Depressive symptoms occur in different phases of psychosis, including prodromal, acute and post-psychotic. Post-psychotic depression (PPD) is a phenomenon that presents as a diagnostic and therapeutic challenge. Having been ascribed various descriptions in the past, PPD has been used in a broad manner to describe depressive symptoms that appear in patients with history of psychosis. PPD unveils itself as a separate nosological entity, differing from the adverse effects typically associated with antipsychotics, the negative symptoms of psychosis, and other psychiatric disorders that present with both psychotic and depressive symptoms (e.g. bipolar disorder, schizoaffective disorder, or psychotic depression).

The authors present a case of a 64 year-old man hospitalized due to inaugural psychosis with persecutory and grandiose delusions as well as auditory hallucinatory activity, who began to develop a depressive clinical picture whilst under treatment. A brief discussion on post-psychotic depression, from its clinical presentation to its treatment and implications in prognosis is also presented.

A brief non-systematized literature review using the Pubmed platform as well as presentation of a clinical case.

Depressive complaints are a common complication of psychotic episodes, with the literature estimating that approximately a quarter of psychotic patients present with PPD. Although typically described in association with schizophrenia, recent literature describes PPD occurring alongside other psychotic presentations, including first-episode psychosis. A division between affect and psychosis has been attempted in terms of psychiatric classification, however, the blurred lines between the two continue to contribute to difficulties in differential diagnosis. This becomes a challenge when distinguishing between extrapyramidal symptoms associated with antipsychotics, negative symptoms (i.e apathy, abulia and alogia) and psychiatric disorders with affective-psychotic overlap. Having only recently been considered a distinct clinical entity in psychiatric classification systems, research on its etiology, course, treatment and prognosis are scarce. In regards to the previously described patient, a depressive disorder whilst in treatment for psychosis was identified, and through early recognition of the symptoms treatment with an antidepressant was initiated with favourable response.

PPD is a relatively common phenomenon which is gaining more attention in recent literature. As classifications have begun to consider PPD as a distinct clinical entity, as well as unifying defining criteria, further studies can be developed so as to clarify aspects which remain to be defined. The clinician should be aware of this entity as well as the potentially confounding symptom presentations, so as to provide adequate early treatment thus contributing to improved patient outcomes.

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The term “depression” can be used in different senses: it can be a syndrome, a mood state, a mental disorder, and all of them are distinct clinical conditions…There are no pathognomonic features of bipolar/unipolar depression. A good medical history is the most important component of the evaluation. We have to use clinical variables and differential epidemiology for a correct diagnosis.

They both analyze clinical, psychopathological and epidemiological characteristics of resistant depression and they review causes, incidence, prevalence, diagnostic, therapeutic tools and the importance of maintaining the treatment, because the abandonment of the treatment is a good predictor of possible relapses.

A literature Review of the last five years concerning resistant depression has been done: prevalence, incidence, pathogenesis and its relationship with other psychiatric disorders encoded in DSM-V.

Unipolar major depression (major depressive disorder) is characterized by a history of one or more major depressive episodes and no previous history of mania or hypomania symptoms. A major depressive episode is presented with five or more of the following nine symptoms for at least two consecutive weeks; at least one of them must be either a depressed mood or a loss of interest or pleasure. In addition, the symptoms must cause significant distress or psychosocial impairment, and not be a direct result of a substance or general medical condition.

Symptoms of unipolar depression in adults can overlap with symptoms of other psychiatric and general medical disorders. Unipolar depression needs to be distinguished from these other disorders to prevent inappropriate treatment.

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Nearly 300 million people worldwide are affected by depression. According to the DSM-5, the depressive episode is characterized by a depressed mood, a marked decrease in interest or pleasure in all activities, insomnia, agitation or psychomotor slowdown. It occurs mainly in the female sex. Traumatic life events are associated with a depressive onset.

It is well known that interpersonal relationships are foundations for human beings, especially emotional ones and that they have an important effect on mental health. Specifically, 60% of divorced people with a previous history of depression will develop a new depressive episode; this will develop in 10% of subjects without a previous history of depression. The recurring thought of death and suicide is also frequent, as well as the abuse of drugs and ethanol in cases of depression. The forensic pathologist often finds himself having to carry out complex inspections in order to trace the cause of death in these types of deaths.

We report the case of a lady, found dead at her home, in her bed.

A medical prescription for benzodiazepines was found on the cabinet next to her bed with five bottles of benzodiazepines, one of which was empty, two semi-empty packs of antidepressants. Under the bed there was a photo album containing 58 pages to which the photographs of the lady’s wedding were attached. In all the photographs the groom’s face appeared torn. The hygienic-sanitary conditions of the house were precarious. The analysis of the medical record showed that the lady was being treated for major depressive disorder with psychotic manifestations, severe chronic insomnia disorder and abuse of ethyl alcohol and anxiolytics, which arose after separation from her husband five years before her. The toxicological examination performed on blood and urine confirmed the presence of massive doses of benzodiazepines and ethanol, causing death from respiratory depression.

In similar cases, the clinical and family history as well as the toxicological examination help the forensic pathologist in defining the cause of death. Depression leads to family and social isolation, affecting all aspects of a person’s life. Divorce is not only a painful and expensive experience but also harmful to health. The subject is not only in a condition of marital and economic abandonment but also health because the resources currently used in this field are few. Together with the legal process, there should also be a health process with prevention strategies such as questionnaires, interviews, exercises in order to identify those at risk and treat them appropriately.

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Transcranial magnetic stimulation (TMS)is perhaps the most popular of the newbrain stimulation techniques because its clinical effects are produced without the need for a craniotomy (as with deep brainstimulation (DBS)) or seizure induction(as with electroconvulsive therapy (ECT)).Recently ,TMS is typically used to improve depression symptoms when other depression treatments haven’t been effective.

This is a review that discuss the efficacy of the antidepressant effect of TMS.

A narrative review was conducted basedon a search in pubmed using thekeywords: “rTMS” and “depression”.

One of the reviews studied proved the efficacy of rtms in the treatment of depressionbut there is still a clinical need for the complementary use of antidepressants.Although rTMS is more expensive than conventional antidepressants, it remains more interesting for patients who have not found benefits with pharmacological treatments.The other review also demonstrated the antidepressant effect of rTMS and that this effect, once completed, appears to be as long-lasting as that of antidepressants. TMS is also a promising new therapy and a powerful research tool. The body of TMS literature suggests that daily, left prefrontal TMS for 3–6 weeks has antidepressanteffects that are clinically meaningful (30% remission), with low side effects and nodrug-drug interactions. Furthermore, TMS shows promise in several other psychiatricdisorders, particularly treating acute and chronic pain.

Even though The Food and drug administration (FDA) has accorded RTMS’ initial clearance of the first device in 2008 ,additional researches are still needed.The TMS coil location, stimulation intensity and frequency, and dosing strategy have to be more precise for better results.

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The response to placebo is robust in studies of various antidepressant treatments. The strong placebo response, combined with the absence of side-effects, has prompted suggestions to use the ethically sound open-label placebo (OLP) as a treatment for depression.

The aim of the present study was to assess the efficacy of OLP in the setting of a randomized controlled trial for the treatment of unipolar depression.

Thirty-eight patients (28 females, 73.7%) were randomized to either an eight-week treatment with OLP (n=18) or four week of treatment as usual (TAU) followed by four weeks of OLP (n=20). Clinical and socio-demographic measures were assessed at baseline, after four weeks, and at the end of the trial. Response to treatment was determined using the Quick Inventory of Depressive Symptomatology (QIDS SR-16).

There was an overall decrease in depression levels over time, F(2,35) = 3.98, p = .028). A significant group x time interaction was found only among non-geriatric patients (<65y) with an early onset of depression (<50y), F(2,22) = 3.89, p = .036]. Post-hoc tests indicated a significant decrease during the first four weeks, but only in the OLP group, t(11) = 2.29, p = .043.Table 1:

Demographic measures of OLP and TAU patients.

Image 3:

Our findings support the possibility that OLP is an effective treatment for the relatively young population of patients suffering from depression. Additional studies are warranted in order to explore the use of open-label placebo in clinical work.

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Treatment Resistant Depression (TRD) is a complex, heterogeneous and multifactorial clinical condition that affects patients’ quality of life, their psychosocial functioning as well as suicidal risk. Intranasal esketamine is a new add-on treatment specifically approved for TRD.

The aim of the study was to evaluate the efficacy and safety of intranasal esketamine treatment combined with intensive Cognitive Behavioral psychotherapy (CBT), together with treatment satisfaction, in two complex clinical cases of TRD with high suicidal risk in a 12 months follow-up.

Two male patients, 67 and 63 years old, with TRD, defined by at least two therapeutic failures with SSRI/SNRI and positive screening for high suicidal risk at the Columbia Suicide Severity Rating Scale, were selected for treatment with intranasal esketamine + CBT as an add-on to SSRI/SNRI antidepressant therapy. Psychopathological assessment were made by means of Hamilton Depression Rating Scale (HAM-D), Hamilton Anxiety Rating Scale (HAM-A), Columbia Suicide Severity Rating Scale (C-SSRS), Clinical Global Impression (CGI), Short Form Health Questionnaire (SF-36 items) at T0, every 7 days for the first 3 months, then every month. Treatment satisfaction was evaluated by means of the Client Satisfaction Questionnaire (CSQ-8), administered by trained nursing staff at 1, 3, 6 and 12 months. CBT specifically focused on depression was administered by a certified psychotherapist, weekly for the first 4 months, fortnightly for the next 3 months, monthly for the remaining 3 months.

After 2 administrations of esketamine the total HAM-D score was reduced by an average of 10 units and the suicidal risk was progressively reduced to zero according to C-SSRS. After 12 months one of the two patients reached and actually maintains clinical remission; the other one maintains a condition of mild depression; both without suicidal ideation and with a significant increase in perceived quality of life. Treatment was well tolerated, with mild and temporary adverse effects, self-limited to the administration sessions. CBT has contributed to increasing insight, cognitive resources, social interaction and self-esteem, and has made it possible to structure and carry on new life projects. The variation of the mean scores for CSQ-8 shows that esketamine + CBT treatment was considered as very satisfactory throughout the observation period.

Intranasal esketamine associated with intensive CBT sessions showed to be effective, safe and satisfactory in the real world clinical management of two complex cases of TRD with high suicidal risk, improving quality of life, social functioning and eliminating suicidal ideation within 12 months follow-up. Satisfaction with the treatment contributed to strengthening adherence and improving the operator-patient therapeutic relationship.

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Self-esteem is an important aspect of adaptive processes at all ages of life and particularly in older adults: it is linked to the quality of adaptation, well-being, life satisfaction and health.

study the links between self-esteem, autonomy and depression in the elderly

This is a descriptive and analytical study carried out over four months in the offices of three doctors. The population of the study were the consultants whose age was over 65 years the study was made using a pre-established sheet with certain socio-demographic characteristics, the pathological antecedents of subjects. We assessed self-esteem using the Rosenberg scale, autonomy using the activities of daily living scale (KATZ index), and depression using the mini GDS. The analysis of the results was carried out using SPSS 17 software.

Our sample is made up of 54 consultants. The average age was 68 years old. The sex ratio was equal to 0.875. Negative self-esteem, loss of autonomy, depression were observed respectively in 40%, 56.7%, 36.7% of cases. We found an association between negative self-esteem and loss of autonomy (p=0.01) on the one hand, and depression (p<0.0001) on the other.

Our work showed an association between loss of autonomy, depression and negative self-esteem. Depression and negative self-esteem could be a consequence of the loss of autonomy or contributing factors?

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The transition to college life can be a stressful period for young adults, and coping strategies can involve changes in eating behaviors.

The aim of this study was to assess the prevalence and correlates of eating disorder risk among Tunisian university students.

We conducted a cross-sectional descriptive and analytical study among 144 university students in Tunisia. Data were collected using an online questionnaire spread throughout social media (Facebook), using the Google Forms® platform.

Attitudes, feelings and behaviors related to eating were measured using “Eating Attitudes Test” (EAT-26) in order to assess the eating disorder risk.

The mean age of our population was 23.38±3.27 years. More females (73.6%) than males (26.4%) participated in the study. Among them, 10.4% were followed for chronic somatic disease while 11.1% suffered from mental illness. Tobacco, alcohol and cannabis use was noted respectively in 12.5%, 3.5% and 3.5% of cases.

The mean score EAT-26 was 20.45. According to this scale, 32,6% of participants were at high risk of eating disorders.

EAT-26 scores were higher in females (21.23) than males (16.95%), without a significant relationship.

Users of psychoactive substances were more likely to present higher EAT-26 scores (p=0.012), especially the use of alcohol (p=0.005) and weed (p=0.024).

EAT-26 scores were significantly higher among students with a prior history of depression.

Our study highlighted a high prevalence of eating disorder risk in university students. Implementation of public health policies are required, and psychological intervention and health awareness programs would effectively prevent the eating disorder risk.

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Aripiprazole is a newer atypical antipsychotic with a favorable side-effect profile, especially a low propensity to result in metabolic syndromes.It is effective at treating bipolar disorder, the positive symptoms of schizophrenia and has the potential to treat negative and cognitive symptoms.

However, prior studies suggested that aripiprazole seem to be associated to a risk of inducing certain impulse control behaviors, such as uncontrollable gambling, hyper sexuality, as well as compulsive eating.

We proposed to assess the evidence for compulsive eating associated with the use of aripiprazole.

We report a rare case of new onset aripiprazole induced compulsive eating behavior in a patient with bipolar disorder. Then, we conducted a literature review using“PubMed” database and keywords “Aripiprazole”, “Impulse Control Behaviors”, “Compulsive Eating”.

He was a 21-year-old patient, diagnosed with bipolar 1 disorder. He was prescribed Aripiprazole, after a neuroleptic malignant syndrome induced by haloperidol (which was prescribed during the first episode psychosis).

One month following the treatment initiation, the patient complained of eating excessively. He was not able to control his eating and gained 30 Kg over the period of 4 months. Metabolic assessment showed a hypercholesterolemia.

Aripiprazole is a promising novel antipsychotic in mental diseases. However current evidence associates compulsive behaviors like eating with the use of Aripiprazole, probably due to the drug affinity to 5-HT receptors. More studies are needed to confirm this rare side effect.

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The night eating syndrome (NES, DSM-V: 307.59) was described in 1955 as a disorder defined by morning anorexia, nocturnal hyperphagia (25% of the daily intake of food during sleep) and insomnia. Attributed to a delay in the circadian rhythm of feeding is characterized by suppression of the daytime appetite and increased in the early morning. It is more prevalent in obese people. Treatment focuses on selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioural therapy (CBT).

Description of a NES clinical case demonstrated satisfactory response to pharmacological treatment with trazodone.

Brief case presentation and review of the NES literature.

A 40-year-old woman diagnosed with binge eating disorder followed by Endocrinology. She had morbid obesity grade III. After the failure of various treatments addressed to impulse control and early morning intakes (topiramate, zonisamide, liraglutide, gastric balloon, hydrochloride Naltrexone/Bupropion and SSRI) she was referred to a mental health center. She was started on Trazodone therapy. Interestingly, Insomnia/binge decreased from 7 to 2 episodes/ week leading to a significant weight reduction with a 500 mg/week rate, loosing 4 kg. The case was oriented as a NES but successfully treated as maintenance insomnia.

NES leads to frequent awakenings and early morning intakes. Awareness of the episode and ability to remember differentiates NES from the sleep-related eating disorder, where the nighttime ingestions cannot be remembered. Unlike binge eating disorder, where the goal is satiety and not falling asleep, so the hypnotic function of nocturnal intake is key in the differential diagnosis with NES . Trazodone, indicated in insomnia of maintenance, has not been reported as a treatment of choice in the NES, enabling a significant decrease on awakenings and consequently the intake.

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Anorexia nervosa is a behavioral mental disorder, characterized by body dysmorphia, an intense fear of gaining weight and behaviors that interfere with this, in addition to a restriction of food intake, associated usually with medical complications, even a considerable risk of death.

Several psychotherapeutic approaches have been used along last decades. Until relatively recently, parents have been recognized as part of the problem, but nowadays we involve them into the therapeutic process through family therapy based on a systemic approach, recommended in current published clinical guidelines and research findings, with consistent evidence, as the first-line treatment of patients with anorexia nervosa.

A case of a patient with anorexia nervosa, is presented followed by a theoretical review on the topic.

A case is presented with a bibliographic review.

A 24-yeard-old female was hospitalized for renutrition due to a significant weight loss and multiple physical symptoms. After 4 months without progress, the patient was transferred to the psychiatric ward.

Once there, physical stabilisation was achieved with family therapy and pharmacological treatment, based on progressive administration of Clomipramine, previously assessed by Cardiology, which improved rumination and obsessive behaviour. We conduct daily individual and weekly family interviews, working on family dynamics, emotional regulation strategies and more adaptive ways of communication. Likewise, several lines of action were found in the systemic work: peripheral father; maternal over-involvement; fraternal rivalry; difficulties of interaction between all of them, derived from “the role of the sick person” and intra-family communication around the illness. Finally, showed effectiveness in terms of an improvement in interpersonal relationships, greater assertiveness and an optimistic attitude with an active search for coping strategies.

Historically, parents have been recognized by a causal factor in the pathogenesis of this disorder. Nevertheless, the abolition of the emphasis on family responsibility, motivated by a philosophic and evidence-based, has allowed us to see them as an essential resource in aiding the patient in the improvement process. This parental involvement has resulted in a relevant reduction in morbidity, as well as a significant decrease treatment attrition rates. It has been noted a re-establishment in other individual and family factors such as self-esteem, quality of life, and some aspects of the experiences of caregiving, and behavioral symptoms have been resolved.

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Psychotic symptoms and eating disorders can occur in the same person, sometimes at the same time. This comorbidity is not well studied despite the difficulties of management at both clinical and pharmacological levels that it may entail. We present the case of a 35-year.old female patient with anorexia nervosa with years of evolution, currently admitted to a center specializing in Eating Disorders, who comes to the emergency department with psychotic symptoms.

To know the prevalence of comorbidity of psychotic symptoms in people with eating disorders, as well as possible risk factors, severity and management of them.

Presentation of a case and review of the available literature on the presence of symptoms of the psychotic sphere in persons diagnosed with eating disorders.

The literature reflects data of a prevalence of 10-15% of patients with eating disorders presenting psychotic symptoms. The presence of psychotic symptoms is not directly related to a greater severity of the eating disorder. Some genetic associations have been found, as well as alterations at the physiological, cognitive and brain structure level that coincide in both pathologies. In some cases, an improvement in eating behavior has been observed when the psychotic symptomatology is resolved. In the case of patients with bulimia nervosa, a higher number of psychotic symptomatology has been observed, such as paranoid ideations, which some studies relate to a greater emotional capacity and histrionic expressiveness of this patient profile.

The comorbidity of psychotic symptoms and eating disorders is relatively frequent and makes us face challenges in the diagnosis, as well as in the management of these patients. This comorbidity is especially important in patients with bulimia nervosa. Future research is necessary to know a more exact management of these pathologies.

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Feeding plays a very important role in our lives. First of all survival, but in general it has a much wider and important social role. Through feeding, in addition to satisfying life’s needs and basic instincts, we experience a sense of satisfaction through the investment of libido. Anorexia nervosa and obesity as the two extremes of eating disorders can be considered as a disturbed experience of the satisfaction of eating, and in the background there is usually a very weak, fragile personality structure. A fragile personality structure tends to use primitive defense mechanisms, but the use of healthier, neurotic defense mechanisms in people with eating disorders should not be neglected.

To investigate the role of the psychological defense mechanism of displacement in people with obesity and anorexia nervosa.

Search of contemporary professional and scientific literature in the field of psychodynamics of eating disorders.

Displacement is a defense mechanism in which, when faced with a problem, the problem is not solved with the initial object of aggression, but the problem is moved to another object or situation that the individual perceives as less dangerous. Thus, when faced with a stressful situation or sadness, obese people may have a need for emotional eating, which can be interpreted as displacement of the problem, which is temporarily “solved” by satisfying the basic instinct, but later the person becomes overwhelmed by internal and external shame. Equally so, a traumatic upbringing and disturbed interpersonal family dynamics, which are often present in people with anorexia nervosa, can cause anxiety drives that are displaced in the form of the need for a strong restriction of food intake.

In people with obesity and anorexia nervosa, the use of the defense mechanism of displacement is pointed out. Through psychodynamic psychotherapy it can be very useful to recognize and interpert the use of displacement and, thus to enable reaching a neurotic and healthier level of functioning in people with the aforementioned eating disorders.

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A review of the literature shows how female sex is a crucial factor in the development of ED, being the proportion of women and men 10 to 1 regardless of the location of the sample (Duncan, Ziobrowski & Nicol, 2017) and different clinical subtypes (AN, BN) (Swanson et al., 2011). However, male population has always been less studied, some works find that only 1% of the articles published in AN is aimed at the study of males (Galusca, 2012).

Nowadays it is accepted that the etiopathogenesis of these disorders is multifactorial and in addition to female gender other risk factors have been identified, such as neurobiological alterations, psychological predictors, personality traits, low self-esteem, extreme perfectionism or thinness values focused on body and figure. On the other hand, certain impulsive behaviours such as self-harm, substance use, physical activity or diets are factors that may be confused as predisposing or as symptoms of the pathology itself (Connan et al., 2003, Treasure, Stein and Maguire, 2015).

Recently, Kinasz, Accurso, Kass and Le Grange (2016) have compared the clinical characteristics that differentiate men (59) from women (560) in a sample of children and adolescents between 6 and 18 years-old, finding that males presented an earlier start of the ED and not appreciating differences in the duration of the disease, income, episodes of purgue and psychiatric comorbidity of anxiety, behaviour disorders or impulsivity.

The aim of this study was to evaluate gender differences in clinical characteristics, levels of depression, previous obsessiveness and personality dimensions in eating disorders (ED) compared with controls.

A total of 80 participants was divided into 4 groups, 20 men and 20 women with ED and 20 men and 20 women without ED (healthy control), matched by age and socioeconomic status. The design of the study was case-control, and data was collected through clinical interview and a battery of cuestionaires.

Men with ED only differ in vigorous physical activity (measured by IPAQ) from controls and women with pathology. Regarding personality traits, men and women with ED do not differ among them, although they do differ in novelty search and harm avoidance respect to their controls.

Behaviors such as physical activity in males frame a slightly different way of reducing their discomfort, however, clinical implication indicates that the treatment may be similar according to gender.

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Eating disorders (ED) historically been adressed as illnesses that only affect young adolescent females. ED’s in males have been documented in literature as early as the 1960’s; yet men continue to be under represented on research on the topic. For decades, the Diagnostic and Statistical Manual of Mental Disorders (DSM) perpetuated the invisibility of males by including amenorrhea as a diagnostic criterion. It was not until 2013 that male inclusion was endorsed thorught the removal of that criterion. It is estimated that one in four people affected with and ED is male.

It is estimated that one in four people affected with and ED is male. The proportion of males reporting lifetime prevalence of Binge eating disorder (BED) was far greater than for Anorexia nervosa (AN) or Bulimia nervosa (BN); the female versus male ratio of BED prevalence was 3:1. AN is the most life-threatening ED, but is least frequently seen in male populations; researchers suggest this is because most men are not interested in the emaciated, thin look.

This poster aims to recognize the presence of ED’s in males and raise awareness on this topic.

Case report and literature review

We present the case of a 50-year-old man with long-standing AN, who had never undergone mental health follow-up. He is referred to psychiatrist by his primary care provider (PCP) due to depressive symptoms. His medical history included vitamine D insufficiency and osteoporosis. At the age of 19 he was obese (BMI 35) and from the age of 23 he started to present dietary restriction after a social event. He had never self-induced vomiting, use of laxatives, binge eating or compulsive exercise. He reported no history or current substance use disorder. BMI at first consultation was 17,6 and showed fear of weight gain. Antidepressant therapy was started and patient was referred to a specialized therapist, nutritionistand nurse.

Overall, the findings demand clinicians develop awareness about ED in males to advance illness management and enhance long-term prognosis. In our case, the delay in receiving treatment has probably led to greater morbidity and chronicity. PCP’s play a key role in detection of ED’s as the often act as a first point of contact for men accesing the health care system. While assesing and ED, the PCP should include general questions on eating habits in their intake interview. Once an a ED is suspected, the first few minutes of the encounter are crucial to gain trust and buy-in from the patient. Once buy-in from the patient is gained, a complete physical exam and diagnostic work-up is required. Priority referrals to the following professionals are critical: psychiatrist, therapist, dietician or nutritionist, and ED specialist if available.

None Declared

It is well known that eating disorders are related to comorbidity. At least, half of these patients have other mental disorders and, in addition to it, the presence of physical comorbidity (cardiovascular, kidney, nervous system, digestive tract, metabolic or endocrine disorders) comes with a decline in life expectancy.

Description of a patient with a diagnosis of anorexia nervosa (AN) who developed a gastric bezoar during hospitalization.

Case treated in a specific Eating Disorder Unit in a Third-Level Hospital.

26 years old woman with a diagnosis of AN hospitalized in General Psychiatric Unit with BMI of 11,78 kg/m2. Nasogastric tube was necessary and, after 1 month with a progressive weight recovery (BMI 13,84 kg/m2), the patient was transferred to the Eating Disorder Unit in order to follow specific psychological therapy. No incidence related to physical exploration or clinical analyses happened during this month apart from pancytopenia due to malnutrition.

However, 8 days after, patient developed nausea and had 3 vomit episodes, constant abdominal pain at hipogastrium (moderate intensity), dizziness, instability and constipation. The patient refused possibility of pregnancy. The physical exam showed bowel sounds augmented but no mass or peritoneal irritation appeared. Blood test results were normal. Abdominal X-Ray showed gastric dilatation with small bowel faeces sign, which suggested diagnosis of gastric bezoar.

The treatment was the dissolution of the bezoar by Coca-Cola, solving the symptoms completely.

The patient refused having eaten hair or any other kind of object or indigestible material but admitted to be following a strict vegan diet. Finally, after an endoscopy was done, the patient was diagnosed of phytobezoar.

Based on literature, bezoars are rare in AN, being phytobezoars the most common between the types of bezoars. Nevertheless, there are some risk factors, such as delayed gastric emptying, dehydration or, in the case of phytobezoar, ingestion of food containing high amount of cellulose, hemi-cellulose, lignin, and tannins (celery, pumpkin, grape skins, prunes, raisins and, in particular, persimmons). Some of the symptoms caused by phytobezoar can be similar to those of the AN (abdominal pain, intestinal obstruction, poor appetite, vomiting, malnutrition, weight loss). Therefore, gastric bezoar could be an underdiagnosed or even undiagnosed disease in this group of patients. Taking this into account could reduce time until diagnosis and treatment, decreasing the risks associated.

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Superior mesenteric artery syndrome is a gastro-vascular disorder in which the third and final portion of the duodenum is compressed between the abdominal aorta and the overlying superior mesenteric artery. This rare, potentially life-threatening syndrome is typically caused by an angle of 6°–25° between the abdominal aorta and the superior mesenteric artery, in comparison to the normal range of 38°–56°, due to a lack of retroperitoneal and visceral fat (mesenteric fat). In addition, the aortomesenteric distance is 2–8 millimeters, as opposed to the typical 10–20. However, a narrow superior mesenteric artery angle alone is not enough to make a diagnosis with no symptoms.

Symptoms are fullness and epigastric tightness after meals, nausea and vomiting (often bilious) and pain in the middle of the abdomen that improves with the prone or knees flexed to the chest. The diagnosis is supported by imaging tests (esophagogastroduodenal transit or CT) showing dilation and stasis proximal to AMS in the third duodenal portion.

Relief from vomiting with feeding through a enteral probe placed beyond the obstruction to the proximal jejunum supports diagnosis.

Precipitating factors should be corrected first, whenever possible. Acute symptoms can be resolved with gastric decompression and intravenous fluids. Therefore, surgical correction should only be done in well-studied patients with chronic recurrent episodes of AMS syndrome. The most recommended surgical technique is a laparoscopic proximal duodenojejunostomy

To describe a case of superior mesenteric artery syndrome and review in literature the organic complications and associated psychopathology of this disorder

Clinical case report and brief review of literatura

17-year-old woman with a diagnosis of anorexia nervosa. Admitted for behavioral disorder, repeated self-harm and low mood. Presents a BMI of 16.6. Irregular rules. Progressive diet is started to which nutritional supplements are added with good initial tolerance. It presents a loss of 2kg and begins with nausea, vomiting and postprandial epigastralgia. Oral panendoscopy and abdominal ultrasound are performed showing possible mesenteric aortic clamp so naso-jejunal probe and exclusive enteral feeding is prescribed. She received enteral jejunal nutrition progressively with feedback syndrome prophylaxis that included parenteral vitamin B1. After a few days, oral supplementation began. He remained hemodynamically stable, with no signs of heart failure. It gained 3kg of weight up to 43.2kg, starting before discharge from the hospital successfully oral tolerance.

Superior mesenteric artery syndrome is a serious complication in anorexia nervosa with a low incidence and an estimated mortality of 33%. A multidisplinar approach that addresses both the medical and psychological needs of these patients throughout their hospital stay is necessary.

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The effect of self-esteem in eating disorders has been investigated in several studies, but it’s still not extensively investigated in orthorexia nervosa.

To study the prevalence and factors associated with orthorexic eating behaviors in medical students and it’s relation with self-esteem.

A cross-sectional study was conducted through an online survey among medical students of the faculty of medicine of Sfax (Tunisia). Participants completed an anonymous self-administered questionnaire. We collected their sociodemographic and clinical data. Orthorexia nervosa (ON) was assessed using the self-reported scale, ORTO-15. We used the Rosenberg’s self-esteem scale to assess self-esteem.

Ninety five medical students completed the survey. The mean age was 25.8±3.4 years and the sex ratio (F/M) was 3.75. The average body mass index was 23.64±3.53 kg /m2.

Fifty-eight percent of the students (58%) reported that they were dissatisfied with their eating habits, and 27.4% tried to control their weight. Several methods of weight control were used, the most frequent (65.4%) were diet and physical exercise, none resorted to laxatives and 8.4% consulted a nutritionist.

Self-esteem was very low in 27.1% and low in 34.7% of the students.

Overall, the prevalence of orthorexia among our participants was 52.6%. The mean score of the ORTO-15 was 39.19±4.48.

Orthorexia was significantly correlated with the use of weight control measures (p=0.035) and physical activity (p=0.042).

Students with low self-esteem had higher tendency for orthorexia but with no significant correlation.

Our study supports a non-negligible frequency of orthorexic behaviors in medical students but future studies are needed to assess the direct effect of self-esteem on orthorexia.

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Evidence is growing for the bio-immuno-metabolic model of pathogenesis in anorexia nervosa (AN), an eating disorder with a chronic and relapsing nature. The role of the gut microbiome in this process is also receiving intense research interest. The gut microbiome and the use of probiotics and prebiotics have been extensively studied in gastrointestinal (GI) disorders such as inflammatory bowel disease (IBD) and functional GI disorders (FGIDs). Exploring links between AN and these GI disorders may open new avenues of treatment such as the use of probiotics and prebiotics in AN.

This review explores: i) GI presentation in AN and its relationship with the gut microbiome ii) factors influencing the gut microbiome presentation in AN including dietary patterns iii) whether the gut microbiome may be involved in the pathogenesis and maintenance of AN iv) gut microbiome presentation in GI disorders and commonalities with AN v) evidence for the potential use of probiotics and prebiotics as adjunct treatment in AN.

GI symptomatology and gut microbiome presentation in AN were examined through literature searches. Gut microbiome changes related to common dietary patterns in AN were explored. Microbiome changes that may influence development or maintenance of AN were considered. Microbiome alterations seen in relevant GI disorders were explored and commonalities considered between these and alterations in the microbiome in AN. Literature searches were performed for the use of probiotics and prebiotics in AN and relevant GI disorders.

GI symptoms occur commonly in AN with evidence suggesting some symptoms continuing beyond weight restoration. Significant disruption of the gut microbiome has been associated with AN with some changes related to typical dietary patterns seen during AN development. Additionally, similarities exist between microbiome alterations in AN and those seen in IBD and FGIDs indicating factors apart from the diet, such as a pro-inflammatory milieu, in play. These changes may not only influence GI presentation in AN but may also have a role in maintenance of the disorder. Some evidence suggests that the pre-morbid gut microbiome may influence risk for AN development. Preliminary evidence of the use of probiotics in AN indicates a positive influence on immune modulation although no evidence exists as yet of their influence on AN symptomatology. There has been extensive research into the use of probiotics and prebiotics in IBD and FGIDs with some evidence for reduction in disease parameters and symptomatology with the use of multi-strain probiotics.

Some theoretical, mechanistic and clinical evidence exists for the use of probiotics in ameliorating GI symptoms in AN. However, further research is needed into the context of the gut microbiome changes in AN, the specifics of efficacy and the effects that probiotics and prebiotics may have in AN.

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Obesity is a major public health problem and some developed countries have declared it ‘the modern day epidemic’. One of the major eating disorders that leads to obesity is BED, which involves consuming large quantities of high carbohydrate food. Studying the factors that cause and contribute to BED can help tackle this major health hazard and alleviate a huge burden on the nationalized health service.

To determine the frequency of Binge Eating Disorder (BED) among obese adults, and to study its relationship to depression, anxiety, life stressors, personality and self esteem.

The sample was a randomised sample of clinically obese individuals, body mass index (BMI) of 30 and above. The sample was collected from two sites; Nutrition Clinic in Student’s Hospital, Cairo University and a Private Nutrition Centre. 250 cases were recruited over one year. All patients were subjected to a clinical interview derived from Kasr El Aini sheet , and measurement of Waist- Hip Ratio. Assessment of depression and anxiety was through Beck Depression Inventory , Hamilton Depression Rating Scale and Taylor Manifest Anxiety Scale(TMAS). Other tools used were the Eysenck’s Personality Inventory, Eating Disorder Inventory -2.

BED among obese adults was 48%; 83 % of them had drive for thinness, 25% were bulimics, 45 % had ineffectiveness feeling. Also 83 % had body dissatisfaction, 8% were perfectionism seeking, 43 % showed interpersonal distrust and 25% presented maturity fears. Impulsivity was scored high in 25% , 66.6%had social insecurity and 77% had severe Extraversion. All were statistically significant. On the other hand there were no statistical significant difference between obese adults with BED and those without on TMAS. Half percent of participants with BED and 34.6 percent of participant without BED had moderate level of anxiety. In addition , there were no significant difference between obese participants with BED and those without BED according to BDI. However, 83.3% of obese cases with BED while 60 % for those without BED had manifest depression ranging from mild to severe depression.

Obese adults with BED have more drive for thinness, body dissatisfaction, feeling of ineffectiveness, perfectionism seeking, interpersonal distrust, maturity fears and social insecurity than non BED. Extraversion and Neuroticism are also more among BED. There were no significance different between both group in relation to Anxiety and Depression.

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