, including functional MRI (fMRI), Evoked Potentials (EPs), brain mapping, and the computer gathered information will be shared, standardized and further developed within the network. Developing new information technology tools for simulation, visualization and data-mining will be required to enable effective search for links between mental disorders and brain characteristics (function, structure) in very large scale data-sets acquired and stored in various research facilities.

The integration of the computer advisory system together with neuroimaging procedures, neurophysiological markers and psychological cognitive tests in order to obtain evidence based system for the physician treating affective disturbance.

WHO has classified depression disturbances--due to widespread existence and serious medical consequences and resulting social and economic effects--as a priority health problem in all the developed countries. The significance of the depression disturbances is fully comparable to such illnesses as heart diseases, cancer and HIV infection. The research made in the USA (NIMH programmer) shows that first contact doctors are not able to detect depression in relation to 50-70% of the people ill with it. Also the research made in other countries shows that a doctor properly identifies only one out of four persons with clear indications of depression. The wrong choice of the antidepressant drug may result in inefficient therapy and in growing risk of suicide. In 1993 the analysis of 50 best selling medicines in the EU made by two Italian pharmacologists showed that in France and Italy in over 45% of the cases the medicines with doubtful efficiency are applied. The aim of our project is to build a European network, which will integrate the research capabilities of a group of research institutes and university departments to provide an infrastructure for creation of the computer advisory system for diagnostics of affective disorders. This network will integrate our original computer expert advisory system called "Salomon" with modem brain imaging techniques and neurophysiological methods, which allows for the delineation of specific subtypes and particular episodes of mental disorders and their neural bases will be studied by state-of-the art (high tech) imaging techniques. This approach will lead to new investigatory, diagnostic and therapeutic techniques.

Diagnostic and treatment dilemmas of persistent chronic hypokalaemia in a patient with anorexia nervosa: a case report.

INTRODUCTION: Anorexia nervosa is an eating disorder that continues to have a devastating impact on the lives of both adolescents and adults worldwide. We present a case of persistent chronic hypokalaemia in a patient with anorexia nervosa. CASE PRESENTATION: A 26-year-old Caucasian woman was admitted to our eating disorders unit under Section 2 of Mental Health Act (1983) with a body mass index of 13.5 kg/m2. On admission, biochemical tests highlighted moderate hypokalaemia (3.0 mmol/L). She was immediately put on two tablets of Sando-K® (potassium supplement; potassium bicarbonate and potassium chloride twice daily. An electrocardiogram showed signs of bradycardia with T-wave inversion in at least two chest leads. Throughout her admission, she exhibited a fluctuating potassium level (2.5 to 5.0 mmol/L). Once on the unit, she was put on Sando-K® (potassium supplement; potassium bicarbonate and potassium chloride) but her potassium still tended to drop. On one occasion when she became normokalaemic, supplementation was stopped and she was put on observations. After 24 hours of 1 to 1 observation by ward staff including fluid input and output monitoring as well as search of her bedroom, she was again found to be hypokalaemic in spite of no evidence to suggest laxative or diuretic abuse. CONCLUSIONS: She kept reiterating to clinicians that her potassium depletion is hereditary, not associated with any purging behaviour and for that reason long-term administration of Sando-K® (potassium supplement; potassium bicarbonate and potassium chloride) tablet remained essential. Self-denial was continued until her planned discharge; however, positive behavioural change was recorded whilst her blood showed normokalaemia for a whole week until her discharge.