A reevaluation of mixed depressive states from the DSM-5- TR perspective: a series of prototypical cases.

Mixed depressive states are defined by the co-presence of depressive and manic symptoms. They represent extremely variable conditions from the point of view of clinical expressiveness and are difficult to recognize, ranging from clear schizophrenic-like psychoses and pseudodemented pictures to subsyndromal psychopathology. At the basis of the extreme variability of depressive pictures with mixed features are the different combinations that depressive and manic symptoms can assume. Furthermore, the intensity of depressive symptoms and manic symptoms, combined, can be variable, a factor that contributes to making the picture even more variable. Each form of mixed depressive state therefore presents its own specific symptomatic characteristics and specific difficulties in differential diagnosis and each form requires a different therapeutic strategy. In this work we have distinguished four possible specific subtypes of mixed depressive states, describing their specific clinical presentation and the therapeutic options most supported by the literature with the aim of contributing to a better recognition of mixed depressive states, to avoid incorrect diagnoses at patient and treatments that are useless if not worsening.

Sodium valproate: cacosmia and dysgeusia as uncommon side effects.

Smell and taste disturbances are potential adverse reactions of many drugs used in Psychiatry, such as antidepressants, anti-Parkinson agents, lithium, minor and major tranquilizers. To our knowledge, only one clinical case regarding valproate and cacosmia has been reported so far. However, several anticonvulsants are reported to cause taste and smell disturbances, although the underlying etiology is currently unclear. Our patient developed cacosmia and dysgeusia when taking valproic acid, both effects quickly disappeared upon drug discontinuation. In this article we not only report this uncommon side effect, but we discuss the plausible mechanisms behind such an adverse reaction. Our case is to date the second similar case in the literature. The aim of the present article is to make clinicians informed about this very uncommon and unpleasant side effect.

Valproate-induced burning mouth syndrome in a male with fibromyalgia and bipolar spectrum disorder.

Burning mouth syndrome is a chronic painful condition characterized by a subjective intraoral pain and burning sensations in the absence of an identifiable medical, dental, or psychiatric cause. Although the underlying etiology is currently unclear, an idiopathic (or primary) form and a secondary form to other conditions are formally recognized. However, as several authors have suggested, it might be of clinical utility to consider the existence of a third clinical entity, namely Drug-Induced Burning mouth syndrome, for its therapeutic implications. The latter has been reported with angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, antiretrovirals, anticoagulants, chemotherapy, and drugs commonly used in the treatment of neuropsychiatric disorders such as antidepressants, benzodiazepines, and antipsychotics. Regarding anticonvulsants a literature search found a previous case of Topiramate-Induced Burning mouth syndrome but no previous report of valproate-induced Burning mouth syndrome. Our case is, to date, the first case in the literature of Burning mouth syndrome onset following the administration of valproate to a patient suffering from fibromyalgia and bipolar spectrum disorder. Symptoms resolved completely when the drug was stopped, and the association between symptoms and drug was replicated after drug re-administration.

Revisiting stimulant use for emotional dysregulation in attention-deficit/hyperactivity disorder (ADHD).

INTRODUCTION: Emotional dysregulation (ED) symptoms are present in a considerable portion of patients with attention-deficit/hyperactivity disorder (ADHD). In recent years, an increasing number of studies investigated the effects of stimulant medications on ED in patients with ADHD. AREAS COVERED: A narrative review of the literature on stimulant treatment for ED is provided, including controlled and observational clinical studies conducted on pediatric and adult samples and neurobiological investigations. Positive effects of stimulants on irritability have been demonstrated in children. Comorbidity with disruptive behavior disorders (DBD) and disruptive mood dysregulation disorder does not prevent stimulant effectiveness. Methylphenidate has also been found to reduce temper problems, affective instability, and emotional over-reactivity in adults with ADHD, although with variable effect sizes. A variety of adverse emotional effects have been reported, especially at high doses and in special populations. However, several possible confounders of treatment-emergent ED have been highlighted. Finally, according to neuroimaging studies, stimulants may mitigate emotional processing anomalies associated with ADHD. EXPERT OPINION: The findings are consistent with models including ED within the core features of ADHD. Stimulant treatment should be prioritized over antipsychotics in ADHD-DBD. It remains to be elucidated whether other medications may be more effective in specific populations with ADHD and/or ED.

Lithium-induced parkinsonism associated with vocal cord paralysis: an atypical presentation.

Drug-induced parkinsonism has been commonly studied and discussed regarding antipsychotic agents, but lithium-induced parkinsonism should also be considered when patients present with parkinsonian symptoms and chronic lithium use. There are several reports of parkinsonism arising during lithium administration and regressing following its reduction or discontinuation. Our case is, to date, the first case in the literature in which vocal cord paralysis occurred as the first symptom of lithium-induced parkinsonism, contributing to confuse doctors and patients and to delay diagnosis and treatment. In our clinical case prompt withdrawal of lithium and its reintroduction at lower doses led to complete resolution of this disabling clinical presentation. This report emphasizes the importance of careful monitoring of lithium levels, especially in elderly subjects, and the need to consider lithium-induced parkinsonism even when unusual motor symptoms appear in chronic lithium users.

Binge eating disorder, impulsivity and bipolar spectrum features in a sample of obese candidates for bariatric surgery.

AIMS: Candidates for bariatric surgery are routinely screened for psychiatric disorders because abnormal eating behaviors are considered common among these patients. This study aimed to evaluate the frequency and persistence, in terms of one month-to-lifetime prevalence ratio, of binge eating disorder (BED) and the potential association with impulsivity features and bipolar spectrum comorbidity in a sample of obese patients undergoing a psychiatric evaluation for bariatric intervention. METHODS: Overall, 80 candidates to bariatric surgery were assessed consecutively over 12 months within the framework of a collaboration between the University of Pisa Psychiatry and Internal Medicine Departments. Patients were evaluated through structured clinical interviews and self-report questionnaires. RESULTS: The lifetime and last-month frequencies of BED according to DSM-5 criteria were 46.3% and 17.5%, respectively, with a prevalence ratio of 37.8%. Rates of formal bipolar disorder diagnoses were extremely low in patients with or without BED. However, patients with BED showed more severe dyscontrol, attentional impulsivity and bipolar spectrum features than patients with no BED. CONCLUSIONS: The relationship of BED, impulsivity, and mood disorders in bariatric patients is more complex than usually reported in the literature. In particular, the presence of bipolar spectrum features should be systematically investigated in these patients because of their essential clinical and therapeutical implications.