Case Report: Depression × dementia with Lewy bodies in the elderly: The importance of differential diagnosis.

Background: Dementia is a clinical syndrome which is more common in elderly people. Dementia with Lewy bodies (LBD) is not so rare in elderly people, with cognitive impairment in about 30% over age 65. The clinical picture is characterized by fluctuation in cognitive functions, recurrent, well-formed, detailed visual hallucinations, and Parkinsonism, with rigidity, tremor, bradykinesia, and slurred speech. Case presentation: We present a case report of LBD in a 73-year-old retired teacher, which a initial wrong diagnosis of refractory depression for at least 3 years. We also conduct a review of recent works on theme. Conclusion: LBD diagnosis can be neglected for years, with a legal and clinical issues to patients and their families. Detailed medical research, including differential diagnosis, are very necessary on those cases, specially when they are called refractory. We encourage new research and adequate clinical training to prevent damage.

Violent behavior by involuntarily committed female offenders with mental disorders: A population-based case series.

The goal of the current study was to investigate the socio-demographic, psychiatric, and criminological characteristics of female violent offenders with mental disorders involuntarily committed to a forensic psychiatric hospital. The present study was a population-based retrospective case series including all female offenders with mental disorders found not guilty by reason of insanity by the criminal courts in the state of Rio de Janeiro, Brazil, and involuntarily committed to a forensic psychiatric facility (n = 27). Patients were assessed with Structured Clinical Interview for DSM-IV Axis I Disorders and the Positive and Negative Syndrome Scale. We found that most offenders were Afro-Brazilian, uneducated unmarried women. Schizophrenia with active psychotic symptoms was the most common clinical condition. Relatives were the frequent victims of aggressive behavior. Most patients had already been diagnosed with a mental disorder and placed under psychiatric treatment, but poor adherence and treatment dropout were common. Violent behavior in psychiatrically ill female patients is associated with a specific socio-demographic and clinical profile and is thus potentially amenable to prevention particularly if the mental health and social services are to provide the much-needed support for economically, socially, and psychologically vulnerable women.

Cessation of dangerousness status: an analysis of 224 reports from the Instituto de Perícias Heitor Carrilho, Rio de Janeiro, Brazil

Objectives: To evaluate factors related to dangerousness cessation at the end of involuntary commitment based on an analysis of expert reports. In light of the current legal requirement of dangerousness cessation as a pre-requisite for prison or internment release of individuals subjected to the safety measure, we sought elements to reflect on the practice of expert examiners in charge of making this decision. Methods: The authors revised 224 expert psychiatric dangerousness cessation reports released 2011 through 2014 and collected data for a statistical analysis. Results: The following variables were associated with positive risk cessation assessments: no inadequate behavior (according to the assistant professionals), no productive psychotic symptoms, no negative symptoms, presence of insight, presence of a support network, and no psychoactive substance abuse. The following variables were associated with negative dangerousness cessation decisions: early onset of malfunction, lack of insight, negative attitudes, active signs of major mental illness, presence of impulsiveness, poor response to treatment, presence of plans lacking feasibility, exposure to destabilizing factors, lack of personal support, and presence of stress. Conclusions: In this study we were able to identify factors associated with dangerousness in a sample of expert reports. The knowledge of factors linked to a higher risk of recidivism in illegal activities or violent behavior is crucial for decision-making regarding the release of offenders after their legally established period of involuntary commitment.

Self-Embedding Behavior in Adults: A Report of Two Cases and a Systematic Review.

Self-embedding behavior (SEB) is the repeated insertion of sharp objects, such as needles or pins, into the soft tissues of abdomen, limbs, and other body parts. In this study, two cases of SEB were reported and the scientific worldwide literature reviewed. Thirty-two cases of SEB were identified through systematic searches in the main bibliographic databases. Mean age was 35 years (SD = 8.97). Just over two-thirds of the patients were female. Although the number of embedded objects could be as high as 200, major clinical and surgical complications were uncommon and mortality was null. Patients with SEB presented three major diagnoses: psychotic (25%), personality (21.9%), and factitious (28.1%) disorders. The practice of SEB largely went undetected as the patients themselves did not bring it to the attention of family members or physicians and usually denied they have engaged in SEB. A high level of suspicion is required to avoid a missed diagnosis.

The worldwide incidence of neonaticide: a systematic review.

Neonaticide is the killing of a neonate on the day of its birth by his/her own mother. Neonaticidal women were reported to be predominantly young, unmarried, and primiparous. The motive for murdering the newborn relates to the shame, the fear of rejection, and abandonment by significant others, and the social stigmas associated with an illegitimate birth. The goal of the present study was to conduct a systematic review of the scientific literature and identify population-based studies reporting the incidence of neonaticide in different countries. A total of 485 abstracts were screened. After applying the inclusion/exclusion criteria, 10 studies were selected. Additional searches identified two more articles. Most of these studies were from Europe, where incidence varied from 0.07 (Finland, 1980-2000 period) to 8.5 neonaticides per 100000 births (Austria, 1975-2001 period). More recent studies have indicated that a growing proportion of neonaticidal women are married, multiparous, and suffers from mental disorders. Preventive measures, such as anonymous free delivery, were shown to reduce the incidence of neonaticide, although this effect may be short-lived. Despite social and institutional changes, neonaticide persists even in the most socially advanced, liberal, and prosperous societies in the world.

Cessation of dangerousness status: an analysis of 224 reports from the Instituto de Perícias Heitor Carrilho, Rio de Janeiro, Brazil.

OBJECTIVES:: To evaluate factors related to dangerousness cessation at the end of involuntary commitment based on an analysis of expert reports. In light of the current legal requirement of dangerousness cessation as a pre-requisite for prison or internment release of individuals subjected to the safety measure, we sought elements to reflect on the practice of expert examiners in charge of making this decision. METHODS:: The authors revised 224 expert psychiatric dangerousness cessation reports released 2011 through 2014 and collected data for a statistical analysis. RESULTS:: The following variables were associated with positive risk cessation assessments: no inadequate behavior (according to the assistant professionals), no productive psychotic symptoms, no negative symptoms, presence of insight, presence of a support network, and no psychoactive substance abuse. The following variables were associated with negative dangerousness cessation decisions: early onset of malfunction, lack of insight, negative attitudes, active signs of major mental illness, presence of impulsiveness, poor response to treatment, presence of plans lacking feasibility, exposure to destabilizing factors, lack of personal support, and presence of stress. CONCLUSIONS:: In this study we were able to identify factors associated with dangerousness in a sample of expert reports. The knowledge of factors linked to a higher risk of recidivism in illegal activities or violent behavior is crucial for decision-making regarding the release of offenders after their legally established period of involuntary commitment.

Chest pain, panic disorder and coronary artery disease: a systematic review.

Chest pain may be due benign diseases but often suggests an association with coronary artery disease, which justifies a quick search for medical care. However, some people have anxiety disorder with symptoms that resemble clearly an acute coronary syndrome. More specifically, during a panic attack an abrupt feeling of fear accompanied by symptoms such as breathlessness, palpitations and chest pain, makes patients believe they have a heart attack and confuse physicians about the diagnosis. The association between panic disorder and coronary artery disease has been extensively studied in recent years and, although some studies have shown anxiety disorders coexisting or increasing the risk of heart disease, one causal hypothesis is still missing. The aim of this systematic review is to present the various ways in which the scientific community has been investigating the relation between chest pain, panic disorder and coronary artery disease.

Homicide by a forensic female sample in Brazil: a preliminary study.

The objective of the study was to evaluate the mental status of all women (n = 14) who were acquitted by reason of insanity of charges of murder or attempted murder and committed to a forensic psychiatric hospital in the state of Rio de Janeiro, Brazil. All cases were retrospectively examined, including medical files, technical records, and forensic experts' official reports. A conclusive psychiatric diagnosis was established using the Structured Clinical Interview for DSM-IV Axis I and II Disorders and clinical and forensic records. The most common diagnosis was schizophrenia/schizoaffective disorders (n = 8; 57.3%). Most victims (n = 12; 75%) were close relatives of the patients. We found that 43% (n = 6) of the patients had a previous history of violent behavior. According to the initial psychiatric forensic evaluation, 5 patients (35.7%) had psychotic symptoms. It is expected that a growing understanding of motivational factors underlying homicidal behavior in mentally disturbed female offenders may further the implementation of effective preventive and therapeutic interventions.

A randomized, naturalistic, parallel-group study for the long-term treatment of panic disorder with clonazepam or paroxetine.

This long-term extension of an 8-week randomized, naturalistic study in patients with panic disorder with or without agoraphobia compared the efficacy and safety of clonazepam (n = 47) and paroxetine (n = 37) over a 3-year total treatment duration. Target doses for all patients were 2 mg/d clonazepam and 40 mg/d paroxetine (both taken at bedtime). This study reports data from the long-term period (34 months), following the initial 8-week treatment phase. Thus, total treatment duration was 36 months. Patients with a good primary outcome during acute treatment continued monotherapy with clonazepam or paroxetine, but patients with partial primary treatment success were switched to the combination therapy. At initiation of the long-term study, the mean doses of clonazepam and paroxetine were 1.9 (SD, 0.30) and 38.4 (SD, 3.74) mg/d, respectively. These doses were maintained until month 36 (clonazepam 1.9 [SD, 0.29] mg/d and paroxetine 38.2 [SD, 3.87] mg/d). Long-term treatment with clonazepam led to a small but significantly better Clinical Global Impression (CGI)-Improvement rating than treatment with paroxetine (mean difference: CGI-Severity scale -3.48 vs -3.24, respectively, P = 0.02; CGI-Improvement scale 1.06 vs 1.11, respectively, P = 0.04). Both treatments similarly reduced the number of panic attacks and severity of anxiety. Patients treated with clonazepam had significantly fewer adverse events than those treated with paroxetine (28.9% vs 70.6%, P < 0.001). The efficacy of clonazepam and paroxetine for the treatment of panic disorder was maintained over the long-term course. There was a significant advantage with clonazepam over paroxetine with respect to the frequency and nature of adverse events.

Imipramine for vestibular dysfunction in panic disorder: a prospective case series.

OBJECTIVE: The purpose of this study was to evaluate the efficacy and effectiveness of imipramine on the treatment of comorbid chronic dizziness and panic disorder. METHOD: Nine patients with panic disorder and agoraphobia associated with chronic dizziness underwent otoneurological screening and were treated with a 3-months course of imipramine. Anxiety levels were measured with the Hamilton Anxiety Scale (HAM-A), dizziness levels were evaluated using the Dizziness Handicap Inventory (DHI), and panic severity and treatment outcome were assessed with the Clinical Global Impression Scale (CGI). RESULTS: At the baseline 33.3% (n=3) had a bilateral peripheral deficit vestibulopathy, the mean scores for HAM-A were 27.2±10.4, for DHI were 51.7±22.7, and for CGI-S were 4.8±0.9. All patients had a significant reduction in their HAM-A (11.1±5.5, p=0.008), DHI (11.5±8.1, p=0.008) and CGI-I (1.8±0.7, p=0.011) levels after 3-months imipramine treatment (mean=72.2±23.2 mg/day). CONCLUSION: This study found a decrease in anxiety levels and in the impact of dizziness in the patients' quality of life after a 3-months treatment course with imipramine.

Imipramine for vestibular dysfunction in panic disorder: a prospective case series / Imipramina para disfunção vestibular em transtorno do pânico: uma série de casos prospectiva

OBJECTIVE: The purpose of this study was to evaluate the efficacy and effectiveness of imipramine on the treatment of comorbid chronic dizziness and panic disorder. METHOD: Nine patients with panic disorder and agoraphobia associated with chronic dizziness underwent otoneurological screening and were treated with a 3-months course of imipramine. Anxiety levels were measured with the Hamilton Anxiety Scale (HAM-A), dizziness levels were evaluated using the Dizziness Handicap Inventory (DHI), and panic severity and treatment outcome were assessed with the Clinical Global Impression Scale (CGI). RESULTS: At the baseline 33.3 percent (n=3) had a bilateral peripheral deficit vestibulopathy, the mean scores for HAM-A were 27.2±10.4, for DHI were 51.7±22.7, and for CGI-S were 4.8±0.9. All patients had a significant reduction in their HAM-A (11.1±5.5, p=0.008), DHI (11.5±8.1, p=0.008) and CGI-I (1.8±0.7, p=0.011) levels after 3-months imipramine treatment (mean=72.2±23.2 mg/day). CONCLUSION: This study found a decrease in anxiety levels and in the impact of dizziness in the patients' quality of life after a 3-months treatment course with imipramine.

OBJETIVO: O objetivo deste estudo foi avaliar a eficácia e efetividade da imipramina no tratamento da tontura crônica e do transtorno de pânico comórbidos. MÉTODO: Nove pacientes com transtorno do pânico e agorafobia associada com tontura crônica foram submetidos à avaliação otoneurológica e tratados durante 3 meses com imipramina. Os níveis de ansiedade foram medidos através da Escala Hamilton de Ansiedade (HAM-A); os de tontura foram avaliados usando o Dizziness Handicap Inventory (DHI), e a gravidade do pânico e sua resposta pela Escala de Impressão Clínica Global (CGI). RESULTADOS: Na avaliação inicial, 33,3 por cento (n=3) da amostra apresentavam vestibulopatia periférica deficitária bilateral; as médias foram: da HAM-A 27,2±10,4, do DHI 51,7±22,7 e do CGI-S 4,8±0,9. Todos tiveram uma redução significativa nos escores de HAM-A (11,1±5,5, p=0,008), DHI (11,5±8,1, p=0,008) e CGI-I (1,8±0,7, p=0,011), após 3 meses de tratamento com imipramina (média=72,2±23,2 mg/dia). CONCLUSÃO: Este estudo encontrou uma diminuição dos níveis de ansiedade e do impacto da tontura na qualidade de vida dos pacientes após um curso de 3 meses de tratamento com imipramina.

Filicide, attempted filicide, and psychotic disorders.

The objective of the study was to describe and discuss the cases of two women who faced criminal charges, one for attempting to murder her three children and the other for killing her 1-year-old boy. After a forensic psychiatric assessment of their level of criminal responsibility, these patients were considered not guilty by reason of insanity and were committed to forensic mental hospitals. These two patients received a diagnosis of paranoid schizophrenia, according to the DSM-IV-TR criteria. In both cases, psychotic symptoms were present before the manifestation of violent behavior, in the form of persecutory delusions, auditory hallucinations, and pathological impulsivity. The investigation into cases of filicide may contribute powerfully to expand our understanding of motivational factors underlying this phenomenon and enhance the odds for effective prevention.

Tapering clonazepam in patients with panic disorder after at least 3 years of treatment.

High-potency benzodiazepines, such as clonazepam, are frequently used in the treatment of panic disorder (PD) because of their rapid onset of action and good tolerability. However, there is concern about their potential to cause withdrawal symptoms. We aimed to develop a protocol for safely tapering off clonazepam in patients with PD who had been receiving treatment for at least 3 years. A specific scale for judging withdrawal was also developed, the Composite Benzodiazepine Discontinuation Symptom Scale. We selected 73 patients with PD who had been asymptomatic for at least 1 year and who wished to discontinue the medication. The trial consisted of a 4-month period of tapering and an 8-month follow-up period. The dosage of clonazepam was decreased by 0.5 mg per 2-week period until 1 mg per day was reached, followed by a decrease of 0.25 mg per week. The mean dosage at the start of tapering was 2.7 +/- 1.2 mg/d. In total, 51 (68.9%) of the patients were free of the medication after the 4 months of tapering according to the protocol, and 19 (26.0%) of the patients needed another 3 months to be free of medication. Clonazepam discontinuation symptoms were mostly mild and included mainly: anxiety, shaking/trembling/tremor, nausea/vomiting, insomnia/nightmares, excessive sweating, tachycardia/palpitations, headache, weakness, and muscle aches. The improvement in PD and general well-being was maintained during both the taper and follow-up phases. Clonazepam can be successfully discontinued without any major withdrawal symptoms if the dose is reduced gradually. We recommend reducing the dosage of clonazepam after intermediate-term use by 0.25 mg/wk.

Nomophobia: the mobile phone in panic disorder with agoraphobia: reducing phobias or worsening of dependence?

OBJECTIVE: In this report, we present and discuss a hypothesis for the development, in individuals with panic disorder and agoraphobia, of dependence on his or her mobile phone (MP). BACKGROUND: This disorder, termed nomophobia, is a result of the development of new technologies. Nomophobia is considered a disorder of the modern world and refers to discomfort or anxiety caused by being out of contact with a MP or computer. It is the pathologic fear of remaining out of touch with technology. METHOD: We present, the case report of a patient who has continuously kept his MP with him since 1995 because of his overwhelming need to feel safe and to be able to immediately call emergency services and people he trusts should he feel sick. RESULT: The patient was treated with medication and cognitive-behavior psychotherapy. He has remained asymptomatic for 4 years. The patient showed significant medical improvement in his panic disorder and phobias, but there has been no change in his nomophobia. CONCLUSIONS: The case presented here illustrates the dependence of an individual with panic disorder on his MP. A specific approach for this dependence should be used in some panic disorder patients.