The authors have not supplied their declaration of competing interest.

In psychiatric clinical practice, we can face numerous organic diseases in the differential diagnosis between primary psychiatric disorders. As an example of this, we can see the autoimmune limbic encephalitis(LE), which in a significant percentage of cases begins with psychiatric symptoms. Currently, one of the theories of the origin of the LE is as a idiopathic autoimmune entity, leaving behind the idea of been generated only by a viral or paraneoplastic etiology.

To achieve a better knowledge about this underdiagnosed entity, presenting a case of an anti-LGI1 limbic encephalitis.

A 60-year-old Caucasian woman who starts with neuropsychiatric symptoms as: behavioral disorders, manic symptoms, memory impairment and attention deficit.

Finally, the diagnosis was confirmed when the patient had positive results in both serum and CSF samples for anti-LGI1 antibodies. Gastric neuroendocrino tumour type I was discovered. Neither paraneoplasic syndrome nor onconeuronal antibodies were shown. A thin hyperintense signal was identified in the left hippocampus using a brain MRI. Despite the patient had been treated with corticosteroids, immunosuppressants and immunoglobulins, she still showed positive antibodies in CSF samples with poor clinical results, especially psychiatric symptoms. The patient required one psychiatric hospitalization due to reference and persecutory delusions and manic symptoms.

Our patient had an unsatisfactory evolution with little response to immune treatment. Given the possible underdiagnosis of this condition, the importance of a differential diagnosis and an early treatment, we consider that there is an important need for a greater knowledge and scientific divulgation of this clinical entity.

The authors have not supplied their declaration of competing interest.

Teachers are confronted with increasing difficulties and demands that make them vulnerable to burnout.

To evaluate burnout among a population of Tunisian teachers and to identify factors that may be involved.

It was a cross-sectional, descriptive and analytic study, involving 165 teachers working in 10 primary schools and 7 high schools in Sfax, Tunisia. The participants completed a self-questionnaire containing their socio-demographic and professional characteristics. They were explored by the scale of the burnout: Le Maslach Burnout Inventory General Survey (MBI-GS).

The mean age of teachers was 39.96 years. The sex ratio (M:F) was 1.32. The majority (75.2%) was married. The burnout syndrome was found in 49.7% of teachers. Moderate burnout was found in 43% of cases and severe burnout in 6.7%. The causes of burnout reported by our population were bad working conditions (71.50%), quality of working relationships (65.5%) and overload work (30.3%). Bad working conditions were associated with a high level of emotional exhaustion (P < 0.005) and a low level of professional efficacy (P < 0.001), while poor quality of work relationships and overload work were associated to a high score on cynicism (P < 0.001) and a low score on professional efficacy (P < 0.001).

According to our study, poor working conditions, overload work and bad quality of relationships seem to be risk factors of burnout in teachers. Preventive measures should be instituted against those factors to reduce the constraints of work and improve the professional quality of life of these individuals, essential thing to optimize the educational level in our country.

The authors have not supplied their declaration of competing interest.

The author has not supplied his/her declaration of competing interest.

Encountering a patient with Münchausen syndrome (MS) or with MS by proxy is more frequent than it is assumed. Treating this type of patient is indeed a challenge, thus, knowing to depict the signs is important for every doctor. A specific therapeutic approach is needed and sometimes, even law enforcement must be involved.

We plan to highlight the signs and consequences of Münchausen syndrome and Münchausen syndrome by proxy.

Clinical data were collected during admissions of patients in the psychiatric hospital. A literature review has been performed.

We report the case of a nurse diagnosed with MS, who had multiple admissions with different diagnostics, before the patient was exposed with the factious disorder diagnosis. We also report the case of a mother diagnosed with MS by proxy and the case of another mother where the obsessive-compulsive elements of her depressive disorder are combined with signs of MS by proxy, both of them inflicting consequences upon the child in care.

Patients suffering from Münchausen syndrome and Münchausen syndrome by proxy can be a burden for society and for themselves. The relationship with them is sabotaged from the start. The diagnostic is difficult to establish. Numerous expensive procedures are being taken and a considerable amount of funds is spent. Most importantly, the abuse of a child with a parent or guardian suffering from this disease is incommensurable and can even lead to death. It is vital to take action as soon as these syndromes are discovered.

The authors have not supplied their declaration of competing interest.

Apathy is commonly defined as lack of, or diminished, emotion, interest, concern, interest and motivation manifesting as poor engagement with others and loss of pleasure in usual interests. Occurs in various medical condition (stroke, HIV, dementia and Parkinson disease) and other psychiatric disorders. It has been related with thalamus stroke, and seen on clinical practice as a blunted emotional response and indifference.

We have tried to link cases of apathy associated with thalamic stroke and systematically review the literature for similar case reports.

We have searched MEDLINE, EMBASE, IBIDS, and the Cochrane Collaboration Database until October 2015. Published case reports of apathy in persons who had suffered a brain stroke were selected.

Support the evidence in the literature of the multidimensional nature of apathy and correlate the psychiatric manifestation with the neurological findings. We find similar case reports that could support the anatomical subtract of the apathy and it's also correlated with the previous data reports.

These findings are discussed and interpreted in the seeking of regarding the neurobiological substrate of apathy.

The authors have not supplied their declaration of competing interest.

A 56-year-old female admitted to psychiatry clinic due to complaints of forgetfulness, visual and auditory hallucinations, inability to go outside alone, washing hands in closet cabin, difficulty finding words for the last one year, progressing in last four months. Personal and family background was unremarkable. Vital signs and physical examination revealed no abnormalities. In neuropsychiatric examination, Glasgow Coma Scale score was 15 without any meningeal irritation signs or gait abnormalities. Cranial nerves, extrapyramidal, motor, cerebellar, and sensory systems were intact. All aspects of orientation (time, place and person) were impaired. She scored 12 points out of 30 in Mini Mental Test. Speech was non-fluent with looseness of associations. Impaired recall, abstract thinking, judgment, behaviour planning and attention were noted. Visiospatial disorientation and contructional dressing apraxia were revealed. MR Imaging reported a T2-weighted signal intensity change in nodular fashion suggesting a granulamatous lesion. Differential diagnoses included granulomatous diseases, neoplasms, infections and Behcet's disease. After necessary excluding evaluations were undergone, a diagnosis of NS was made due to increased angiotensin converting enzyme levels in cerebrospinal fluid. The clinical picture responded well to prednisone treatment and symptoms resolved within one month.

Increased awareness is essential to identify rare granulamotous diseases as a differential diagnosis in encountering psychotic symptoms accompanying demantial clinic presentation.

The authors have not supplied their declaration of competing interest.

Clinical applications of mindfulness have become widespread since the introduction of the mindfulness-based stress reduction (MBSR), a treatment program originally developed for the management of chronic pain. Neuroimaging techniques have allowed uncovering the neural mechanisms behind Mindfulness techniques.

To review some of the psychological and neural mechanisms behind mindfulness practice in order to explore the unique factors that account for its positive impact on emotional regulation and health.

Psychological and neural mechanisms behind mindfulness practice are reviewed.

A literature review of the theme is surveyed. Several articles were searched on Medline with the keywords “mindfulness”, “meditation”, “neurobiology” and “neurocognitive”.

Mindfulness may achieve effective outcomes in the treatment of anxiety, depression, and other psychopathologies through the contribution of emotional regulation. Cognitive reappraisal has been suggested as a core cognitive control skill whereby mindfulness practice may regulate emotions. It seems that a neural circuit comprising the prefrontal cortex (PFC), the anterior cingulate cortex (ACC), the amygdala (A), and the insula (I) are involved in the unique processes of mindful emotion regulation.

Recent models of mindfulness allow for more rigorous examination and operationalization of the method to guide research. Increasingly investigators are focusing on the impact that mindfulness has on emotional regulation, which accounts for the effects on mental health.

The authors have not supplied their declaration of competing interest.

Aggressiveness is a multidimensional phenomenon, characterized by many cognitive and emotional processes, which is often present in psychiatric disorders. Until the present time, mechanical restraint has been a tool used in order to avoid risks for patients or other people around them. It should be used as a last option, so new strategies to reduce the use of these measures favoring others are being developed.

We try to analyze the influence of clinical and organizational changes in the frequency and duration of mechanical restraints, in order to provide new data and built hypothesis for future intervention plans.

This oral communication presents a retrospective analysis of mechanical restraints carried out in the Mental Health Hospital Unit of Jerez de la Frontera between 2007 and 2014, both inclusive, a sample of 950 episodes. Several variables will be analyzed and related to the different organizational events conducted in the Clinical Management Unit of Jerez de la Frontera.

There has been a gradual reduction in the duration of mechanical restraints carried out in the Mental Health Unit Hospital of Jerez de la Frontera over the eight years studied, specially after the implementation of the agitation protocol developed in 2011.

In our experience, the implementation of a comprehensive clinical record, deep observation of the patient by the professionals and the development of protocols to regularize interventions performed during an episode of psychomotor agitation are useful strategies to reduce the duration of each mechanical restraint episode.

The authors have not supplied their declaration of competing interest.

Various medical and psychiatric conditions can determine the occurrence of disruptive behavior and aggression. Mechanical restraint is part of the strategies for managing these risks. Its use implies a multidisciplinary, phased and individualized for each case strategy, with attention to the ethical and legal issues surrounding this coercive intervention.

The objective of this work is the analysis of the profile of patients who required mechanical restraint during hospitalization in a psychiatric inpatient unit.

Retrospective descriptive analysis by collecting data of patients, who required mechanical restraint during admission, between 2007 and 2014. The data sources were medical clinical history and nursing records. Variables analyzed were sex, age, clinical diagnosis at discharge and clinical state during the episode of mechanical restraint.

Of the total sample of patients requiring restraint (n = 266), 66.92% were men. The mean age of patients was 38.01 years. Distribution of clinical diagnoses based on ICD-10 coding: 30.23% F60 personality disorder (n = 289), 19.56% diagnosed with F31 bipolar disorder (n = 187) and 14.02% F20 schizophrenia. Regarding the clinical characteristics of the episode, 49.47% of patients had an agitation/violent state and in 23.11% risk of impulsive self-injury was evident, 13.47% had confusional syndrome.

Data analyzed shows differences in frequency distribution because of patient profile and clinical diagnosis. Otherwise, organizational factors and appropriate amendments to this level appear to play a key role in minimizing the use of such coercive measures.

The authors have not supplied their declaration of competing interest.

The theory of self-medication in patients with severe mental illness has been exposed for years but to date has not been confirmed or ruled out. With this study, we intend to show the latest available evidence regarding this context.

An exhaustive literature research in Medline and the latest forth in APA 2015.

More and more evidence refute the veracity of this theory deeply rooted among some professionals.

There are theoretical alternatives that relate more sustained manner the relationship between consumption and toxic psychosis.

The authors have not supplied their declaration of competing interest.

After seventy-five years of its introduction, electroconvulsive therapy (ECT) remains the most effective treatment for severe depressive disorders. It is known that the antidepressant effect is not due only to the electric current itself, but by the general seizure activity. As so, for beneficial or adverse effects of ECTs, it's mainly important to induct a well-generalized seizure. Those can be influence by several variables like, seizure duration and threshold, ECT practice factors and medication, resulting in a lack efficacy. It's advantageous to treatment if physiological markers of adequacy are established to seizure quality, because a high seizure quality has been successfully correlated with better outcome in many studies.

The aim of this work is to review the available international literature regarding to identified parameters that influence and evidence seizure quality.

Although throughout history ECT is embroiled in controversy, according to international bibliography, this is a technique of great therapeutic relevance and precise indications. It is noteworthy, that it has been shown to be an effective and safe treatment for many psychiatric disorders. Nevertheless, there is not a consensus regarding to the parameters to its efficacy, particularly the seizure quality. Thus, it's important to current practice, to do more studies in this field, in order to establish those parameters, have homogenise clinical practice and promote better results.

The authors have not supplied their declaration of competing interest.

A 48-year-old male, diagnosed with impulsive control disorder, sex addiction disorder and mental retardation was followed-up by different psychiatrists for the last 20 years. He consults because of presenting depressive symptoms and behavioural disturbances related to the death of his mother two years before. The patient reports to experimenting depressed mood, irritability, insomnia and trends to cry. He has lost motivation for his job and hobbies (he used to show interest in topics such as physics, philosophy, maths, and medicine). He has feelings of loneliness, which make him look for social interaction and support through continuous calls to telephone sex lines. This act has made him spend large amounts of cash, thus, making him be in deep debts. He does not feel integrate in society.

Introvert, limited social skills, coherent language, echolalic, monotone, tangential speech, depressed mood, feelings of guilt and futility, dysphoria, partial anhedonia, ideas of hopelessness, structured death ideation, unconsciousness of his own acts, with trend to impulsiveness and compulsive behaviour and insomnia.

Wais test: no mental retardation found.

Autistic spectrum disorder (F84.0); major depressive disorder (F32.1); bereavement (V62.82).

The patient showed classic diagnostic criteria DSM 5 associated with autistic spectrum disorder (Asperger's disorder in DSM-IV); the permanent inability for social interactions and repetitive, restricted and stereotypic behavioural patterns.

The authors have not supplied their declaration of competing interest.

The authors have not supplied their declaration of competing interest.

Trichotillomania is described as a recurrent failure to resist impulses to pull out hairs. It is usually associated with obsessive-compulsive disorder and body dismorphic disorder. It is usually confined to one or two sites in the body.

The aim of our work is to describe a case of delusional infestation with secondary trichotillomania and briefly review the theoretical aspects of this clinical presentation.

We searched online databases and reviewed current case reports published, using the keywords “delusional infestation”, “Ekbom syndrome” and “trichotillomania” and compared similarities in the presentation, development and outcome. We present a clinical vignette of a 38-year-old female, with no relevant psychiatric history. The patient developed severe itching that she believed was caused by bugs that lived inside her hair follicles, so she pulled out completely all of her eyebrows, eyelashes, pubic and underarms hairs. She maintained some hair on her head, that she repeatedly pulled out and proceeded to break in order to kill the bugs. She claimed to have absolutely no itchiness in the hairless areas of her body.

The patient was referred to psychiatric consultation and was started on oral antipsychotics but, as the review from literature suggested, the clinical evolution only became satisfactory when an antidepressant (SSRI) was added.

Although, trichotillomania is more commonly seen in clinical practice in association with other psychiatric disorders, it may also present itself as a symptom of delusional activity.

The authors have not supplied their declaration of competing interest.

Catatonia is a neuropsychiatric syndrome that appears in medical, neurological or psychiatric conditions. There are presentation variants: “malignant catatonia” (MC) subtype shares many characteristics with the neuroleptic malignant syndrome (NMS), possibly reflecting common pathophysiology.

We present a clinical vignette and review the literature available on online databases about MC/NMS.

We present a man, 41-years-old, black ethnicity, with no relevant medical history. He had two previous episodes compatible with brief psychosis, the last one in 2013, and a history of adverse reactions to low doses of antipsychotics. Since the last episode he was asymptomatic on olanzapine 2.5 mg id. He acutely presented to the Emergency Room with mutism, negativism, immobility and delusional speech, similar to the previous episodes mentioned and was admitted to a psychiatric infirmary, where his clinical condition worsened, showing muscle rigidity, hemodynamic instability, leukocytosis, rhabdomyolysis and fever. Supportive care was provided, olanzapine was suspended and electroconvulsive therapy (ECT) was initiated. After two months, he was discharged with no psychotic symptoms. He is still under ECT and no antipsychotic medication was reintroduced.

Many studies suggest that clinical or laboratory tests do not distinguish MC from NMS and that they are the same entity. These two conditions are life-threatening and key to treatment is a high suspicion level. There is no specific treatment; supportive care and stopping involved medications are the most widely used measures. ECT is a useful alternative to medication.

The authors have not supplied their declaration of competing interest.

Trazodone is a heterocyclic antidepressant that exerts its effect via the inhibition of selective serotonin reuptake and the antagonism of 5-HT2A and 5-HT2 C receptors. Antidepressant-induced gynecomastia and galactorrhea and increases in prolactin levels have rarely been reported.

A 73-year-old man presented to the psychiatric clinic with depressive symptoms and insomnia that was the reason that his GP introduced paroxetine 20 mg/day three months before. One month later because the insomnia persisted, trazodone (100 mg/day) was added to the treatment. At a 2-month follow-up, the patient reported improvement in depressive symptoms but also presented gynecomastia on the left side that is non-tender on palpation. No other medications were noted. Laboratory testing was within normal limits, with the exception of on elevated prolactin level (38.2 ng/mL). Ultrasonography indicated normal results. Treatment included the tapering and discontinuation of trazodone with continued paroxetine therapy. Lorazepam was initiated for the treatment of insomnia. Two weeks later, the prolactin level was 13.1 ng/mL and gynecomastia was practically resolved. Lorazepam was initiated for the treatment of insomnia.

Effects of trazodone on PRL are unclear, there is one study reported that trazodone increases the PRL level, and another one reported that trazodone reduces them, in our case, the trazodone use led to hyperprolactinemia via hypothalamic postsynaptic receptor stimulation and it should be remembered that gynecomastia and galactorrhea may appear as a rare side effect of trazodone.

The authors have not supplied their declaration of competing interest.

International professional mobility is a reality, people have skills they can put in the global marketplace. The increasing migration of health professionals to wealthy countries is a phenomenon known as “brain drain”.

This work aims to present the push factors that pressure people to migrate from Portugal.

A cross-sectional survey was carried out with the psychiatric trainees in Portugal. A self-administered structured questionnaire was distributed to collect psychiatry trainees’ demographic and educational characteristics.

In Portugal, the majority of trainees have a Portuguese citizenship. Almost 2/3 did not have a short-mobility experience, and the majority never migrated to another country. Less than half consider staying in Portugal in the next years, and nearly 4/5 have considered leaving the country. Working conditions ranked first as the priority condition to be improved in psychiatry in Portugal, followed by financial conditions. In fact, an attractive job for psychiatry trainees in Portugal must have as the most important feature a pleasant work environment.

An alarming percentage of psychiatry trainees from Portugal intend to migrate. Impact on future career, financial conditions of doctors, job opportunities and better working conditions were some of the motivating factors behind the migration.

The authors have not supplied their declaration of competing interest.

The authors have not supplied their declaration of competing interest.

Huntington's Disease is an autosomal dominant neurodegenerative disease characterized by motor, psychiatric and cognitive symptoms. Irritability, affective disorders, apathy and psychosis are among the most frequent psychiatric symptoms and can predate the pre-clinical period.

The authors’ goal is to understand the complexity of Huntington's disease clinical presentation. Additionally, we present an illustrative clinical case.

To convey the importance of collecting reliable information in order to make a proper diagnosis.

A PubMed database review was performed using “Psychiatry”, “Psychiatric”, “Symptoms” and “Huntington's Disease” as keywords; retrieved papers were selected according to their relevance. The patient clinical record was reviewed.

The authors report a case of a 39-year-old woman, who was referred in 2014, to a psychiatrist because of depressive mood and suicidal ideation with two suicidal attempts in the past 5 years. However, she did not disclose her family history of Huntington's disease neither to her GP nor her psychiatrist. She never complied with the treatment plan and was admitted, in November, into a psychiatric unit because of subtle motor changes and apathy, which had resulted in personal neglect. The diagnosis could only be made after a family interview was held and the family medical history was revealed.

Corroborative history from caregivers is of extreme importance in psychiatry. Early detection of symptoms can help mitigate the disease social impact. In our patient's case, by the time of proper diagnosis, she was estranged from her family and had endured distressing psychiatric symptoms without adequate treatment.

The authors have not supplied their declaration of competing interest.