Did Mozart suffer from Asperger syndrome?

The most reliable biographies of Mozart highlight elements that are compatible with current diagnostic criteria for Asperger syndrome including qualitative impairment in social interaction and stereotyped and repetitive motor mannerisms. Furthermore, numerous features are documented including difficulty in communicating his emotional state and in inferring the mental state of his interlocutors, motor clumsiness, specific skills and genius, left-handedness, special sense of humour, physical developmental abnormalities, bizarre thinking, overvalued ideas and delusions.

Lithium treatment in elderly patients affected by mood disorders.

OBJECTIVE: The aim of this study is to provide information about lithium effectiveness and safety in the treatment of old patients with mood disorders. METHODS: The study is naturalistic in nature and design and considers all patients aged ≥75 years attending our center in the past 10 years. We obtained patients' socio-demographic and clinical characteristics, the worst Global Assessment of Functioning score assigned in the course of treatment, the Clinical Global Impression (CGI) score at the beginning of treatment, the CGI-Improvement (CGI-I) highest score achieved in the follow-up, and drop-out rates. We compared patients treated with lithium, in some cases associated with other psychotropic medications, and patients treated with psychotropic medications other than lithium. Furthermore, we analyzed lithium side effects and causes of lithium withdrawal. RESULTS: In the considered period, 25 lithium-treated patients achieved higher CGI-I scores after treatment in comparison with 138 patients not receiving lithium. Drop-out rates were similar in the two groups. Mean dose of lithium was 390 ± 178.5 mg/day. Among lithium treated patients, neither hypothyroidism nor renal failure were significant problems. Thyroxine treatment was prescribed to 8 (32%) lithium-treated patients. Lithium was withdrawn in 6 (24%) patients, respectively for ineffectiveness, heart disease (unrelated to lithium), erratic and unpredictable metabolism of lithium, poor compliance (two cases), and mitigation of the disease. CONCLUSIONS: Lithium remains irreplaceable and maintains a high effectiveness in the treatment of elderly patients. Low doses and frequent monitoring are recommended.

Clozapine safety, 40 years later.

Clozapine is, and will remain in the coming years, an irreplaceable drug in psychiatry which has elective indication in treatment-resistant schizophrenia, suicide risk in schizophrenia spectrum disorders, aggressiveness or violence in psychiatric patients, psychosis in Parkinson's disease, prevention and treatment of tardive dyskinesia. Unfortunately, the drug is largely underused for many and serious side effects. Only a good knowledge of these side effects and of the main strategies to prevent their occurrence or minimize their impact can allow overcoming the underutilization of this valuable therapy. The article describes the clinical and epidemiological features of the non-motor side effects of clozapine including blood dyscrasias, constipation, diabetes, enuresis, fever, hepatitis, hypersalivation, ileus, myocarditis, nephritis, priapism, seizures, serositis, weight gain and metabolic syndrome. The paper suggests several strategies, supported by scientific evidence, in the management of these side effects. The neuropsychiatric side effects of clozapine are not discussed in this review.

Impulsive and compulsive behaviors during dopamine replacement treatment in Parkinson's Disease and other disorders.

Impulsive and compulsive behaviors, including pathologic gambling, hypersexuality, compulsive shopping, compulsive eating, excessive engagement in hobbies, punding, and Dopamine Dysregulation Syndrome (DDS), are increasingly reported serious side-effects of dopaminergic medication, used in the treatment of Parkinson's Disease (PD) and other disorders. Dopamine Agonists (DA) are strongly related with Impulse Control Disorders (ICDs), while L-dopa is associated with DDS. The present paper focuses on ICDs. The estimated prevalence of ICDs in PD patients treated with DA is as high as 14%. ICDs pathophysiology is complex, due to multiple contributing factors. Dopamine neurotransmission along the meso-cortico-limbic pathway is a modulator of risk behavior and can be altered in PD and in the course of dopaminergic treatment. Psychiatric complications, associated with treatment of PD are still underdiagnosed, although their consequences can be serious, even catastrophic. Physicians treating PD with DA should warn the patients and their relatives of the risk of inducing ICDs. Psychiatrists should be trained to recognize these side effects, that can mimic primary psychiatric conditions. The management of ICDs includes discontinuation of DA or switching from DA to other drugs for the treatment of PD. Cognitive behavior therapy, serotonin selective reuptake inhibitors, nalmefene, zonisamide, low dose of anti-dopaminergic drugs, as quetiapine or clozapine, can be effective. Psychological, spiritual, and ethical support (familial or individual) can help.

Competence to consent to sexual activity in bipolar disorder and schizophrenic spectrum disorders.

Little is known about the ability of persons with severe mental disorders to give consent to sexual activity. A possible reason for this shortcoming is the absence of specific criteria and tools to measure sexual consent in psychiatric clinical settings. We developed a clinician oriented semi-structured interview, the Sexual Consent Assessment Scale (SCAS), and investigated sexual consent capacity in a sample of hospitalized patients with bipolar disorder (n = 54, M (age) = 38.1 years, 48% males) and schizophrenic spectrum disorders (n = 31, M (age) = 38.4 years, 29% males). The SCAS items were derived from the criteria proposed by Kennedy and Niederbuhl (Am J Ment Retard, 106:503-510, 2001). The full scale and a shorter scale comprising 10 items (SCAS-10) achieved good initial validity. Patients with schizophrenic spectrum disorders had worse sexual consent capacity than patients with bipolar disorder. This difference was unexpectedly independent from patients' symptomatology, as measured by the Brief Psychiatric Rating Scale. Conversely, poor cognitive functioning measured by the Raven's Standard Progressive matrices was associated with reduced capacity to give sexual consent in both groups. Subjects in the schizophrenic spectrum disorders group were more frequently judged incapable in basic knowledge of birth control methods and in domains underlying metacognitive abilities. Principal component analysis revealed two SCAS-10 interpretable factors: "appropriateness-recognition" and "consequences-metacognition." Our study suggests that patients with severe psychiatric disorders, especially those with cognitive dysfunction, might be at risk of incapacity to give valid sexual consent.

Clozapine safety, 35 years later.

Clozapine is the best treatment option in several clinical circumstances, including treatment-resistant schizophrenia, non treatment-resistant schizophrenia, suicide risk in schizophrenia spectrum disorders, aggressiveness or violence in psychiatric patients, psychosis in Parkinson's disease, prevention and treatment of tardive dyskinesia. However, clozapine is associated with many serious side effects. Furthermore, monitoring requirements, i.e., frequent blood draws and frequent visits, discourage clozapine use. Therefore, the drug is underused. The only way to avoid the underuse of clozapine is full awareness of its side effects and competence to minimize them. The aim of the paper is reviewing the safety profile of clozapine and the suggested strategies in the management of its side effects, including neutropenia, eosinophilia, seizures, myocarditis, weight gain, diabetes, metabolic syndrome, hypersalivation, fever, constipation, ileus, urinary incontinence, sweating. The neuropsychiatric side effects of clozapine are not discussed in this review.

AUTISM Spectrum Disorders and Suicidality.

The paper describes the suicidal ideation and behavior in a series of 26 adult psychiatric patients affected by Autism Spectrum Disorders (ASDs), the clinical features and the psychiatric comorbidity of patients presenting suicidal behavior, and the history of suicide or suicide attempt in their relatives. Two (7,7%) patients committed suicide. One (3.8%) patient attempted suicide twice, and one (3.8%) patient self-harmed by cutting his face and one finger of his hand with a razor. Eight (30.8%) patients presented suicidal ideation. Two (7.7%) patients had one relative who had attempted suicide, and two (7.7%) patients had one or more relatives who had committed suicide. Most patients with suicidal behavior or ideation presented psychotic symptoms. Although it is not clear whether the high suicidal risk is related with ASDs per se or with psychotic symptoms, a high index of suspicion is warranted in evaluating suicidal risk in patients affected by ASDs, whatever is their age, psychiatric comorbidity, and setting of visit.

Lithium and kidney, 60 years later.

Lithium, an old and invaluable psychiatric therapy, is still the best treatment option in several clinical circumstances, including acute mania, bipolar and unipolar recurrent mood disorders, suicidal ideation and behavior, recurrent or chronic unipolar depression that has not responded to other treatments, aggressive or impulsive behavior and alcoholism, especially when an affective component is manifest. However, lithium has a narrow therapeutic index and is associated with many serious acute and long-term side effects. Furthermore, monitoring requirements, i.e., frequent blood draws and frequent visits, discourage lithium use. Therefore, the drug is underused. Full awareness of lithium side effects and competence to minimize them is the only contrast to this ominous trend. Renal side effects are frequent in the course of lithium treatment. Although not serious in the large majority of cases, they may seldom become severe and result in chronic renal failure and end stage renal disease. The aim of the paper is reviewing the renal safety profile of lithium and the suggested strategies in the management of the lithium associated renal side effects.

Autistic spectrum disorders and schizophrenia in the adult psychiatric setting: diagnosis and comorbidity.

BACKGROUND: The relationship between Autism Spectrum Disorders (ASDs) and schizophrenia is currently unclear. We aimed to (a) assess psychotic symptoms in a consecutive series of adult patients with ASDs, (b) evaluate the comorbidity diagnosed to account for the concurrent psychotic symptoms in patients with ASDs, and (c) compare the clinical features between the patients with schizophrenia and patients with comorbid schizophrenia and ASDs. SUBJECTS AND METHODS: We included patients with ASD that were seen in adult psychiatric clinical settings during a 15-year period. The sample was further grouped according to the existence of a comorbid diagnosis of schizophrenia. Clinical and epidemiological features were assesed in in the whole sample, and further compared between the two groups. RESULTS: We identified 26 patients with first-time diagnosed ASDs. Among the 22 cases who manifested psychotic symptoms (84.6%), 16 had a concurrent diagnosis of schizophrenia (72.73%) and 6 of mood disorders (27.27%). Compared with patients with schizophrenia patients with comorbid ASDs and schizophrenia were more often men, of younger age, and more frequently developed motor side effects to antipsychotics. CONCLUSIONS: Adult psychiatric service users with ASDs are often misdiagnosed. This could be in part due to the fact that adult psychiatrists are not familiar with the diagnosis of ASDs. The high prevalence of psychotic symptoms in this sample is likely to depend on the specific setting of the study, i.e., that people with more severe forms of ASD than those typically followed-up in the national health service were reaching our public inpatient and private outpatient services. The high comorbidity rate between ASDs and schizophrenia could be related to shared neurobiology, but also to arbitrary restrictions imposed by current diagnostic systems.

No cathartic effect in suicide attempters admitted to the emergency department.

The goal of the present study was to test the hypothesis that suicide attempts have a cathartic effect. We retrospectively investigated sociodemographic and clinical characteristics of suicide attempters admitted to the emergency department of a university hospital who were referred for a psychiatric assessment. The participants were 158 consecutive patients admitted to the emergency department because of a suicide attempt between January, 2006, and February, 2007; controls were 360 consecutive psychiatric referrals who did not report suicidal behavior. More than 70% of suicide attempters were coded on the triage classification system as critical/urgent. Loglinear analysis indicated that the risk of suicidal ideation was 9 times higher (p <0.001) and the risk of depressive mood was twice as high (p <0.001) among the attempters as in the control group of nonattempters, while their risk of anxiety (p <0.05) and agitation (p <0.05) was approximately half that of the nonattempters. The attempters also had a 5 times greater risk of being diagnosed with bipolar disorder (p <0.001) than the nonattempters. However, despite the fact that bipolar disorders were overrepresented in the group of attempters, suicidal ideation in the few hours after a suicide attempt was associated only with depressive mood. Based on these findings, it is recommended that psychiatric evaluation of suicide attempters in the emergency department should ideally include the use of psychometric instruments evaluating suicide ideation and suicide risk.

Suicidal ideation induced by episodic cannabis use.

The report describes a patient who presented suicidal ideation only in two different occasions, immediately after acute cannabis intoxication. He used cannabis only in these two circumstances. Although a definite association between cannabis use and suicidal ideation or behavior has been already reported in the literature, the described case presents two original clinical aspects that deserve consideration. First, episodic assumption of cannabis induced suicidal ideation abruptly. Second, suicidal ideation appeared independent of mood depression, stressors, or life events, suggesting that suicidality may be not a direct consequence of depression and appears to be a relatively independent psychopathological dimension. There seems to be no linear relation between the severity of depression and the risk of suicide.