W12 – trainees
O1 Unusual presentations in psychiatry and the pitfalls. A case review of AntiNMDA encephalitis
Dr Rowena Carter, Psychiatry trainee, South London and the Maudsley NHS trust
Background
In recent years a new category of encephalitis as been defined called Anti-N-Methyl-Daspartate receptor (NMDAR) encephalitis in which antibodies to NR1 and NR2 heteromers
of NMDAR are present in the CSF and serum of affected patients1
Patients typically present with psychotic symptoms that have an onset over days to
weeks and this can be easily mistaken for first presentation psychosis.
This distinction between the two can be difficult, particularly when the patient presents
as very behaviorally disturbed and physical investigations are therefore complicated.
Methods
The Author presents two very similar cases which highlight the importance of considering
a physical diagnosis when assessing a first presentation of apparent psychotic illness.
Results
Two case studies are compared and contrasted for onset, presentation, progression of
illness as well as investigations and overall outcome.
Although the two cases presented initially as indistinguishable, subtle differences in the
cases develop which will be highlighted and the importance of when to investigate with
CT/MRI/LP will be discussed.
One case had a diagnosis of bipolar affective disorder with psychotic features and
responded well to ECT, the second case had a diagnosis of Anti-NMDA encephalitis and
remains functionally impaired.
Conclusion
Anti-NMDAR encephalitis is severe and the progression of the illness is relatively fast.
Ultimately it can be fatal, however if it is identified and treated then the deficits can
potentially be reversible.
The decision of when to investigate psychotic patients is difficult and made more
complex when the behavior is challenging however it is important to reflect on potential
physical diagnosis when reviewing psychotic patients.
Category: Education and Training
O2 Trauma, Post Traumatic Stress Disorder and Psychiatric Disorders in a
middle income setting: prevalence and comorbidity in a Sri Lankan population
Dr Sarah Dorrington, Psychiatry trainee, King's College London; Dr Helena Zavos,
Researcher, King's College London; Dr Harriet Ball, Faculty of Medicine, Imperial College
London; Prof Peter Mcguffin, Professor, King's College London; Dr Fruhling Rijsdijk,
Researcher, King's College London; Dr Sisira Siribaddana, Endocrinologist and
Researcher, Institute of Research and Development, Colombo, Sri Lanka
Background; Most studies of post traumatic stress disorder (PTSD) in low and middle
income countries (LMI) have focused on ‘high risk’ populations defined by exposure to
trauma.
Aims; To estimate the prevalence of criterion A traumas and lifetime PTSD (DSM-IV) in a
LMI population, the conditional probability of PTSD given traumatic event and the
strength of associations between traumatic events and other psychiatric disorders.
Method; Our sample contained a mix of 3995 twins and 2019 non-twins, analysed as
individuals from the Colombo Twin And Singleton Study (CoTASS), a Sri Lankan
population-based study.
Results; Traumatic events were reported by 36.3% of participants. Lifetime PTSD was
present in 2.0% of the sample. Of people who had experienced 3 or more traumatic
events, 13.3% had lifetime PTSD and 40.4% had a non-PTSD psychiatric diagnosis.
Conclusions;
1) Despite high rates of exposure to trauma, this population was found to have much
lower rates of PTSD than high-income populations
2) There are high rates of non-PTSD diagnoses associated with trauma exposure that
could be considered in interventions for trauma-exposed populations.
Category: Research
O3 Brain Temperature, Cognition and Glutamate in Recent Onset Schizophrenia:
a 7T MRS study
Dr Sotirios Posporelis, Psychiatry trainee, Johns Hopkins University School of Medicine,
South London & Maudsley NHS Foundation Trust; Dr Teppei Tanaka, Post-Doc Fellow,
Johns Hopkins University School of Medicine; Dr Anouk Marsman, Johns Hopkins
University School of Medicine; Mr Mark Varvaris, Research Assistant, Johns Hopkins
University School of Medicine; Prof Peter B. Barker Barker, Professor of Radiology, Johns
Hopkins University School of Medicine; Prof Akira Sawa, Professor of Psychiatry and
Behavioral Sciences / Director, Johns Hopkins Schizophrenia Center / Director, Molecular
Psychiatry Program, Johns Hopkins University School of Medicine
Aims & Hypothesis: to elucidate the links between brain temperature, cognition and
glutamatergic function.
Background: Brain temperature (BT) is an important pshysiological parameter, reflecting
the amount of heat produced and sustained by bodily processes. Apart from its role as
an index of metabolism, it can be viewed as a factor that directly affects brain cells, their
activity and consequently function. In schizophrenia-although there is evidence of
dysfunctional thermoregulation, glutamate dysfunction, inflammation and oxidative
stress all of which can potentially affect BT- little is known about BT and this is mostly
due to the invasive nature of conventional measurement methods.
Methods: 11 recent onset DSM-IV schizophrenia patients and 9 healthy non-smoking
volunteers matched for age, sex, race, education status have been studied using 7 tesla
proton magnetic resonance spectroscopy. A combination of semi-LASER and STEAM
sequences were utilized to measure absolute brain temperature and identify the
following peaks of interest in the anterior cingulate: glutamate, glutamine, GABA, NAA.
All participants completed a broad neuropsychological battery, assessing a wide variety
of cognitive domains.
Results: Schizophrenia patients performed poorly in processing speed, attention/working
memory and ideational fluency. The schizophrenia group had higher levels of glutamate
but significance did not survive Bonferroni correction. BT has been consistently higher
than core body temperature (CBT) in every study participant. Only in the control group
did we find an inverse corelation between glutamate and BT. The level of glutamine
negatively correlated with CBT but significance did not survive Bonferroni correction. The
difference between BT and CBT in the schizophrenia group was positively correlated with
negative symptoms, adjusting for duration of illness.
Conclusions: to our knowledge, this is the first study to measure metabolite
concentrations and absolute brain temperature, in the anterior cingulate of recent onset
schizophrenia patients utilising a 7 Tesla system. Furthermore, it is the first to link brain
temperature to glutamate, cognitive function and negative symptoms. The results link
abnormal energy turnover to negative symptoms and highlight the importance of brain
temperature in schizophrenia research.
Category: Research
O4 Does having a common mental health problem predict Emergency
Department attendance?
Dr Amy Green, Psychiatry trainee, University of Bristol and the Severn Deanery; Prof
Chris Dickens, Professor of Psychological Medicine, University of Exeter; Dr Will Lee,
Plymouth University Peninsula Schools of Medicine and Dentistry; Prof Else Guthrie,
Professor of Psychological Medicine, Manchester University; Simon de Lusignan
Aims and hypothesis: Having a common mental health problem (CMHP), such as
depression or an anxiety disorder may be associated with increased Emergency
Department (ED) attendance. This study investigated the characteristics of individuals
associated with ED attendance using British primary care data.
Background: The use of urgent and unscheduled care in the UK has been increasing
steadily over recent years and the factors driving this are poorly understood. It is well
established that people with long-term physical conditions (LTCs) and depression,
frequently use urgent and unscheduled care. The independent contribution of having a
CMHP to this problem has not been previously explored using British data.
Methods: Data were gathered from primary care records of 117,317 adult patients from
two locations one in the North and one in the South of England over an 18 month period
(1/10/07-30/4/09). These patients’ data were linked to corresponding hospital episode
statistics to identify ED attendances. Multivariable logistic regression was used to identify
characteristics independently associated with subsequent ED attendance.
Results: ED attendees were more likely than non-ED attendees to suffer from 1 or more
LTC (29% vs 21%, p=<0.001 in the Northern centre and 25% vs 12%, p=<0.001 in the
Southern centre), and more likely to suffer from a CMHP (21% vs 13%, p<0.001 in the
Northern centre, and11% vs 5%, p<0.001 in the Southern centre). Using multivariable
logistic regression, after adjusting for age and distance from the ED, ED attendance was
associated with: having multiple LTCs [OR in the Northern centre=3.67, (95% CI
2.81,4.79) and OR in the Southern centre = 6.51, (95% CI 4.47,9.40)] and having a
CMHP [OR in Northern centre= 1.69 (95% CI 1.161,1.78) and OR in Southern centre =
2.27, (95% CI 2.05,2.05)].
Conclusions: In addition to the number of LTCs, ED attendance was independently
predicted by the presence of CMHP. Better treatment of CMHPs in primary care,
particularly among people with multiple LTCs, might reduce ED attendances.
Category: Research
O5 Suicide in students with mental illness, 1997-2010: A national clinical
survey
Dr Suhanthini Farrell, Psychiatry trainee, Centre for Suicide Prevention, Manchester; Dr
Kirsten Windfuhr, Project Manager, NCISH, Centre for Suicide Prevention, Manchester;
Prof Nav Kapur, 5, Centre for Suicide Prevention, Manchester
AIMS AND HYPOTHESIS We aimed to examine the socio-demographic, clinical, and
behavioural characteristics associated with university student suicide compared with
non-student suicide in a mental health patient population. We hypothesised that
students would be less likely to have enduring psychotic illness and more likely to have a
short history of contact with mental health services.
BACKGROUND: Entering Higher Education represents a transitional time in the life of
many young people, and coincides with the typical age of onset of some serious mental
illnesses. We believed awareness of the distinguishing characteristics of student suicide
would assist clinicians in managing risk in this group.
METHODS: Data collected by the National Confidential Inquiry into Suicide and Homicide
by People with Mental Illness for the period 1997 to 2010 for those aged 15-35 were
analysed. Univariate and multivariate conditional logistic regression were carried out to
identify factors independently associated with student suicide. Odds ratios were
calculated with 95% confidence intervals.
RESULTS: There were 243 student suicides in the clinical sample over the 14-year
period. Students who died were significantly less likely to be male** or living alone**,
and more likely to be from an ethnic minority**, than non-students. More students had
affective disorders** or eating disorders**, while psychotic disorders** and substance
misuse/dependence** were less likely. Psychological treatment was given to students
more often** and medication prescribed substantially less frequently*, even accounting
for diagnosis. Student suicides were characterised by shorter duration of illness**,
shorter history of contact with mental health services**, and reduced likelihood of
previous admission**. Fewer students fell into a recognised “priority group” of the
current UK suicide prevention strategy*. (* p<0.005, ** p<0.001).
CONCLUSIONS: Mentally ill students who die by suicide appear to be a clinically distinct
group in regard to diagnosis, treatment, and illness history. Medical under-treatment of
mental illness may be a particular feature of student suicides.
Category: Research
O6 Substance abuse patterns and ten-year outcome in FEP
Dr Melissa Weibell, PhD student, Stavanger University Hospital; Prof Jan Olav
Johannessen, Psychiatry consultant, Stavanger University Hospital, University of
Stavanger; Prof Tor Ketil Larsen, 6, Stavanger University Hospital, University of Bergen;
Dr Wenche ten Velden Hegelstad, clinical psychologist, Stavanger University Hospital; Dr
Inge Joa, professor, Stavanger University Hospital, University of Stavanger; Prof Svein
Friis, Psychiatry consultant, University of Oslo
Aims and hypothesis
The study aimed to investigate different patterns of substance use in an epidemiological
first-episode psychosis (FEP) sample, hypothesizing that persistent use would predict
poorer symptom outcomes compared to never users or stop users.
Background:
Substance use is common in FEP and has been linked to poorer outcomes. Patients may
use substances on-off or stop using. Little is known about the effect of different patterns
of substance use on outcomes.
Methods
301 patients aged 16-65 with first episode non-affective psychosis were included (19972001) from three separate catchment areas in Norway and Denmark. We defined four
patterns of substance use; never used (N=153), persistent use (N=43), stop use
(N=36), and on-off use (N=48) during the first 2-years of follow-up.
114 patients were followed up at 10 years and compared on symptom levels (PANSS,
GAF) and remission status.
Results
Patients who stopped using had similar 10-year symptom outcomes as patients who had
never used with significantly lower symptom levels on PANSS positive and depressive
symptoms and GAF compared to patients with on-off or persistent use. There was a
trend for persistent users showing increasing negative symptoms over time. We found a
large and significant difference in remission rates, with 56.6% of never users and 63.3%
stop users achieving remission at 10 years compared to 32.2% for on-off users and
34.4% for persistent users.
Conclusions
Results clearly indicate that substance use cessation in FEP is associated with similar
outcomes to FEP patients who never used any substances; on-off use may be almost as
detrimental to mental health as persistent use. The harmful effects of substance use in
FEP can be substantially reduced if clinicians are able to assist patients to stop using
altogether.
Financial disclosure
Health West (#911369), National Research Council (#133897/320;#154642/320), the
National Council for Mental Health/Health and Rehabilitation (#1997/41;#2002/306),
Health South East (#2008001) and Health West #200202797-65; #911313, Norway;
the Theodore and Vada Stanley Foundation; NARSAD Distinguished Investigator Award.
Category: Research