The risk of early suicide and diagnostic issues in Cotard's syndrome associated to self-starvation.

BACKGROUND AND OBJECTIVE: Cotard's syndrome is a rare neuropsychiatric disorder in which the patient holds nihilistic delusions concerning his/her own existence, including the conviction of being dead or having lost parts of the body. There are occasional reports of Cotard's syndrome being accompanied by nutritional deficiencies or self-starvation. METHODS: The authors describe the peculiar case of a 40-year-old man who developed severe malnutrition within a few months. At first, a diagnosis of anorexia nervosa was made. The man was admitted to the hospital where other significant psychopathological symptoms emerged. RESULTS: One of the consequences of Cotard's syndrome is self-starvation because of negation of existence of self. The presented case points out that, although Cotard's syndrome has been reported to be associated with various organic conditions and other forms of psychopathology, loss of appetite and nutritional deficits can erroneously lead to mistake this diagnosis for anorexia nervosa, thus underestimating the high risk of these patients of committing suicide following hospital discharge. CONCLUSION: Taking into account its rarity and possible subdiagnosis, as a distinct clinical entity the aim of this case report is to emphasize that these patients may initially be addressed to general practitioners, due to the dysmetabolic consequences of malnutrition, rather than to psychiatrists. An early recognition of signs indicative of Cotard's syndrome can be vital to prevent the situation from worsening. In fact, missed diagnoses can put these patients at an higher risk of suicidal behaviour.

The Doppelgänger phenomenon and death: a peculiar case of homicide by a subject with first-episode psychosis.

The Doppelgänger phenomenon refers to the experience of a direct encounter with one's self, characteriswed by: (i) the perception of a figure with one's own identical physical features; or (ii) the apprehension that the perceived figure shares the same personality and identity. The Doppelgänger does not only look like the same person, it is his/her double. The perceptual element is usually a hallucination, although occasionally a false perception of an actual figure may be involved. This phenomenon has been described in individuals suffering from overwhelming fear, severe anxiety or intoxication, epilepsy, as well as in the sleep-wakefulness transition. It has also been reported in major psychoses. The fear of imminent death often precedes the Doppelgänger experience. This report presents the case of a 30-year-old man, Mr. Y, who was stabbed to death by Mr. X, his "double". The aggressor and his victim, although not related, were truly doubles; remarkably, they shared the same name and surname, age, professional activity and place of work. Moreover, they attended the same sports center but barely knew each other. The forensic psychiatric evaluations in Mr. X, subsequent to the crime committed, were suggestive of a psychotic condition. This case is unique in the scientific literature. In the most serious psychotic forms, the issue of the "double" calls into question not only the dissociative processes involved in the etiopathogenesis of the disorder, but also bio-psycho-social elements, as well as personal data in this case, which made the victim and the aggressor "identical". In the context of psychopathological functioning, the delusional mood (Wahnstimmung) that precedes the development of delirium is a sort of gateway to an impending psychotic illness, involving delusional awareness or mood (atmosphere). In psychosis, splitting is the main issue and this influence is seen as an evil, foreign, apocalyptic and unknown side no longer recognised as belonging to the self even in a physical sense. In such a situation, it is felt that the only way to survive is by suppressing one's double as a defense against disorganisation of the self.

The mourning process and "living with the dead": Two case reports and a review of the literature.

The discovery of mummified bodies in domestic settings is not unusual in the medico-legal context. It is often a marker of social isolation, even in our urban modern society, and usually occurs among elderly people living alone or in precarious conditions. However, bereaved subjects can sometimes be found managing their grief by deliberately keeping the corpses of their loved ones at home. Investigation of these atypical cases can be challenging and often requires a multidisciplinary effort by different forensic specialists. We report two cases of people who lived for several months with the mummified remains of a relative. In both cases, the judge ordered a forensic psychiatry assessment of the survivors' competency and the reasons for this peculiar behavior, which is regarded as abnormal in our society. Case 1 describes a shared psychosis, which developed out of a condition of extreme seclusion of the entire family. Case 2 shows that even a mild personality disorder on which a series of traumatic events operates can trigger psychotic decompensation, causing extreme denial of the reality of death. The analysis of these cases contributes to our knowledge of the scantly studied phenomenon of "Living with the Dead" and raises questions about the psychopathology behind it. It is useful to identify subjects who are more prone to developing this "deviant" behavior, in order to distinguish people with mental illness from those who merely want to profit from the death of a loved one.

Differential diagnosis between physical maltreatment and cupping practices in a suspected child abuse case.

Physical maltreatment is one of the most common forms of child abuse. Cutaneous injuries often raise the suspicion of child maltreatment. Nevertheless, among health professionals there is still uncertainty in the evaluation of such injuries. In the literature, there are few indications about the most important factors that allow the differentiation of physical abuse findings from signs/lesions that are caused by "folk medicine practices" with similar presentations. We report the case of two brothers who were brought to the Emergency Department of a pediatric hospital by their father because each of them showed one painful, circular and red-purple bruise on their back. Suspecting child abuse, the emergency physicians reported the case to a multidisciplinary unit (dedicated to child abuse). After a careful physical examination, psychological interviews, as well as the evaluation of their medical history, the operators pointed out that the lesions were the result of cupping practices (a form of folk medicine). This case highlights the need for a multidisciplinary approach and demonstrates the importance of a careful evaluation of the cultural background of the family.

The risk of assault against mental health professionals: a fatal case report and literature review.

Assaults by patients against healthcare providers are an increasing phenomenon worldwide. Mental health professionals in acute facilities and rehabilitation wards have the highest risk of being attacked at work. Verbal abuse or intimidating behaviors represent the most common types of violence. Fatal assault by psychiatric patients has been rarely reported in the literature. We present a case of a female psychiatrist who was fatally stabbed in her office in a Mental Health Center. At autopsy seventy stab wounds were found: four wounds of the neck, fifty penetrating wounds of the thorax, three wounds of the abdomen, six wounds of the lumbar region, and seven wounds of the upper arms including defense injuries. The cause of death was massive blood loss due to multiple stab wounds. The perpetrator was a 44-year-old male patient who had been referred to the victim after a previous admission to hospital following experiences of suicidal ideation and confusion. The extreme and unmotivated violence in a non-acute setting were notable. A borderline-antisocial personality disorder was later diagnosed by forensic experts. This case emphasizes the significant occupational risk for mental healthcare staff to sustain life threatening injuries or death, with implications for training of clinicians, and strategies for preventing aggressive behaviors.

Risk of hepatocellular carcinoma in HBV cirrhotic patients assessed by the combination of miR-122, AFP and PIVKA-II.

BACKGROUND: Reliable biomarkers for early detection of hepatocellular carcinoma (HCC) in patients with cirrhosis are lacking. We evaluated the use of miR-122, alpha-fetoprotein (AFP) and protein induced by vitamin k absence/antagonist II (PIVKA-II) for HCC risk prediction in patients with HBV-related cirrhosis under surveillance. METHODS: We first analyzed a group of 63 patients with HBV-related liver cirrhosis of whom 33 had HCC. Then we performed a retrospective analysis on another group of 13 cirrhotic patients who developed HCC during surveillance, of whom serial serum samples were available (at time of HCC diagnosis [T0], 6-9 months [T-1] and 12-18 months [T-2] before HCC detection). Serum miR-122 levels were assessed by quantitative real time-PCR, whereas AFP and PIVKA-II were measured by fully automated chemiluminescent enzyme immunoassay. RESULTS: Serum levels of miR-122, AFP and PIVKA-II were different between patients with cirrhosis and those with HCC (P=0.024, P<0.001 and P<0.001, respectively). Areas under the curve (AUC) were 0.675 for miR-122, 0.791 for AFP and 0.846 for PIVKA-II, while their combination improved the discrimination power between cirrhosis and HCC (AUC=0.918). In the longitudinal study, we found a significant variation overtime for the biomarkers combination (P=0.011) but not for each single biomarker (miR-122, P=0.163; AFP, P=0.170; PIVKA-II, P=0.447). Combined miR-122+AFP+PIVKA-II adjusted Hazard Ratio for HCC development was 10.63, 95% confidence interval 1.87-60.28 (P<0.001). CONCLUSIONS: In HBV-related cirrhosis, the combination of miR-122, AFP and PIVKA-II enables the identification of patients at higher risk of HCC development that could benefit from closer monitoring.