Uso de perampanel en insomnio resistente al tratamiento / Use of perampanel in treatment-resistant insomnia

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Retraso diagnóstico en un caso de porfiria aguda intermitente con síntomas psicóticos / Diagnostic delay in a case of acute intermittent porphyria with psychotic symptoms

La porfiria aguda intermitente (PAI) es la forma más frecuente de entre las porfirias agudas. Aunque la presentación típica cursa con ataques de dolor abdominal, en algunos casos aparecen síntomas mentales. Presentamos el caso de una PAI en un paciente varón de 34 años que llevaba 10 años diagnosticado de esquizofrenia paranoide. La atipicidad de los síntomas psicóticos y la concurrencia, durante el último episodio, de clínica neurológica y autonómica, sugirieron el diagnóstico de porfiria. El cuadro se trató exitosamente con la administración de glucosa, lo que permitió la retirada del tratamiento antipsicótico. El diagnóstico se confirmó posteriormente mediante prueba genética. La PAI es una entidad infradiagnosticada por la inespecificidad de su expresión clínica y por las dificultades técnicas en el diagnóstico. La PAI puede ser fácilmente confundida con una enfermedad psiquiátrica, con consecuencias deletéreas. Los profesionales de salud mental deberían conocerla, así como las dificultades que entraña su diagnóstico (AU)

Acute intermittent porphyria (AIP) is the most frequent form of acute porphyria. Although the typical clinical presentation is with abdominal pain, mental symptoms are also present in some cases. The case is presented of a 34-year-old male patient with AIP, who had been diagnosed with paranoid schizophrenia for 10 years. The atypicality of the psychotic symptoms and the concurrence, with neurological and autonomic signs during the last episode, suggested the diagnosis of porphyria. The episode was successfully treated with the administration of glucose, which enabled the antipsychotic treatment to be withdrawn. The diagnosis was later confirmed by genetic testing. AIP is an under-diagnosed condition due to the non-specificity of its clinical expression and the technical difficulties of the diagnosis. AIP can be easily mistaken for a psychiatric illness, with detrimental consequences. Mental health professionals should be aware of this, as well as about the difficulties involved in its diagnosis (AU)

Escala Abreviada de Personalidad y Acontecimientos Vitales para la detección de los intentos de suicidio / Short Personality and Life Event scale for detection of suicide attempters

Objetivo. Desarrollar una escala breve y fiable para identificar a las personas en riesgo de conducta suicida. Método. Diseño: estudio de caso-control. Muestra y centro: 182 individuos (61 personas que intentaron suicidarse, 57 controles psiquiátricos y 64 controles sanos) con una edad de 18 años o más, admitidos en la Unidad de Urgencias del Hospital Universitario Puerta de Hierro de Madrid, España. Mediciones: todos los participantes rellenaron un formulario que incluía sus características sociodemográficas y clínicas, y la Escala de Personalidad y Acontecimientos Vitales (27 cuestiones). Para evaluar los diagnósticos del Eje I, a todos los pacientes psiquiátricos (incluyendo a las personas que intentaron suicidarse) se les realizó la Entrevista Neuropsiquiátrica Internacional. Análisis estadístico: se aplicó estadística descriptiva para los factores sociodemográficos. Además, se aplicaron las pruebas de independencia de χ2 para evaluar las diferencias de las variables sociodemográficas y clínicas, y de la Escala de Personalidad y Acontecimientos Vitales entre grupos. Se llevó a cabo una regresión lineal escalonada con selección de variable retrospectiva para elaborar la escala abreviada de Personalidad y Acontecimientos Vitales (S-PLE). A fin de evaluar la precisión se realizó un análisis de ROC. Se evaluó la fiabilidad interna utilizando la α de Cronbach, y la fiabilidad externa mediante un procedimiento de prueba-reprueba. Resultados. La escala S-PLE, que se compone únicamente de 6 cuestiones, reflejó un buen desempeño al discriminar los controles sanos, los controles psiquiátricos y los intentos de suicidio en una muestra independiente. Por ejemplo, la escala S-PLE discriminó a las personas que intentaron suicidarse y a las que no lo hicieron en el pasado, con una sensibilidad del 80% y una especificidad del 75%. El área bajo la curva ROC fue del 88%. Un análisis factorial extrajo solamente un factor, lo que revela la dimensión única de la escala S-PLE. Además, la escala S-PLE aporta valores de fiabilidad interna y externa que se incluyen dentro de los rangos débil (prueba-reprueba: 0,55) y aceptable (α de Cronbach: 0,65). El tiempo de realización es de alrededor de un minuto. Conclusiones. La escala S-PLE es un instrumento útil y preciso para calcular el riesgo de conducta suicida en centros asistenciales donde escasea el tiempo (AU)

Objective. To develop a brief and reliable psychometric scale to identify individuals at risk for suicidal behaviour. Method. Design: Case-control study. Sample and setting: 182 individuals (61 suicide attempters, 57 psychiatric controls, and 64 psychiatrically healthy controls) aged 18 or older, admitted to the Emergency Department at Puerta de Hierro University Hospital in Madrid, Spain. Measures: All participants completed a form including their socio-demographic and clinical characteristics, and the Personality and Life Events scale (27 items). To assess Axis I diagnoses, all psychiatric patients (including suicide attempters) were administered the Mini International Neuropsychiatric Interview. Statistical analysis: Descriptive statistics were computed for the socio-demographic factors. Additionally, χ2 independence tests were applied to evaluate differences in socio-demographic and clinical variables, and the Personality and Life Events scale between groups. A stepwise linear regression with backward variable selection was conducted to build the Short Personality Life Event (S-PLE) scale. In order to evaluate the accuracy, a ROC analysis was conducted. The internal reliability was assessed using Cronbach's α, and the external reliability was evaluated using a test-retest procedure. Results. The S-PLE scale, composed of just 6 items, showed good performance in discriminating between medical controls, psychiatric controls and suicide attempters in an independent sample. For instance, the S-PLE scale discriminated between past suicide and past non-suicide attempters with sensitivity of 80% and specificity of 75%. The area under the ROC curve was 88%. A factor analysis extracted only one factor, revealing a single dimension of the S-PLE scale. Furthermore, the S-PLE scale provides values of internal and external reliability between poor (test-retest: 0.55) and acceptable (Cronbach's α: 0.65) ranges. Administration time is about one minute. Conclusions. The S-PLE scale is a useful and accurate instrument for estimating the risk of suicidal behaviour in settings where the time is scarce (AU)

Coprophagia in a patient with borderline personality disorder

Background and Objectives: Human coprophagia is a rare phenomenon with severe medical and social consequences. So far, coprophagia has mainly been associated with severe mental retardation, schizophrenia, dementia, and depression. We report a caseof coprophagia in a 30-year-old woman with Borderline Personality Disorder (DSM-IV).This case report illustrates the severity of symptoms and maladaptive social consequences of severe personality disorders, comparable to those of patients with schizophrenia. Pharmacological interventions and, particularly intensive psychotherapy might be effective for patients diagnosed with borderline personality disorder displaying severe behavior disorders. The treatment of choice for coprophagia is aversive behavioral intervention (AU)

Short Personality and Life Event scale for detection of suicide attempters.

OBJECTIVE: To develop a brief and reliable psychometric scale to identify individuals at risk for suicidal behaviour. DESIGN: Case-control study. SAMPLE AND SETTING: 182 individuals (61 suicide attempters, 57 psychiatric controls, and 64 psychiatrically healthy controls) aged 18 or older, admitted to the Emergency Department at Puerta de Hierro University Hospital in Madrid, Spain. MEASURES: All participants completed a form including their socio-demographic and clinical characteristics, and the Personality and Life Events scale (27 items). To assess Axis I diagnoses, all psychiatric patients (including suicide attempters) were administered the Mini International Neuropsychiatric Interview. STATISTICAL ANALYSIS: Descriptive statistics were computed for the socio-demographic factors. Additionally, χ(2) independence tests were applied to evaluate differences in socio-demographic and clinical variables, and the Personality and Life Events scale between groups. A stepwise linear regression with backward variable selection was conducted to build the Short Personality Life Event (S-PLE) scale. In order to evaluate the accuracy, a ROC analysis was conducted. The internal reliability was assessed using Cronbach's α, and the external reliability was evaluated using a test-retest procedure. RESULTS: The S-PLE scale, composed of just 6 items, showed good performance in discriminating between medical controls, psychiatric controls and suicide attempters in an independent sample. For instance, the S-PLE scale discriminated between past suicide and past non-suicide attempters with sensitivity of 80% and specificity of 75%. The area under the ROC curve was 88%. A factor analysis extracted only one factor, revealing a single dimension of the S-PLE scale. Furthermore, the S-PLE scale provides values of internal and external reliability between poor (test-retest: 0.55) and acceptable (Cronbach's α: 0.65) ranges. Administration time is about one minute. CONCLUSIONS: The S-PLE scale is a useful and accurate instrument for estimating the risk of suicidal behaviour in settings where the time is scarce.

Clusters de casos de suicidio espacio-temporal en la comunidad de Antequera (España) / Space-time suicide clustering in the community of Antequera (Spain)

Introducción. En España, cada año consuman suicidio alrededor de 3.500 personas. El principal objetivo del presente estudio fue examinar si eran evidentes agrupaciones (clusters) espacio-temporales de suicidio en la región de Antequera (Málaga, España). Métodos. Muestra y procedimiento. Entre el 1 de enero de 2004 y el 31 de diciembre de 2008, se identificaron todos los casos de suicidio consumado (fuente: Servicio de Patología Forense del Instituto de Medicina Legal, Málaga, España). Geolocalización. Usamos Google Earth para calcular las coordenadas del domicilio de todos los casos de suicidio. Análisis estadístico. Usamos el programa SaTScan® espacio-temporal y la función K de Ripley para examinar la presencia de agrupaciones (clusters) espacio-temporales de los casos de suicidio. Acto seguido, utilizamos la prueba de la X2 de Pearson para determinar la presencia de diferencias estadísticamente significativas entre los casos de suicidio identificados dentro y fuera de las agrupaciones de suicidio. Resultados. En los análisis del presente estudio efectuado en el municipio de Antequera, de un total de 120 individuos que cometieron suicidio se incluyeron 96 (80%). Se identificaron pruebas estadísticamente significativas para 7 agrupaciones espacio-temporales de suicidio dentro de los límites críticos de 0-2,5 km de distancia y durante la primera y segunda semana después del caso de suicidio (p < 0,05 en ambos casos). Entre los casos de suicidio dentro de agrupaciones (n = 17), no hubo ningún individuo en el que se hubiera establecido un diagnóstico de trastorno psicótico actual, mientras que, entre los casos de suicidio fuera de las agrupaciones espacio-temporales, en el 20%, se había establecido dicho diagnóstico (X2 = 4,13; gl = 1; p < 0,05). Conclusiones. En la región circundante de Antequera están presentes agrupaciones (clusters) espacio-temporales de los casos de suicidio. Entre pacientes con un diagnóstico de trastorno psicótico actual hubo menos probabilidades de una influencia por los factores que determinan las agrupaciones espacio-temporales de los casos de suicidio consumado (AU)

Introduction. Approximately 3,500 people commit suicide every year in Spain. The main aim of this study is to explore if a spatial and temporal clustering of suicide exists in the region of Antequera (Málaga, España). Methods. Sample and procedure: All suicides from January 1, 2004 to December 31, 2008 were identified using data from the Forensic Pathology Department of the Institute of Legal Medicine, Málaga (España). Geolocalisation. Google Earth was used to calculate the coordinates for each suicide decedent's address. Statistical analysis. A spatiotemporal permutation scan statistic and the Ripley's K function were used to explore spatiotemporal clustering. Pearson's chi-squared was used to determine whether there were differences between suicides inside and outside the spatiotemporal clusters. Results. A total of 120 individuals committed suicide within the region of Antequera, of which 96 (80%) were included in our analyses. Statistically significant evidence for 7 spatiotemporal suicide clusters emerged within critical limits for the 0-2.5 km distance and for the first and second semanas (P < .05 in both cases) after suicide. There was not a single subject diagnosed with a current psychotic disorder, among suicides within clusters, whereas outside clusters, 20% had this diagnosis (X2 = 4.13; df = 1; P < .05). Conclusions. There are spatiotemporal suicide clusters in the area surrounding Antequera. Patients diagnosed with current psychotic disorder are less likely to be influenced by the factors explaining suicide clustering (AU)

[Space-time suicide clustering in the community of Antequera (Spain)]. / Clusters de casos de suicidio espacio-temporal en la comunidad de Antequera (España).

INTRODUCTION: Approximately 3,500 people commit suicide every year in Spain. The main aim of this study is to explore if a spatial and temporal clustering of suicide exists in the region of Antequera (Málaga, España). METHODS: Sample and procedure: All suicides from January 1, 2004 to December 31, 2008 were identified using data from the Forensic Pathology Department of the Institute of Legal Medicine, Málaga (España). Geolocalisation. Google Earth was used to calculate the coordinates for each suicide decedent's address. Statistical analysis. A spatiotemporal permutation scan statistic and the Ripley's K function were used to explore spatiotemporal clustering. Pearson's chi-squared was used to determine whether there were differences between suicides inside and outside the spatiotemporal clusters. RESULTS: A total of 120 individuals committed suicide within the region of Antequera, of which 96 (80%) were included in our analyses. Statistically significant evidence for 7 spatiotemporal suicide clusters emerged within critical limits for the 0-2.5 km distance and for the first and second semanas (P<.05 in both cases) after suicide. There was not a single subject diagnosed with a current psychotic disorder, among suicides within clusters, whereas outside clusters, 20% had this diagnosis (X2=4.13; df=1; P<.05). CONCLUSIONS: There are spatiotemporal suicide clusters in the area surrounding Antequera. Patients diagnosed with current psychotic disorder are less likely to be influenced by the factors explaining suicide clustering.

Are major repeater patients addicted to suicidal behavior?

The literature provides support for the hypothesis that some major repeaters (individuals with >=5 lifetime suicide attempts) are addicted to suicidal behavior (SB). This study explores whether major repeaters are addicted to SB or not using 7 criteria: tolerance (Criterion 1), withdrawal (Criterion 2), loss of control (Criterion 3), problems in quitting/cutting down (Criterion 4), much time spent using (Criterion 5), substantial reduction in activities (Criterion 6), and adverse physiological/physical consequences (Criterion 7). Total dependence on SB was indicated by the presence of 3 or more of the 7 criteria in the last 12 months. This cross-sectional study at Puerta de Hierro University Hospital (Madrid, Spain) recruited 118 suicide attempters including 8 major repeaters (7%, 8/118), who were all females. The association between each SB addiction criterion, physiological dependence and total dependence with major repeater status was tested for significance and for effect size with odds ratios (ORs) and their 95% confidence intervals. As hypothesized, major repeaters met significantly higher frequency of criteria for total dependence on SB, OR=62.9 (6.4-615). A backward stepwise logistic regression model was used to provide an OR between major repeater status and total dependence status corrected by confounding variables. Age, panic disorder without agoraphobia, borderline personality disorder, history of psychiatric inpatient admission, and total dependence on SB were introduced as independent variables with major repeater status as the dependent variable. The model selected total dependence and age as the remaining significant variables in the last step. Accordingly, major repeaters appear to be addicted to SB.

A cross-sectional study of major repeaters: a distinct phenotype of suicidal behavior.

OBJECTIVE: The characterization of major repeaters (individuals with ≥ 5 lifetime suicide attempts) is a neglected area of research. Our aim was to establish whether or not major repeaters are a distinctive suicidal phenotype, taking into account a wide range of potential competing risks including sociodemographic characteristics, personal and familial history, psychiatric diagnoses, and personality traits. METHOD: This cross-sectional study included 372 suicide attempters admitted to a specialized unit for suicide attempters in Montpellier University Hospital, Montpellier, France, between October 12, 2000, and June 10, 2010. Logistic regression models controlling for potential confounders were used. RESULTS: When compared with subjects who attempted suicide < 5 times, major repeaters were more likely to be female (odds ratio [OR] = 5.54; 95% CI, 1.41-21.81), to have a lower educational level (OR = 5.1; 95% CI, 1.55-17.2), to have lifetime diagnoses of anorexia nervosa (OR = 3.45; 95% CI, 1.10-10.84) and substance dependence (OR = 5.00; 95% CI, 1.37-18.27), and to have lower levels of anger expressed outward (OR = 0.17; 95% CI, 0.06-0.47) and higher levels of trait anger (OR = 2.82; 95% CI, 1.18-6.75). Major repeaters had significantly higher suicide risk (lethality) scores (OR = 2.14; 95% CI, 1.08-4.23). CONCLUSION: Major repeaters are a distinctive suicidal phenotype characterized by a distinctive sociodemographic (ie, female gender, low education) and clinical profile (ie, trait anger, substance dependence, anorexia nervosa). If our results are replicated, specific preventive plans should be tailored to major repeaters.

Are major repeater patients addicted to suicidal behavior? / ¿Están los grandes repetidores adictos a los comportamientos suicidas?

The literature provides support for the hypothesis that some major repeaters (individuals with ≥5 lifetime suicide attempts) are addicted to suicidal behavior (SB). This study explores whether major repeaters are addicted to SB or not using 7 criteria: tolerance (Criterion 1), withdrawal (Criterion 2), loss of control (Criterion 3), problems in quitting/cutting down (Criterion 4), much time spent using (Criterion 5), substantial reduction in activities (Criterion 6), and adverse physiological/physical consequences (Criterion 7). Total dependence on SB was indicated by the presence of 3 or more of the 7 criteria in the last 12 months. This cross-sectional study at Puerta de Hierro University Hospital (Madrid, Spain) recruited 118 suicide attempters including 8 major repeaters (7%, 8/118), who were all females. The association between each SB addiction criterion, physiological dependence and total dependence with major repeater status was tested for significance and for effect size with odds ratios (ORs) and their 95% confidence intervals. As hypothesized, major repeaters met significantly higher frequency of criteria for total dependence on SB, OR=62.9 (6.4-615). A backward stepwise logistic regression model was used to provide an OR between major repeater status and total dependence status corrected by confounding variables. Age, panic disorder without agoraphobia, borderline personality disorder, history of psychiatric inpatient admission, and total dependence on SB were introduced as independent variables with major repeater status as the dependent variable. The model selected total dependence and age as the remaining significant variables in the last step. Accordingly, major repeaters appear to be addicted to SB

La escasa literatura existente sugiere que los «grandes repetidores» (individuos con 5 intentos de suicidio a lo largo de la vida) pueden ser considerados «adictos» a los comportamientos suicidas. Este estudio explora si los grandes repetidores sufren una adicción a los comportamientos suicidas usando 7 criterios: tolerancia (Criterio 1), abstinencia (Criterio 2), pérdida de control (Criterio 3), problemas para dejar de tener o disminuir esos comportamientos (Criterio 4), uso de tiempo excesivo (Criterio 5), reducción importante de actividades (Criterio 6), y consecuencias físicas adversas (Criterio 7). La dependencia total a los comportamientos suicidas era diagnosticada si el sujeto cumplía 3 o más de los 7 criterios en los últimos 12 meses. Se trata de un estudio transversal realizado íntegramente en el Hospital Universitario Puerta de Hierro (Madrid, Spain) , donde fueron reclutados 118 individuos que se presentaron en los servicios de urgencia por un intento de suicidio, incluyendo 8 grandes repetidores (7%, 8/118), siendo todos ellos mujeres. Se estimó si había asociaciones estadísticamente significativas y el tamaño del efecto con la razón de oportunidades y los intervalos de confianza (95%)entre cada uno de los criterios de adicción a los comportamientos suicidas, la dependencia fisiológica, y la dependencia total. Nuestra hipótesis se verificó, ya que los grandes repetidores presentaron con mayor frecuencia criterios para la dependencia a las conductas suicidas, OR=62.9 (6.4-615). Usamos un modelo de regresión logística para estamiar el riesgo de la asociación entre ser un gran repetidor y la dependencia total corregido por diferentes variables. La edad, el trastorno de pánico sin agorafobia, el trastorno de personalidad límite, la historia de ingresos previos en unidad de hospitalización psiquiátrica, y la dependencia total a los comportamientos suicidas fueron introducidos como variables independientes y la categoría de grandes repetidores como variable dependiente. El modelo final seleccionó la dependencia total y la edad como las variables estadísticamente significativas en el último paso. En conclusión, nuestro estudio sugiere que los grandes repetidores podrían ser individuos adictos a los comportamientos suicidas