Anxiety disorders are common in children. Much of anxiety in children is embedded in the parent- child relationship. In Asian countries many cultural practices can lead to insecure attachment and severe stress in children, especially in girls. Appropriate psychotherapeutic intervention must be sensitive to cultural influences.

To report clinical symptoms, individual and family dynamics, important points in psychotherapy for a girl with an anxiety disorder.

A Thai-Chinese 9 year- old girl presented with obsessions about her mother dying and herself killing her mother. She also had hallucinations which she described as “voices telling me to kill my mother”. She was diagnosed as having OCD with psychotic features. The patient was the first twin and was described as a ‘moody’ and ‘not so smart’, while her twin brother, the only male grandchild of the family, was described as ‘pleasant’ and ‘clever’.

Family assessment revealed cultural practices that led to severe frustration and anxiety in this girl. The main factor was the practice of son preference. This, together with severe punishment, led to insecure attachment, feelings of rejection, anger, guilt and shame. Family therapy and behavior management were the main psychotherapeutic interventions in the early phase. CBT was initiated in the later phase. Interesting points in treatment and the VDO tape of psychotherapy sessions will be presented.

The case vignette illustrated the role culture plays in initiating severe anxiety in girls. Understanding such a role will enable therapists to treat anxiety in girls more effectively.

Vortioxetine is a 5-HT3, 5-HT7 and 5-HT1D receptor antagonist, 5-HT1B receptor partial agonist, 5-HT1A receptor agonist and inhibitor of the 5-HT transporter (SERT).

To study the in vitro properties of vortioxetine at rat and human targets and relate them to rat brain target occupancies and effects in rat models assessing antidepressant activity and cognitive function.

The in vitro properties were assessed using radioligand binding and cell-based functional assays, brain target occupancies were studied using ex vivo autoradiography, antidepressant activity was studied in conventional behavioural models and in a progesterone withdrawal model, and effects on cognitive function were assessed by quantitative EEG [qEEG] and after 5-HT depletion in recognition and spatial memory tasks.

Vortioxetine was more potent at human than rat 5-HT1A and 5-HT7 receptors and the SERT, whereas the opposite was found for 5-HT1D and 5-HT3 receptors. The rat in vitro and ex vivo potency rank orders were aligned. Vortioxetine showed antidepressant activity in conventional models and the fluoxetine-insensitive progesterone withdrawal model. qEEG analyses demonstrated increases across power bands with vortioxetine, but not duloxetine or escitalopram. Vortioxetine restored memory deficits induced by low 5-HT, whereas duloxetine and escitalopram had no effect.

1. 1. Species comparisons of target activities and inclusion of target occupancy measures in animal studies supports thetranslation from preclinical to clinical settings.

2. 2. Vortioxetine exerts antidepressant and memory-enhancing effects in rats via mechanisms beyond that of SERT inhibition.

Among minority patients with depression, the CCM is significantly more effective in achieving treatment response and remission compared to usual care. Adaptation of this model across various population groups should be considered.

Mounting evidence suggests that immune dysfunction may play a crucial role in the pathophysiology of autism spectrum disorders (ASD). In addition, several studies have reported that congenital and postnatal infections may contribute to the neurobiological basis of ASD.

This study aimed to investigate the relationship between infections during pregnancy and after birth, and ASD.

A case-control study design was adopted. Both cases and controls were retrieved from a historic birth cohort (HBC) maintained at Statens Serum Institute in Copenhagen/Denmark and were followed up retrospectively during pregnancy and after birth over four pre-defined periods. Study subjects were followed-up utilizing Danish nation-wide health registers for outpatient and hospital admissions due to infections. Associations between infections and ASD were analyzed using Mantel- Haenszel estimate of the odds ratio (OR) and logistic regression models.

In total, 414 ASD cases and 820 controls were followed-up during pregnancy and a mean 16.3 years after birth. Crude, but not adjusted estimates showed that ASD cases had an increased risk of hospital admission due to infection at the end of the first year of life (OR = 1.48 [range: 1.07-2.05], P = 0.02) and at the end of the follow-up period (OR = 1.30 [range: 1.02-1.64], P = 0.03).

The present findings indicate that infections have a potential role in the pathophysiology of ASD; however, further studies are necessary to determine if infections etiologically contribute to ASD or if they act as an epiphenomenon due to distorted immunity in children with ASD.

The diagnosis of personality disorder (PD) in individuals with an intellectual disability (ID) is clinically relevant, but there is little research on the subject. Because the impact of PD on both patients and carers is substantial, it is important to increase the understanding of how ID and PD co-occur.

The aim of the present study was to examine the prevalence of all axis II DSM-IV-TR PD diagnoses in a well- defined sample of ID out-patients in two specialized secondary care ou-patient treatment centers, in the Netherlands. Special attention was paid to borderline ID (70≤Total IQ < 85), prevalence of co-morbid axis I disorders and associations of PD with several demographic variables.

The present study was a cross-sectional medical chart review. On January first, 2011, 599 patients were registered at the two centers. Diagnostic information was available for 576 patients. Diagnoses were based on Došen's integrative approach and formulated according to the DM-ID.

194 patients (33.7%) were diagnosed with a PD. PD NOS (19.1%) was most common, followed by borderline PD (8.7%). Patients with borderline ID were most likely to be diagnosed with a PD (43.7%). 85.1% of patients diagnosed with a PD had at least 1 co-morbid axis I diagnosis. PTSD was the most common co-morbid disorder (23.7%).

Diagnosed according to strict criteria, PDs often occur in ID out-patients, mostly together with axis I disorders. Importantly, PDs and PTSD often co-occur in this group, indicating special care needs and signifying an interesting direction for further research.

A full time urgent consult clinic was opened for adolescents presenting with risk to self or others. To date these adolescents have presented to ERs, held in the ER or admitted to the ward added to waitlists. This study is a part of a 1 year outcome study to examine whether urgent assessment and brief crisis intervention reduce ER visits, admissions and reduce the waiting lists.

1. a) examine 3 month outcome after urgent clinic assessment

2. b) examine variables that may affect outcome

3. c) examine effect of urgent consult assessment and intervention on ER visits, admission, repeat presentation and waitlist for other child and adolescent psychiatric outpatient clinics.

Adolescents 12 -17 years of age seen in the UCC will be given information sheet and consent form to participate. Data will be gathered on demographic variables and a number of other pertinent variables including reason for referral, suicidality previous contact with MH services, past psychiatric history, family history of psychiatric disorders, diagnosis and management. The patients will complete a mental health screen, CDI and Connors Questionnaire Parents will complete the CBCL. The data will be checked against ER contact,admissions and wait lists at 3 month post assessment. Data analysis will be conducted using SPSS.

It is expected that there will be a decrease in the number of adolescents presentating to the ERs, a reduction in ER admission to the ward and a decrease in the numbers of patients on the Outpatient wait list.

People with an intellectual disability (ID) are likely to experience traumatic events and more vulnerable to its disruptive effects and thus to post traumatic stress disorders (PTSD). Little is known about how these PTSDs present themselves in patients with ID and whether this presentation differs from patients without an ID.

The aim of the present study was to compare PTSD symptomatology in psychiatric outpatients with borderline to mild ID and outpatients without ID in naturalistic out-patient samples from psychiatric secondary care.

From June 1th 2010 to March 15th 2012, 56 patients were diagnosed with PTSD. Using Routine Outcome Monitoring (ROM), 45 patients (80.4%) had complete data on both the Impact of Events Scale Revised (IES-R) and the Brief Symptom Inventory (BSI). They were compared to 45 gender- and age-matched non-ID patients diagnosed with PTSD in the same period.

Preliminary results show that there are some small differences in general psychological symptom patterns between ID and non-ID patients with PTSD as shown on the subscales obsession-compulsion, psychoticism and depression of the BSI. On the IES-R, there was no difference between ID and non-ID patients. There was no difference in symptomatology between patients with borderline or mild ID.

PTSD symptomatology does not differ in ID patients compared to non-ID patients. Consequently, ID patients deserve the same evidence based care.

Bulimia nervosa is one the main subtypes of eating disorders. Recent neurobiological research is greatly contributing to the understanding of eating disorders.

To review and discuss current topics under investigation with neuroimaging studies in bulimia nervosa, as well as future interesting lines of research in this area.

To analyze the state of the art of neuroimaging research in bulimia nervosa.

MEDLINE and PubMed databases were searched for peer-reviewed studies, published between 2000 and 2012, by using combinations of the Medline Subject Heading terms neuroimaging and bulimia nervosa. A selection of relevant articles to the study aim was carried out. An analysis of the reviewed studies including current topics of research and future suggestions was also done.

Articles reviewed encompassed functional and structural neuroimaging or clinical reviews, connectivity and neurotransmitter studies, as well as debate or opinion articles. The main topics addressed were cerebral activation secondary to food stimuli, neuropsychological paradigms, diagnosis and classification of eating disorders based on neurobiological findings, neurobiology of eating disorders, and disordered eating mechanisms. The main future research avenues proposed were development of eating disorder psychopathology-related fMRI paradigms, as well as connectivity-based and molecular imaging studies.

The neurobiology of eating disorders is a growing exciting field of research. Neurobiological studies, namely neuroimaging studies in bulimia nervosa, may provide an important research framework for a better knowledge of psychopathological mechanisms of eating disorders.

Binge eating shares some similar clinical features with addictive disorders, such as impulsivity, altered reward sensitivity, and compulsive behavior. Some authors support the concept of food addiction for both conditions, whereas others argue against it.

To review arguments in favor or against the concept of food addiction, and its relation with bulimia nervosa and binge-eating disorder.

To discuss and explore the concept of food addiction, and how it may be related to bulimic-type behaviors.

MEDLINE and PubMed databases were searched for peer-reviewed studies undertaking analyses of evidence in favor or against the concept of food addiction, published between 2000 and 2012, by using combinations of the Medline Subject Heading terms addictive behavior and bulimia.

Several arguments in favor of the concept of addictive properties of food are present in many of the reviewed articles. However, many differences between substance addiction disorders and the so-called “behavioral addictions” are reported in the literature, underlining different neurobiological, psychological, and environmental mechanisms.

There is no consensus in the current literature regarding the concept of food addiction. Further studies concerning the issue are, therefore, warranted.

Compared to anorexia nervosa, bulimia nervosa has received less attention on neuroimaging research. However, in the past decade, more functional resonance imaging studies were done to study bulimia nervosa, by using different types of paradigms, namely symptom-related paradigms.

To review functional magnetic resonance imaging (fMRI) studies in bulimia nervosa using food stimuli.

To discuss recent contributions of functional neuroimaging to the understanding of bulimia nervosa.

MEDLINE and PubMed databases were searched for peer-reviewed articles, published between 2000 and 2012, by using combinations of the Medline Subject Heading terms functional neuroimaging and bulimia nervosa. A selection of relevant papers to the aim of this review was carried out. The selected studies were reviewed with respect to type of paradigm, participant characteristics, main results, strengths and limitations.

Most studies reported altered functional activation in the frontal, cingulate, temporal, and parietal cortical regions secondary to food-related fMRI paradigms in bulimia nervosa.

The reviewed studies suggest that bulimia nervosa is associated with functional imaging brain abnormalities.

The understanding of neurobiology of eating disorders has received a remarkable contribution from neuroimaging research.

To review the literature on structural neuroimaging in bulimia nervosa.

To discuss recent contributions of structural neuroimaging to the understanding of bulimia nervosa.

MEDLINE and PubMed databases were searched for peer-reviewed studies, published between 2000 and 2012, by using combinations of the Medline Subject Heading terms structural neuroimaging and bulimia nervosa. A selection of relevant articles to the aim of this review was carried out.

Relatively few articles on structural neuroimaging were found in bulimia nervosa, and the studies showed conflicting results. Some studies reported evidence of brain volume loss in patients with bulimia nervosa, possibly related to associated chronic dietary restriction. Other studies have found increased grey matter volumes in frontal and ventral striatal areas. Finally, further studies did not find any structural abnormality at all in patients with bulimia nervosa, compared to healthy control subjects.

The scarce literature available on structural neuroimaging in bulimia nervosa provides conflicting results. Further studies are, therefore, warranted.

Self-harm patients utilize many resources. This is especially so for those with underlying maladaptive personality traits, which, have not been examined locally.

To estimate the prevalence of maladaptive personality traits in self-harm patients.

A 5-months cross sectional study was conducted at Changi General Hospital (CGH). English-speaking patients over 21 years old admitted for self-harm behavior were recruited into our study after being referred to our consultation liaison team. The ICD-10 (WHO 1993) was used for psychiatric diagnoses, and the International Personality Disorders Examination (IPDE) ICD-10 version screening questionnaire and the Depression Anxiety Stress Scale (DASS) 21 were administered. STATA version 10.1 was used for statistical analyses.

Of all patients referred, forty patients were eligible and 37 of them consented to participate in the study. All participants were screened positive for at least one class of maladaptive personality traits, with the majority (89.19%) being screened positive for more than 1 class of maladaptive traits. The three most prevalent classes of maladaptive traits were anankastic (75.68%), schizoid (67.57%) and paranoid (62.16%). More than three quarters (78.38%) of the participants had 3 or more classes of maladaptive traits.

Maladaptive personality traits are common and inherent in self-harm patients, with majority of them exhibiting anankastic, schizoid and paranoid traits in this study. Understanding the nature of maladaptive traits in self-harm patients can help us in tailoring future interventions towards such self-harm behavior to bring about improvements in psychiatric care, reduction of self-harm frequency and reduce health care cost.

The mechanism of psychological stress induced infertility is unknown.

Evaluation of oscillation pattern of GnRH release by the hypothalamus in different mental states.

To clarify whether hypothalamic oscillation is the target of stress.

Twenty two patients were evaluated on four different sessions (day 6 and 14) within two consecutive cycles in addition to the MCMI-III and the Hamilton's depression scale.

The pattern of oscillation was indirectly correlated with Hamilton scale and the anxiety state and showed statistically significant lowering of frequency during anxiety and depression states. Besides, the slope of GnRH between two consecutive sessions (d0GnRH0/GnRH1dt) showed also a prominent reduction and even flattening. In addition the time to ovulation was also postponed in cycles with prominent anxiety.

1. 1. Psychological stress exerts its effect through a reduction of pulsation frequency in GnRH release.

2. 2. The pattern of GnRH pulsation changes in the range of ¼ to 1/15 of baseline by external stimuli.

3. 3. Patients with borderline, schizoid, dependent, depressed and passive aggressive personality suffer most from irregularity of menstruation cycles.

4. 4. Patients with chronic major depression are subject to menstrual irregularity highest during stabilization of disease and in the early phases of recovery due to drug treatment with mostly SSRI.

5. 5. Treatment of depression of anxiety causes a reduction of menstrual cycles even to very short ranges.

6. 6. Measurement of GnRH, FSH, LH and Estradiol on two sessions one week apart is a nice marker for regularity and ovulation.

Personality, also designed as one's identity gives color to the notions, beliefs, social activities, self image … We wondered how personality could affect sexual life and functioning in a systematic way.

Many sexual dysfunctions, either primary or acquired are rooted in deep personality related beliefs and cannot be treated easily.

To find newer ways of treating more profound psychopathology in patients with sexual dysfunction by adding personality guided therapy into the sex therapy sessions.

Fifty four patients with sexual dysfunction were evaluated by Millon's clinical Multiaxial inventory III in addition to Questionnaire on Sexual attitude and function 2009. Half the patients received only sex therapy and if needed drug therapy while the other half received additionally intensive (twice weekly) personality guided therapy which included supportive psychotherapy, cognitive therapy and behavior therapy based on the personality category diagnosed at the beginning. After 12 weeks, both groups were evaluated with the same tools in addition to a clinical interview.

The latter group fared significantly (p< 0.03) better in regard to both personality and sexuality scales. A reduction of anxiety, depression, alcoholism and drug abuse scales was also encountered. Patients in the latter group explained themselves less disturbed, less ashamed and more ambitious to solve their problems as exemplified by the clinical interview.

Personality is a more and possibly the sole prominent risk factor of sexual dysfunction in the majority of patients and inclusion of treatment in this regard is extremely effective and with faster response.

Some personalities are more prone to mood disorders than others and treatment of mood disorders is more difficult in the setting of personality disorders.

Many boots of depression attacks are without major life events. Personality disordered persons show earlier attacks of mood disorders in their life with a tendency to treatment resistance and early recurrence designing a model on mutual interaction of mood and personality might be very fruitful.

To find more practical risk factors for chronic depression and improving the prognosis of these patients.

Three hundred and fifty nine patients with major depression were evaluated with the MCMI-III and Hamilton's depression scale at diagnosis and 12 and 24 weeks after medical treatment. Two sixty patients group with comparable personalities were compared for receiving personality guided therapy or not.

Personality disordered patients have a double chance of developing major depression during their lifetime as compared to normal persons as exemplified by their reference to our center. Hamilton's depression scale was reduced significantly more in personality normal patients than their disordered counterpart (p< 0.04). Those who received personality guided therapy fared also much better after 12 and 24 weeks after treatment.

We conclude that personality is a major risk factor both in developing depression and in reduced responsiveness to conventional treatments. Patients with premorbid personalities should receive more intensive drug therapy in addition to personality guided therapies. Personality acts both cis (in the same side) and trans (in the opposite side) of mood.

Schizophrenic patients have shown by experience to have reduced sense of humor and do not understand jokes completely.

It is unclear whether this is the result of a global emotional numbness, a dysfunctional abstract thinking or problem of semantic field. Besides, the relevance of this issue in mood disturbances in psychotic patients must be reappraised.

Increase of sociability in schizophrenic patients by way of augmenting sense of humor.

Hundred schizophrenic patients were evaluated by way of interview and three questionnaires for their sense of humor and abstract thinking in response to non sexual jokes. They were asked to tell ten jokes and grade them in regard to funniness. In addition ten jokes were told to them and asked them to grade these jokes in a 10 strength scale. These steps were repeated after 12 weeks of conventional antipsychotic treatment in addition to short courses of psychotherapies.

Schizophrenic patients have an overall reduced sense of humor for jokes even if they can understand the core reality of them hence not a matter of deranged abstract thinking. They show also reduced expression of joy in response to jokes that they have rated highest. This denotes some degrees of emotional numbness. Treatment of patients with conventional antipsychotics cannot completely restore the sense of humor even after a 3 months period.

We conclude that sense of humor is a central issue in social functioning and some additional treatments must be used to normalize patients with schizophrenia.

In a society with religious and cultural restrains a standardized tool for sexual evaluation is urgently needed.

To study sexual problems of our patients and standardizing it for patients with different backgrounds we developed a questionnaire with 240 phrases that were extracted from a pool of 1400 sentences addressing sexual problems. Sixty four scales under four headings (sexual general characteristics, deviations, dysfunctions and psychodynamic syndromes) (16 items each) were evaluated based on criteria of DSM-IV and ICD 11. Five validity scales (honesty, desirability, debasement, guilt feeling and overall validity) were also used for better assessment.

Evaluation of the clinical relevance of the QSAF 2009.

A total of 1300 patients in the four variants of the test were evaluated during a time span of 7 years. The questions were presented to examinees at 8th grade and higher in a calm environment and the results were evaluated by computer software specifically developed for this purpose.

The last version of the test was completed by 734 patients with excellent compliance. It was rated as polite and comprehensive. For almost all scales the sensitivity and specificity were around 85 and 92% respectively.

QSAF 2009 is an excellent tool both in clinics (diagnosis and follow up) and epidemiology with high sensitivity and specificity. It has also application in cross cultural studies, medico - legal issues and medical documentation. It prevents face to face interviews, breaks patients’ resistance and is less time consuming than scheduled interviews.

Dysmenorrhea causes much morbidity in high percentage of the population and despite its uniform molecular pathogenesis exhibits wide range of symptoms.

Many patients attribute menstrual symptoms to sex while others attribute it to an intra-abdominal organic disease.

To evaluate whether dysmenorrhea patients have peculiar notion about sex

We evaluated 60 normal and 60 dysmenorrhea patients with QSAF-2009. The latter group used routinely drugs for dysmenorrhea in a PRN basis. Dysmenorrhea was not graded according to severity and stress was laid on personal view about the matter (major concern versus no concern).

Patients without dysmenorrhea were sexually more self conscious, became sexually active earlier in their life, had lower scores in most sexual dysfunction scales, had higher scores in experimentation, sensational, erotic, extramarital relationship, sex addiction and lower scales in couple problems while women with dysmenorrhea showed higher scores in couple problems, sexual pain syndromes, vaginism and a series of psychodynamic syndromes (0.04>p>0.07). Curiously, these people showed higher scores in homo- bisexuality scales. They showed high rates of sexual guilt feeling and the overall validity of their test was questioned. They showed increased reluctance to answer the questions, regarded their problems as personal secrets and reported fewer visits to gynecologists. They preferred female gynecologists, and had never been visited by midwives. Most of them preferred cesarean delivery under general anesthesia.

We conclude that dysmenorrhea patients are categorically distinct from normal persons in regard to their sexual attitude and function.

Dysmenorrhea is a pain variant syndrome with wide range of manifestations and intensity even in the same person. Like other pain variants it seems to be very subjective and personality dependent.

Despite uniform molecular basis of dysmenorrhea further risk factors are needed to be clarified.

To find out which subgroup of patients express more severe symptoms and need stronger treatments.

Hundred and twenty consecutive patients (half reported dysmenorrhea of some concern while the other half of no or minor concern) were evaluated with the Millon's Clinical Multiaxial inventory MSMI-III. The former group used routinely drugs for dysmenorrhea in a PRN basis and some used medications as prophylaxis. The former group was free to use psychoactive medication but people using psychoactive medications were excluded from the latter group. Dysmenorrhea was not graded according to severity and stress was laid on personal view about the matter.

Patients with dysmenorrhea had higher scores in passive aggressive, borderline, avoidant, dependent, histrionic and obsessive personality scales (p< 0.04) while patients without dysmenorrhea showed higher scores in narcissistic, schizoid, schizotypal, paranoid personality scales (p< 0.07).

Dysmenorrhea patients show lower pain threshold, increased preoccupation about disease and higher rates of menstrual irregularity, are more regularly visited by their gynecologist, ask more questions about cancer and are more prone to adjustment disorder. We conclude that although the pathophysiological basis of dysmenorrhea can purely be attributed to organic and molecular landmarks the expression of pain and reaction to it is personality dependent.