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Introduction Individuals with schizotypal personality disorder are characterized by tendencies to magical thinking, unusual perceptions, discomfort in social situations, and restricted affect. It is frecuent that they have social anxiety and have difficulty in understanding the motivations and thoughts of others. Objectives Presentation of a case of a patient who was first diagnosed with adjustment disorder, but on a closer study, was discovered to have a schizotypal personality disorder. Methods We conducted a bibliographic review by searching for articles about schizotypal personality disorder and theory of mind in Pubmed. Results We present the case of a 39-year-old woman, diagnosed with adjustment disorder after a conflict at work with a colleague that caused her anxiety-depressive symptoms. In consultations, the patient shows verbiage without expansiveness or euphoria, with rambling speech. She expresses feelings of indignation and injustice, she is irritable, with contained anger. She refers that she prefers to be distrustful of others because she does not understand their intentions. Her thoughts are very rigid, which leads her to have avoidant and phobic attitudes, having no relationships of friendship throughout her life. A neuropsychological evaluation is carried out, resulting in a surprising WAIS with a TIC of 128. However, the Mayer‐Salovey‐Caruso Emotional Intelligence Test (MSCEIT) shows difficulties in Perception, Comprehension and Emotional Management Considering the patient’s symptomatology as a whole, it is noteworthy: – Sustained social isolation throughout their life history – Superficiality of interpersonal relationships – Distrust and slight self-referentiality. Deficit in inferring the feelings and thoughts of others – Peculiar speech with ideas of magical content, superstitions and rituals… Which together supported a diagnosis of schizotypal personality disorder and generalized anxiety disorder. From this point we started to work on her self-esteem, modification of irrational beliefs and cognitive distortions, interpersonal communication and metacognitive therapy, with good results. Conclusions The type of schizotypal patients who come to consultations most frequently are the actively isolated/timorous profile due to their intense social anxiety and difficulties in understanding and adapting to the social world around them. Initial therapy should be empathic support. The theory of mind is the ability to infer the other’s mental states and therefore predict their behavior, this ability being diminished in the schizotypal patient. Mentalization tasks, metacognitive therapy, cognitive flexibility training, social skills training, and promoting self-worth are useful. On some occasions it may be necessary to start psychopharmacological treatment to control anxiety and unusual perceptions when they cause discomfort. Disclosure of Interest None Declared

Introduction Clozapine is an atypical antipsychotic synthesised in 1958. It was withdrawn from the market in the 1970s due to the appearance of agranulocytosis, but was reintroduced due to strong evidence of its efficacy and superiority over other antipsychotics in treatment-resistant schizophrenia. Objectives To describe the adequate response to clozapine in treatment-refractory psychosis. Methods Review of the scientific literature based on a relevant clinical case. Results A 16-year-old woman was admitted to a psychiatric inpatient unit for psychotic symptoms and behavioural disorders. She lives with her father and older sister; she has not been in contact with her mother, who lives in another country, for several years. She attends secondary school, with poor academic performance. Maternal diagnosis of schizophrenia. She started using cannabis two years ago, with a progressive increase up to 20 grams per week. He reports the onset of a feeling of strangeness a year ago, with progressive isolation in his room, referring to delirious ideation of harm towards classmates and people from his town, self-referentiality and delirious interpretations of religious mystical content (“God speaks to me through a dove”). He comments on the phenomenon of theft and thought-reading. Soliloquies and unmotivated laughter are observed. Conclusions Treatment was started with risperidone, progressively increasing the dose up to optimisation, without achieving a decrease in positive symptoms, but with the appearance of excessive sedation and sialorrhoea. It was combined with aripiprazole up to 20mg, maintained for a couple of weeks, without significant clinical improvement. Given the failure of two lines of therapy, it was decided to change to clozapine up to a dose of 75mg, with adequate tolerance and response, achieving a distancing of the delirious ideation. Regular haematological controls were performed, with no alterations in haemogram or troponins. Disclosure of Interest None Declared

Introduction It is widely described in the scientific literature that patients who suffer from some type of congenital syndrome such as Di George Syndrome are more likely to present some type of psychopathological alteration during their development that may require intervention and treatment by infant and juvenile mental health teams in coordination with neuropediatrics (1). On this occasion, we will present the clinical case of a patient who regularly attends psychiatry consultations for management of anxious symptoms with impulse control deficits associated with intellectual disability, diagnosed since childhood with tetralogy of Fallot and later with Di George syndrome. In this type of case, treatment is usually considered taking into account possible comorbidities at the organic level (since there may be cardiological involvement, which can be an added difficulty when taking into account the adverse effects of some psychotropic drugs) (2). Objectives This is followed by the presentation of the clinical case, which can serve to exemplify this type of case and clarify any doubts that may arise regarding treatment. Methods Presentation of the clinical case and review of updated scientific literature on the subject. Results Patient who first came to the infantile-junior consultations at the age of 8 years due to delay in the acquisition of verbal language and impulsivity. The patient had a history of pediatric follow-up since birth for different physical symptoms that finally led to the diagnosis of Di George syndrome. Given the difficulties he presented both at home and at school, different psychometric tests were performed and it was determined that it could be beneficial to initiate treatment with extended-release methylphenidate. Prior to treatment, psychomotor restlessness (without aggressiveness) and difficulty in concentration prevailed, which improved significantly after upward adjustment of the dose to a guideline corresponding to his age and weight. It was not necessary in this case to administer other treatments (the possibility of starting Aripiprazole in case of episodes of agitation was considered, but it was not necessary). The patient has continued to be monitored by cardiology to assess the possible side effects of the treatment (since it can increase heart rate and blood pressure (3), but so far no complications have been detected). Thanks to psychotherapeutic and educational intervention, language acquisition was achieved, although to date he still requires support due to the difficulties he still presents. Conclusions It is important to take into account the possible side effects of psychopharmacological treatment in patients with an associated congenital syndrome. Intensive and comprehensive follow-up by psychiatry and pediatrics (and later by their primary care physician) should be performed. Disclosure of Interest None Declared

Introduction Lithium was the first mood stabilizer and today continues to be a first-line treatment in the treatment of bipolar disorder despite its adverse effects, which make it important to monitor blood levels and control kidney function. Objectives Presentation of a case of litium withdrawal and relapse in bipolar disorder. Literature review relating to the risk of relapse when lithium treatment is interrupted. Methods We present a clinical case of a patient who suffers a deterioration in renal function that requires the withdrawal of lithium and who consequently suffers a relapse. We conducted a bibliographic research of articles in Pubmed on this topic. Results A 49-year-old male, with a history of multiple admissions to UHB since the age of 18 with a diagnosis of bipolar disorder and treatment with lithium. Decompensations towards the manic pole have always been related to interruptions in lithium treatment. On several occasions when the patient was feeling well emotionally, he believed himself to be “cured” and abandoned the treatment, triggering a manic episode, showing verbal aggression, increased self-esteem and delusional ideation of harm. Remission was usually achieved with the reintroduction of lithium and the addition of high-dose quetiapine. Between episodes, constant overvalued ideas of economic scarcity seemed to persist, which were accentuated in the form of delusional ideas of ruin in depressive decompensations. After 7 years of stability, control analysis showed blood litemia of 2.2 mEq/L with deterioration of kidney function and generalized tremor was observed, without improvement after serum therapy. He was admitted for dialysis and lithium was suspended. Treatment with valproate was started and a consultation scheduled in a week to adjust the dose. The patient did not attend that consultation and was admitted three days later to Psychiatry Hospitalization showing a challenging attitude, evident dysphoric mood, accelerated speech, with derailments and echolalia. Delusional ideation of harm with auditory hallucinations. Insomnia and hyporexia. Chronic renal failure persisted. Conclusions Lithium is a very effective drug but with a narrow therapeutic range that requires adequate monitoring due to the possible consequences of its use at different organs and systems of the body. when lithium is found in the blood at toxic levels with deterioration of kidney function and glomerular filtration fails to recover, lithium treatment should be suspended. Sudden withdrawal of lithium significantly increases the risk of relapse due to rebound effect. More than 50% of patients experience a recurrence within 10 weeks of withdrawal. Disclosure of Interest None Declared

Introduction Schizotypal personality is a condition suffered by 4% of the population. It is defined by presenting interpersonal, behavioral and perceptual features similar to the clinical features of psychotic disorders, such as schizophrenia, in less intensity and dysfunctionality, but at risk of reaching psychosis. Objectives Presentation of a clinical case about a patient with premorbid schizotypal personality traits presenting with an acute psychotic episode. Methods Literature review on association between schizotypal personality and psychosis. Results A 57-year-old woman with a history of adaptive disorder due to work problems 13 years ago, currently without psychopharmacological treatment, goes to the emergency room brought by the emergency services due to behavioral alteration. She reports that “her husband and son wanted to sexually abuse her”, so she had to run away from home and has been running through the streets of the town without clothes and barefoot. Her husband relates attitude alterations and extravagant behaviors of years of evolution, such as going on diets of eating only bread for 40 days or talking about exoteric and religious subjects, as believing that the devil got inside her husband through a dental implant. He reports that these behaviors have been accentuated during the last month. She has also created a tarot website, and has even had discussions with several users. She is increasingly suspicious of him, has stopped talking to him and stays in his room all day long, with unmotivated laughter and soliloquies. It was decided to admit him to Psychiatry and risperidone 4 mg was started. At the beginning, she was suspicious and reticent in the interview. As the days went by, communication improved, she showed a relaxed gesture and distanced herself from the delirious ideation, criticizing the episode. Conclusions In recent years, there has been increasing interest in understanding the association between schizotypy and serious mental disorder. Several theories understand schizotypy as a natural continuum of personality that reveals genetic vulnerability and that can lead to psychotic disorder when added to precipitating factors. Other theories define schizotypy as a “latent schizophrenia” where symptoms are contained and expressed in less intensity. Around 20% evolves to paranoid schizophrenia or other serious mental disorders. It is complex to distinguish between those individuals in whom schizotypy is a prodrome and those in whom it is a stable personality trait. To date, studies applying early psychotherapeutic or pharmacological interventions have had insufficient and contradictory results, and the follow-up and treatment of these individuals could be a stress factor and a stigma. Some studies are looking for reliable markers of evolution to schizophrenia in order to establish adequate protocols for detention, follow-up and treatment. Disclosure of Interest None Declared

Introduction Delusional parasitosis, also known as delusional infestation or Ekbom’s syndrome, is a rare psychotic disorder characterized by the false belief that a parasitic skin infestation exists, despite the absence of any medical evidence to support this claim. These patients often see many physicians, so a multidisciplinary approach among clinicians is important. Many patients refuse any treatment due to their firm belief that they suffer from an infestation, not a psychiatric condition, so it is crucial to gain the trust of these patients. Objectives The comprehensive review of this clinical case aims to investigate Ekbom syndrome, from a historical, clinical and therapeutic perspective. Methods Literature review based on delusional parasitosis. Results A 65-year-old woman comes to the psychiatry consultation referred by her primary care physician concerned about being infested by insects that she perceives through scales on her skin for the last three months. She recognizes important impact on her functionality. She is also convinced that her family is being infected too. As psychiatric history she recognizes alcohol abuse in the past (no current consumption) and an episode of persecutory characteristics with a neighbor, more than ten years ago. On psychopathological examination, she shows delusional ideation of parasitosis, with high behavioral repercussions, cenesthetic and cotariform hallucinations, as well as feelings of helplessness and anger. Treatment with Pimozide was started and the patient was referred to dermatology for evaluation, a plan she accepted. Her primary care physician and dermatology specialist were informed about the case and the treatment plan. In the recent reviews, the patient is calmer, however, despite the corroboration of dermatology and in the absence of organic lesions in cranial CT, she is still unsatisfied with the results, remaining firm in her conviction of infestation. It was decided to start treatment with atypical neuroleptics (Aripiprazole), with progressive recovery of her previous functionality. Conclusions Despite the increase in the number of studies in recent years, there are still few studies on this type of delirium. The female:male ratio varies in the bibiliography (between 2:1 and 3:1). The onset is usually insidious, generally appearing as a patient who comes to his primary care physician convinced of having parasites in different skin locations. It is usual to observe scratching lesions or even wounds in search of the parasite. In the past, the most used and studied treatment was Pimozide. Currently the treatment of choice is atypical neuroleptics due to their lower side effects. The latest reviews on the prognosis of this disorder show data with percentages of complete recovery between 51% and 70%, and partial responses between 16.5% and 20%. Finally, for a good diagnosis and therapeutic management, it is important to achieve a multidisciplinary approach. Disclosure of Interest None Declared

Introduction The harmful consumption of alcohol is known for how tortuous its management can be in mental health, encouraging introspection of it as a serious problem is perhaps the main key to starting to battle against its damaging influence on the development of a functional and full life. Objectives To describe a clinical case showing an unpredictible complication in an alcohol detoxification process. Methods 54-year-old man, native of Cádiz, widowed for half a decade, without children. He resides with his parents in the family home. Currently unemployed for approximately a year. He has previously worked in the IT sector. As a notable somatic history, we found long-established arterial hypertension and a total hip replacement. He has been under irregular follow-up with a mental health team for anxiety-depressive symptoms in the context of grief. He goes to the emergency service brought by his family to begin the detoxification process in the hospital setting. He acknowledges ethanol consumption since he was widowed, which began when he awakes; quantities that ranged between one or up to three bottles of distilled liquor per day, generally consumption is in the home environment. A little less than a year ago, he began to isolate himself in his room and abandon his self-care, eating increasingly insufficient food intake, refusing to receive professional care to quit the habit, mainly because he did not recognize it as disruptive. The patient was admitted to hospital with symptoms suggestive of withdrawal, making it extremely difficult to control blood pressure levels. On the third day of admission to the acute care unit, fever peaks, blood pressure levels well below normal parameters, and compromised level of consciousness began to be evident. Results Blood tests were performed that, together with the clinical picture, suggested imminent septic shock, so critical care was contacted for transfer and stabilization. A germ of probable urinary etiology sensitive to a broad spectrum of antibiotics was isolated in blood cultures, and the medication of the detoxification process was progressively optimized. Once clinical stability was achieved at all levels, an inpatient cessation resource was managed, which the patient accepted and considered suitable for his complete recovery. Conclusions A holistic approach to the alcoholic patient is important, since serious problems of an organic nature often arise. This is why a multidisciplinary intervention is necessary, as well as a holistic approach to care, involving both classic pharmacology and assiduous long-term psychotherapeutic intervention. Disclosure of Interest None Declared

Introduction In recent years, there has been an increase in the prevalence of illicit use of fentanyl and other opioids in the United States population. This has led to an increase in medical, psychopathological and abuse-associated comorbidity, an increase in deaths and a decrease in the age of consumption, and has become a serious emerging problem in young people. We present the case of an 18-year-old woman from the United States who recently settled in Spain and started a follow-up in Mental Health due to opioid and other substance abuse problems. Objectives To address the growing problem surrounding the illicit use of fentanyl and opioids as drugs of abuse based on the presentation of the clinical case mentioned above. Methods Bibliographic search and description of a clinical case of a patient under follow-up by Mental Health at the “Hospital Clínico Universitario de Valladolid”. Results An 18-year-old woman from the United States who has been living with her father in Spain since the summer of 2023, having moved to Spain due to problems related to substance abuse. With no previous medical or surgical history and with a history of follow-up in Mental Health in her country of origin for depressive symptomatology, dysfunctional personality traits and abuse of different toxic substances since adolescence. After a brief and erratic follow-up in Psychiatry for anxious-depressive symptoms reactive to a complex and conflictive relationship with his mother and marked academic difficulties during the first years of adolescence, at the age of 15 he started using cannabis and alcohol, thus beginning a period marked by relationships with marginalized sectors of the population, substance abuse and school failure. As his cannabis consumption intensified, he began to consume fentanyl prescribed to his mother, as well as other opioids to which he had access illegally, for which reason he had to be admitted twice to detoxification centers without results, which is why his family finally decided to move him to Spain. Conclusions In recent years, fentanyl abuse has become a serious public health problem that is mainly centered in the young population. High levels of impulsivity and lack of frustration tolerance predispose to the use of illicit substances for elusive purposes. Substance abuse carries with it not only an important organic comorbidity, but also a marked socio-familial and economic repercussion. Disclosure of Interest None Declared

Introduction Subjective memory complaints remain a relevant aspect to be considered in patients with mild cognitive impairment. Likewise, their association with depressive symptoms, quality of life and cognitive performance is also an objective to be studied in such patients. Objectives Our clinical case represents just one opportunity to study how memory complaints are related to depressive states and how they affect the quality of life of patients with mild cognitive impairment. Methods We conducted a bibliographical review by searching for articles in Pubmed. Results PERSONAL HISTORY: Male, 73 years old, separated, residing alone in Valladolid. He has home help, a person comes to help him with the household chores. Little social and family circle. History in Mental Health He has a history of an admission in 2013 to this Short Hospitalization Unit for ethanol detoxification. Since then, he has been followed up in the Mental Health Unit. According to the reports, he has been diagnosed with depressive disorder and cluster B personality disorder. Current psychopharmacological treatment: diazepam, olanzapine, duloxetine 60 mg, quetiapine. Toxic habits: history of chronic ethanol consumption. Smoker. He denies other toxic habits. Current Episode The patient presents a worsening of his mood of 15 days of evolution, coinciding with a voluntary decrease of his psychopharmacological treatment that the patient has carried out on his own. He walks with the aid of a crutch. Hypomimic facies. Slowed language, circumstantial, with speech focused on current discomfort. On assessment, he reports initial improvement after reducing his medication, but in recent days he has experienced a decrease in initiative accompanied by feelings of emptiness, sadness and loneliness. He refers to memory complaints for which he is awaiting evaluation by Neurology. The patient explains that at other times in his life he has presented self-harming ideas that he has been controlling. At this time he expresses desire for improvement and adequate future plans, and accepts plans to attend a memory workshop. He also reports visual hallucinations with no affective repercussions and preserved judgment of reality. Therapeutic Plan Treatment adjustment: Duloxetine 60 mg, 2cp/day. The patient is recommended to lead an active lifestyle and attend a day center or memory workshop. Conclusions In numerous patients with mild cognitive impairment, we have observed that memory complaints are closely related to depressive symptoms and to the patient’s functioning in daily life. In one study memory complaints were a negative predictor of quality of life in these patients. Therefore, in addition to considering the importance of treating depressive symptoms, it is also important to address quality of life in patients with mild cognitive impairment. Disclosure of Interest None Declared

Introduction Depression during pregnancy can appear with a prevalence of up to 11% of pregnant women. Psychotherapeutic treatment in these cases is considered the first option, but treatment with antidepressants is sometimes required in these cases. Objectives To present a clinical case of a pregnant patient diagnosed with depression. Methods Literature review of the psychopharmacological treatment of depression during pregnancy and possible complications. Results A 25y Year old woman, 22 weeks pregnant, who lives with her partner. She has no background in mental health. Paternal aunt diagnosed with type I Bipolar Disorder. She goes to the Mental Health Center for evaluation, due to anxiety and depressive symptoms of 4 weeks of evolution, she refers sadness and apathy, continuous crying, somatic anxiety and obsessive ruminations in relation to childbirth and inability to care for your child. Suicidal ideation as a resolution of her discomfort. She presents with global insomnia and a significant loss of appetite, with a weight loss of 3 kg. Treatment with sertraline 50 mg/day was started, with good tolerance and clinical response Conclusions The psychopharmacological treatment of antenatal depression is a challenge for the psychiatric professional. In all cases, an adequate balance must be made between the risks and complications for the fetus and the psychopathological stability of the pregnant woman. Among the main risks of untreated depression are: preterm delivery and low birth weight, an increased risk of suicide and alterations in the development during the baby’s infancy. The most used antidepressants are the SSRIs, with sertraline being a good option. Paroxetine has been associated with cardiac defects in the newborn. There are studies with tricyclics and duals but no specific teratogenic pattern has been seen. They are associated with an increased risk of spontaneous abortion. Exposure during the third trimester may be associated with obstetric complications. Disclosure of Interest None Declared

Introduction In the early stages of schizophrenia the person experiences feelings of strangeness about themselves, difficulty in making sense of things and difficulty in interacting with their environment. Based on this, self-disorder assessment instruments have been developed and empirical studies have been conducted to assess people at risk of developing a schizophrenia spectrum disorder. These studies show that self-disorders are found in pre-psychotic stages and that their manifestation can predict the transition to schizophrenia spectrum disorders. Objectives We present the case of a patient with multiple diagnoses and mainly dissociative symptoms who, after years of evolution, was diagnosed with schizophrenia. Methods Bibliographic review including the latest articles in Pubmed about self-disorders and schizophrenia. Results We present the clinical case of a 51-year-old woman with a long history of follow-up in mental health consultations and with multiple hospital admissions to the psychiatric unit, with several diagnoses including: dissociative disorder, histrionic personality disorder, adaptive disorder unspecified psychotic disorder and, finally, schizophrenia. The patient during the first hospital admissions showed a clinical picture of intense anxiety, disorientation and claiming to be a different person. The patient related these episodes to stressors she had experienced, and they improved markedly after a short period of hospital admission. Later, psychotic symptoms appeared in the form of auditory and visual hallucinations and delusional ideation, mainly of harm, so that after several years of follow-up and study in mental health consultations and in the psychiatric day hospital, she was diagnosed with schizophrenia and treatment with antipsychotics was introduced, with a marked clinical improvement being observed. Conclusions It is important to take into account this type of symptoms (self-disorders), as they allow the identification of individuals in the early stages of the disorder and create the opportunity for early therapeutic interventions. Disclosure of Interest None Declared

Introduction Bipolar disorder comorbidity rates are the highest among the major mental disorders. In addition to other intoxicants, alcohol is the most abused substance because it is socially accepted and can be legally bought and consumed. Estimates are between 40-70% with male predominance, which further influences the severity with a more complicated course of both disorders. Objectives The objective of this article is to highlight the impact of substance use on the course and prognosis of bipolar disorder, as well as to make a differential diagnosis of a manic episode in this context. Methods Bibliographic review of scientific literature based on a relevant clinical case. Results We present the case of a 45-year-old male patient. Single with no children. Unemployed. History of drug use since he was young: alcohol, cannabis and amphetamines. Diagnosed with bipolar disorder in 2012 after a manic episode that required hospital admission. During his evolution he presented two depressive episodes that required psychopharmacological treatment and follow-up by his psychiatrist of reference. Since then, he has been consuming alcohol and amphetamines occasionally, with a gradual increase until it became daily in the last month. He went to the emergency department for psychomotor agitation after being found in the street. He reported feeling threatened by a racial group presenting accelerated speech, insomnia and increased activity. Conclusions The presence of substance abuse complicates the clinical presentation, treatment and development of bipolar disorder. It is associated with a worse prognosis with multiple negative consequences including worsening symptom severity, increased risk of suicide and hospitalization, increased medical morbidity and complication of social problems. In addition, this comorbidity delays both the diagnosis and treatment, by masking the symptoms, and making more difficult an adequate differential diagnosis. Disclosure of Interest None Declared

Introduction Adult ADHD diagnosis sometimes represents a challenge for the clinician, due to the comorbid psychiatric diseases that are often associated and which complicate de recognition of the primary symptoms of ADHD. The prevalence of ADHD in adult populations is 2’5% and it is a relevant cause of functional impairment. Objectives Presentation of a clinical case of a male cocaine user diagnosed with adult ADHD. Methods Literature review on adult ADHD and comorbid substance abuse. Results A 43-year-old male who consulted in the Emergency Department due to auditory hallucinosis in the context of an increase in his daily cocaine use. There were not delusional symptoms associated and judgment of reality was preserved. Treatment with olanzapine was started and the patient was referred for consultation. In psychiatry consultations, he did not refer sensory-perceptual alterations anymore, nor appeared any signals to suspect so, and he was willing to abandon cocaine use after a few appointments. He expressed some work concerns, highlighting that in recent months, in the context of a greater workload, he had been given several traffic tickets for “distractions.” His wife explained that he had always been a inattentive person (he forgets important dates or appointments) and impulsive, sometimes interrupting conversations. In the Barkley Adult ADHD Rating Scale he scored 32 points. He was diagnosed with adult ADHD and treatment with extended-release methylphenidate was started with good tolerance and evolution, with improvement in adaptation to his job and social environment. Since then, the patient has moderately reduced the consumption of drugs, although he continues to use cocaine very sporadically. Conclusions Early detection of ADHD and its comorbidities has the potential to change the course of the disorder and the morbidity that will occur later in adults. Comorbidity in adult ADHD is rather the norm than the exception, and it renders diagnosis more difficult. The most frequent comorbidities are usually mood disorders, substance use disorders, and personality disorders. Treatment of adult ADHD consists mainly of pharmacotherapy supported by behavioral interventions. When ADHD coexists with another disorder, the one that most compromises functionality will be treated first and they can be treated simultaneously. The individual characteristics of each patient must be taken into account to choose the optimal treatment. Disclosure of Interest None Declared

Introduction Both in consultations with the general practitioner and with the psychiatrist, antidepressants are one of the most used drugs (1). These have multiple indications, and there are different groups according to their mechanism of action. In relation to this case, we are going to talk about Venlafaxine, a dual-type antidepressant, that is, it inhibits the reuptake of serotonin and norepinephrine. One of the most common side effects is digestive discomfort, which usually resolves after a few weeks (2). However, we should not ignore these symptoms, since they can hide something more serious. Objectives Presentation of a clinical case on a patient who presented an increase in pancreatic amylase after starting treatment with Venlafaxine. Methods Bibliographic review including the latest articles in Pubmed on side effects of antidepressant treatment, and more specifically at the gastrointestinal level (in this case we will talk about pancreatitis). Results We present the case of a 49-year-old woman, who was hospitalized 2 years ago, due to a first depressive episode. During this admission, psychopharmacological treatment was started for the first time, on that occasion with a selective serotonin reuptake inhibitor (SSRI), treatment of first choice (3). The patient had no side effects at that time, but the response was very modest, so it was decided to replace that antidepressant with Venlafaxine (with dual action), up to 150mg. The depressive symptoms improved markedly, however the patient began to feel digestive discomfort (which at first did not seem to be of great importance). A general analysis was performed, in which an increase in lipase (978 U/L) and amylase (528 U/L) was detected. An echoendoscopy, an abdominal scan, and a magnetic resonance cholangiography were performed; Pancreatitis secondary to drugs was suspected (a severe condition). Luckily, no significant lesions were found in the tests, and the levels of amylase and lipase decreased when Venlafaxine treatment was withdrawn (without reaching the normal range). The patient was discharged and continued to attend consultations. In the last control, amylase had dropped to 225 U/L. His abdominal pain disappeared. Treatment with Vortioxetine (a multimodal antidepressant) was started, however the amylase levels continue to be monitored, and the patient continues to see the gastroenterologist. Conclusions Gastrointestinal side effects are very common when taking antidepressant treatment, and in most cases they do not usually represent a serious problem. However, it is described in the scientific literature that in some cases, acute pancreatitis secondary to some drugs, including Venlafaxine, can occur (4). In order to detect it, it is necessary to perform a blood test and sometimes also other complementary tests. For its treatment, the fundamental thing is to withdraw the causing drug, trying to find other alternatives, and carry out a control to monitor possible complications Disclosure of Interest None Declared

Introduction There is a fine line separating psychiatry and neurology. Most movement disorders can have psychiatric symptoms, not only those caused by the disease itself, but also those induced by the drugs used to treat them. Objectives Presentation of a clinical case about a patient diagnosed with Parkinson’s disease presenting a several-month-long delirious episode due to dopaminergic drugs. Methods Literature review on drug-induced psychosis episodes in Parkinson’s disease. Results A 57-year-old patient with diagnosis of Parkinson’s disease for six years, who went to the emergency room accompanied by his wife due to delirious ideation. He was being treated with levodopa, carbidopa and rasagiline for years, and rotigotine patches whose dosage was being increased over the last few months. His wife reported celotypical clinical manifestations and multiple interpretations of different circumstances occurring around her. He chased her on the street, had downloaded an app to look for a second cell phone because he believed she was cheating on him, and was obsessed with sex. He had no psychiatric background. It was decided to prescribe quetiapine. The following day, he returned because he refused to take the medication since he thought he was going to be put to sleep or poisoned. It was decided to admit him to Psychiatry. During the stay, rasagiline and rotigotine were suspended. Olanzapine and clozapine were introduced, with behavioral improvement and distancing from the psychotic symptoms which motivated the admission. The patient was also motorically stable. Although levodopa is best known for causing psychotic episodes, the symptons were attributed to rotigotine patches for temporally overlapping the dose increase. Conclusions Psychiatric symptoms are the third most frequent group of complications in Parkinson’s disease after gastrointestinal complications and abnormal movements. All medication used to control motor disorders can lead to psychosis, not only dopaminergics, but also selegiline, amantadine and anticholinergics. Excessive stimulation of mesocortical and mesolimbic dopaminergic pathways can lead to psychosis, which is the most common psychiatric problem related to dopaminergic treatment. In the face of a psychotic episode, antiparkinsonian drugs which are not strictly necessary for motor control should be withdrawn. If this is not sufficient, levodopa dose should be reduced, considering the side effects that may occur. When the adjustment of antiparkinsonian treatment is not effective, neuroleptics, especially quetiapine or clozapine, should be administered. In a recent study, pimavanserin, a serotonin 5-HT2 antagonist, was associated with approximately 35% lower mortality than atypical antipsychotic use during the first 180 days of treatment in community-dwelling patients. Medication should always be tailor-made to suit each patient and we usually have to resort to lowering or withdrawing the dopaminergic medication. Disclosure of Interest None Declared

Introduction Interconsultation with the psychiatry service is frequently requested from other specialties for the assessment and treatment of patients who present neuropsychiatric symptoms secondary to organic alterations. On the other hand (and in relation to this case), within the possible causes for the elevation of calcaemia figures, the most frequent are hyperparathyroidism and neoplasms, representing between these two entities 90% of cases (1). Among the organic mental disorders, Delirium stands out, with an approximate prevalence between 1 and 2% (general population), which increases in hospitalized and elderly patients (2). Objectives Presentation of a clinical case about a patient with delirium secondary to hypercalcemia, with hallucinations and behavioral disturbance. Methods Bibliographic review including the latest articles in Pubmed about delirium (causes and treatment) and hypercalcaemia secondary to neoplasms. Results We present a 52-year-old male patient, who went to the emergency room accompanied by his wife, due to behavioral alteration. Two days before, he had been evaluated by Neurology, after a first epileptic crisis (with no previous history) that resolved spontaneously. At that time, it was decided not to start antiepileptic treatment. The patient reported that he had left his house at midnight, looking for a cat. As he explained, this cat had appeared in his house and had left his entire bed full of insects. His wife denied that this had really happened, and when she told the patient to go to the emergency room, he had become very upset. As background, the patient used to consume alcohol regularly, so the first hypothesis was that this was a withdrawal syndrome. However, although the consumption was daily, in recent months it was not very high, and at that time no other symptoms compatible with alcohol withdrawal were observed (tremor, tachycardia, sweating, hypertension…). We requested a general blood test and a brain scan. The only relevant finding was hypercalcaemia 12.9mg/dL (which could also be the origin of the previous seizure). It was decided to start treatment with Diazepam and Tiapride in the emergency room, with serum perfusion, and keep under observation. After several hours, the patient felt better, the hallucinations disappeared, and calcium had dropped to 10.2mg/dL. A preferential consultation was scheduled, due to suspicion that the hypercalcaemia could be secondary to a tumor process. Image: Conclusions It is important to rule out an organic alteration in those patients who present acute psychiatric symptoms. Hypercalcaemia is frequently associated with tumor processes (1) due to secretion of PTH-like peptide (4), so a complete study should be carried out in these cases. Delirium has a prevalence between 1 and 2% in the general population (2). Psychopharmacological treatment is used symptomatically, with antipsychotics (3). For the episode to fully resolve, the underlying cause must be treated. Disclosure of Interest None Declared

Introduction Conversive disorder is characterised by the presence of one or more involuntary neurological symptoms that are not due to a clear medical pathology. On the other hand, consciously simulated illnesses fall into two diagnostic categories: factitious disorders and malingering, which are differentiated by both the motivation for the behaviour and the awareness of that motivation. Factitious disorder behaviours are motivated by an unconscious need to assume the sick role, whereas malingering behaviours are consciously driven to achieve external secondary gains. Objectives Study of the differences between conversion disorder and factitious disorder and their repercussions from a case of difficult diagnosis. Methods Bibliographic review of scientific literature based on a relevant clinical case. Results We present the case of a 14-year-old male patient. Adoptive parents. Studying in high school. Social difficulties since childhood. He comes to the emergency department on several occasions referring stereotyped movements and motor tics in the four extremities with left cervical lateralization. Increase of these symptoms in the last month, so it was decided to admit him to the pediatric hospital. After observation and study of the patient’s movements with normal complementary tests he should return home. The following day he returned to the emergency department after an episode of dizziness, mutism and emotional block. It was decided to admit him to Psychiatry for behavioral observation and differential diagnosis. Conclusions In the assessment of patients it is essential to make an appropriate diagnosis taking into account the patient’s symptomatology and the patient’s background and life context. Conversion disorder is the unintentional production of neurological symptom, whereas malingering and factitious disorder represent the voluntary production of symptoms with internal or external incentives. They have a close history and this has been frequently confounded. Practitioners are often confronted to medically unexplained symptoms; they represent almost 30% of neurologist’s consultation. The first challenge is to detect them, and recent studies have confirmed the importance of “positive” clinical bedside signs based on incoherence and discordance. Multidisciplinary therapy is recommended with behavioral cognitive therapy, antidepressant to treat frequent comorbid anxiety or depression, and physiotherapy. Factitious disorder and malingering should be clearly delineated from conversion disorder. Factitious disorder should be considered as a mental illness and more research on its physiopathology and treatment is needed, when malingering is a non-medical condition encountered in medico-legal cases. Disclosure of Interest None Declared

Introduction Schizotypal disorder is conceptualized as a stable personality pathology (Cluster A) and as a latent manifestation of schizophrenia. It can be understood as an attenuated form of psychosis or high-risk mental state, which may precede the onset of schizophrenia or represent a more stable form of psychopathology that doesn’t necessarily progress to psychosis. Objectives To exemplify the continuum of psychosis Methods Review of scientific literature based on a relevant clinical case. Results 39-year-old male living with his parents. He started studying philosophy. He is a regular cannabis user and has an aunt with schizophrenia. He’s admitted to psychiatry for behavioral disturbance in public. He refers to having been hearing a beeping noise in his street for months, what he interprets as a possible way of being watched due to his past ideology. Without specifying who and why, he sometimes shouts “until it bursts” to stop the noise and he thinks that his neighbours alerted the police about his behavior. During the interview he alludes to Milgram’s experiment, saying that throughout history there have been crimes against humanity and those who pointed them out were labeled “crazy”. His father refers that he has always been “strange” and with certain extravagant revolutionary ideas and thoughts. He doesn’t maintain social relationships and dedicates himself to reading and writing. Conclusions It’s important to understand psychosis as a continuum to advance the understanding of etiology, pathophysiology and resilience of psychotic disorders and to develop strategies for prevention and early intervention Disclosure of Interest None Declared

Introduction Maintenance electroconvulsive therapy (mECT) is an option in the treatment of affective disorders which progress is not satisfactory. It is certainly neglected and underused during the clinical practice. Objectives To evaluate the efficacy of mECT in reducing recurrence and relapse in recurrent depression within a sample of three patients. Methods We followed up these patients among two years since they received the first set of electroconvulsive sessions. We applied the Beck Depression Inventory (BDI) in the succesives consultations for evaluating the progress. Results The three patients were diagnosed with Recurrent Depressive Disorder (RDD). One of them is a 60 year old man that received initially a cycle of 12 sessions; since then he received 10 maintenance sessions. Other one is a 70 year old woman that received initially a cycle of 10 sessions; since then she received 6 maintenance sessions. The last one is a 55 year old woman that received initially a cycle of 14 sessions; since then she received 20 maintenance sessions. All of them showed a significant reduction in depressive symptoms evaluated through BDI and clinical examination. In the first case, we found a reduction in the BDI from the first consultation to the last that goes from 60 to 12 points; in the second case, from 58 to 8 points; and in the last case, from 55 to 10 points. The main sections that improved were emotional, physical and delusional. As side-effects of the treatment, we found anterograde amnesia, lack of concentration and loss of focus at all of them. Conclusions We find mECT as a very useful treatment for resistant cases of affective disorders like RDD. It should be considered as a real therapeutic option when the first option drugs have been proved without success. Disclosure of Interest None Declared

Introduction Migrations are a source of stress for patients, which can have repercussions on their Mental Health. We present the case of a native Senegalese patient who presented a first psychotic episode. Objectives Presentation of a clinical case of an immigrant patient with a psychotic disorder. Methods Bibliographic review on migration and psychosis by searching for articles in Pubmed. Results We present the case of a patient of 20 years, a native of Senegal, who has been living in Spain for 3 months in a shelter home. He has no family or relations in Spain, and only speaks Wolof, presenting serious difficulties in communication with healthcare workers. He came to Hospital with his social worker because strange behaviors had been observed. He presented delusional ideation of self-referential and mystical-religious content, related to “the prophet” and “the need to fulfill a mission”. He also presented auditory hallucinations that he identified as of divine origin, and ordered him to perform behaviors such as picking hairs from the ground and various rituals. He acknowledges cannabis and alcohol use in the previous days. Paliperidone treatment was started. Throughout the admission, he begins to show concern for the state of his relatives in Senegal and the need to send them money. Conclusions Multiple studies indicate that migrants are at higher risk of psychosis, specially those from countries where the majority of population was black, according to some series. The challenge lies in understanding the mechanisms underlying this increased incidence, taking into account psychosocial factors such as social isolation and trauma. Disclosure No significant relationships.

Introduction Brain lesions may induce psychiatric symptoms in some cases. Imaging tests are important to make a differential diagnosis, and therefore initiate an appropriate treatment. Objectives Presentation of a clinical case about a patient with psychiatric symptoms who presented an organic lesion. Methods Bibliographic review including the latest articles in Pubmed about psychiatric symptoms induced by organic lesions. Results We present a 51-year-old male patient, with adequate previous functionality, who attended psychiatric consultations due to changes in his character, with delusional mystical and megalomaniac ideation, verbiage, hypoprosexia, memory loss and insomnia (diagnosed with Bipolar Disorder type II, hypomanic episode). Eventually, a brain computed tomography scan was performed, in which meningioma was visualized. The patient underwent surgery, and he asked to keep a sample of his tumor to always carry it with him on a pendant. Psychiatric symptoms induced by organic lesions are highly variable, depending on the location and size of the lesion, and they may be the first and/or only symptom of a meningioma (up to 21% according to various studies), so it is important to perform imaging tests in some cases. At this time, the patient is under follow-up, he has remained euthymic and stable, and he refuses to take psychopharmacological medication. Conclusions Psychiatric symptoms may be the first and/or only manifestation of an organic lesion in some cases. Neuroimaging tests (CT and MR) may be useful in the differential diagnosis. It is important to carry out an indiviualized treatment based on the patient’s pathology, which may include surgery and/or drugs. Disclosure No significant relationships.

Introduction The harmful use of alcohol is an important risk factor for the health of the population around the world. The incidence of alcohol dependence in women is increasing and both its consumption pattern and its consequences have unique characteristics. Objectives To present a literature review focused on alcohol use disorder with a gender perspective. Methods Literature review. Results - Women use to start using alcohol sooner than men and this seems to be a risk factor to become addicted. - Due to physiological and psychological factors women experience more negative health effects from excessive alcohol use than men and it occurs at lower levels of use. - Psychiatric comorbidity associated with alcohol abuse such as anxiety and depression is more common in women and this in turn worsens the alcohol use disorder. - Alcohol consumption increases the vulnerability of women on several levels, including an increased risk of physical abuse. Conclusions Alcohol abuse among women deserves special attention and a specific intervention focused on the gender perspective. Disclosure No significant relationships.

Introduction There is a high comorbidity between psychiatric disorders and juvenile myoclonic epilepsy (JME), observed in up to 58% of these patients; specifically, mood disorders, anxiety and personality disorders (PD). In some patients with PD there are nonspecific alterations in the EEG, which nevertheless sometimes involve pathology. The presence of personality disorders along with JME has been repeatedly described. Previous studies have emphasized the difficulties in treating patients with JME, which have been attributed to some specific psychiatric, psychological and psychosocial characteristics. Objectives Describing distinctive personality traits in JME Methods Review of scientific literature based on a relevant clinical case. Results 19-year-old woman, single. Psychiatric history since she was 12 due to anxiety-depressive symptoms, after being diagnosed with JME. 4 admissions in Psychiatry, with a variety of diagnoses: eating disorder, attention deficit hyperactivity disorder and borderline personality disorder. The evolution of both disorders has been parallel, presenting epileptic seizures due to irregular therapeutic adherence together with pseudo-seizures, which made difficult their differential diagnosis. In addition, he has had frequent visits to the emergency room for suicide attempts and impulsive behaviors. Conclusions In 1957, for the first time, distinctive personality traits were described in patients with JME: lack of control and perseverance, emotional instability, variable self-concept and reactive mood, which have been confirmed in subsequent studies. It is believed as epilepsy progresses, patients tend to develop symptoms of depression, anxiety, social problems, and attention deficit. Therefore, these patients have difficulty in following medical recommendations, especially precautions regarding precipitating factors for seizures. Disclosure No significant relationships.

Introduction The Covid-19 pandemic has had a significant impact on the mental health of adolescents. Several descriptive studies and systematic reviews have shown an increase in suicide rates in this age group. Objectives - To present a literary review on the impact of the Covid-19 pandemic on the mental health and suicidal behavior of adolescents around the world. - To present data on admission rates due to suicidal behavior during the first year of the Covid-19 pandemic in a Spanish child-adolescent psychiatric hospitalization unit. Methods - We will present a literature review and a retrospective cross-sectional study on admission rates for suicidal behavior in a child-adolescent psychiatric hospitalization unit. - Admission rates for suicidal behavior during the year prior to the pandemic will be compared with rates relative to the first year of the pandemic. Results - We have found a significant increase in admission rates for suicidal behavior during the year of the pandemic. Similar results have been found in different studies and meta-analyzes. - The socio-demographic characteristics of the patients are quite similar in the two periods of time analyzed, but the reference to intra-family problems has been more frequent in the year of the pandemic. Conclusions Our data is in line with other studies suggesting that the Covid-19 pandemic has had a strong impact on teenage suicidal behavior. Disclosure No significant relationships.

Introduction Mutism is the inability or unwillingness to speak, resulting in an absence or marked paucity of verbal output. Mutism is a common manifestation of psychiatric, neurological, and drug-related illnesses. Psychiatric disorders associated with mutism include schizophrenia, affective disorders, conversion reactions, dissociative states, and dementias. Neurological disorders causing mutism affect the basal ganglia, frontal lobes, or the limbic system. Objectives Outline the importance of setting a differential diagnosis of mutism in the Emergency Room. Methods Review of scientific literature based on a relevant clinical case. Results Male, 58 years old. He has lived in a residence for 3 months due to voluntary refusal to ingest. Diagnosed with paranoid personality disorder. He is refered to the Emergency Service due to sudden mutism. During this day, he has been stable and suitable with a good functionality. For 3 hours he is mutist, oppositional attitude and stiff limbs, refusing to obey simple orders. Hyperalert and hyperproxia. Not staring. After ruling out organic pathology: normal blood tests, negative urine toxins and cranial CT without alterations, he was admitted to Psychiatry for observation and, finally, he was diagnosed with Psychotic Disorder NOS. Conclusions Mutism most often occurs in association with other disturbances in behavior, thought processes, affect, or level of consciousness. The most common disorder of behavior occurring with mutism is catatonia. The differential diagnosis of mutism is complex. In some cases the diagnosis will be clarified only by careful observation and after a neurological evaluation. Published studies show neurological disorders presenting with mutism can be misdiagnosed as psychiatric. Disclosure No significant relationships.

Introduction Megalomanic ideas in a patient with limited intellectual functioning may be due to the psychotic clinic or be the result of their disability. Objectives This case is intended to highlight the importance of a joint approach between psychiatrists and psychologists to assess functionality before and after the psychotic episode. Methods 34-year-old woman with no mental health history. She came to the emergency department for an episode of aggression at home. Her parents report that they have observed strange behaviour, she is more aggressive, speaks alone, changing voices and global insomnia in the last few days. Her language is incoherent and disorganised, with a long response latency. Megalomaniacal and catastrophic delusions. Possible auditory hallucinations and thought control phenomena. Results During admission, antipsychotic treatment was introduced with good tolerance and response on the part of the patient. She has been distancing herself from the ideas and has become somewhat critical. A psychological evaluation was carried out with different scales that showed borderline IQ. Conclusions It is important to make a good assessment of the patient’s symptoms in order to make a differential diagnosis. In this case, it is advisable to carry out a control and follow-up, as well as a neuropsychological assessment before and after the acute episode. In addition, a multidisciplinary approach with psychologists, psychiatrists and social workers is important. Disclosure No significant relationships.

Introduction We present the clinical case of a patient where the psychotic clinic coexists with gender dysphoria. This scenario can be the result of a change in gender identity derived from the psychotic process or appear independently of it. Objectives We want to explain the importance of knowing how to act with a patient in whom these two processes coexist. Methods 20-year-old woman, with no history of mental health. She comes to the emergency department for behavioral alteration. The family observes strange behaviors, unmotivated laughter, soliloquies and aggressive episodes. Abandonment of studies, hobbies and radical physical change. Delusions of prejudice and self-referential delusions. Possible phenomena of echo and diffusion of the thought. Auditory hallucinations talking to her in male gender, since then she presents doubts about her sexual identity and manifests her desire to change sex. Altered judgment of reality. Results During admission, we started treatment with an antipsychotic with good tolerance and she was referred to mental health team, where psychopharmacological treatment was adjusted with good response. In the following medical appointments the psychotic clinic disappeared at the same time that sexual identification was completely restored and made a critique of the behavior and experiences. Conclusions This case highlights the importance of assessing the chronology of symptoms, the patient’s criticality, the response to antipsychotic treatment and the need to exclude the psychotic background of the desire for gender reassignment before making a therapeutic decision. Disclosure No significant relationships.

Introduction The therapeutic alliance is critical to the efficacy of psychiatric treatment and can be weakened by involuntary treatment measures. In Western culture, mental illness is still associated with violence and if significant risk of violence is detected, in Spain a civil court can order the application of involuntary treatments such as Involuntary Outpatient Commitment. Objectives To discuss the effectiveness of some psychiatric involuntary treatments used in Spain. Methods - Literature review about involuntary psychiatric treatments used in Spain - Case report about a patient undergoing Involuntary Outpatient Commitment Results We present the case of a 54-year-old man, diagnosed with schizophrenia, admitted to our acute psychiatric yard more than five times due to violent behavior and psychotic symptoms. Five years ago, he was summitted to a period of three years of Involuntary Outpatient Commitment. In Spain this measure can include the administration of involuntary medication, an injectable antipsychotic treatment in this case. At the end of the order, he immediately stops attending consultations and abandoned psychopharmacological treatment. Conclusions Involuntary Outpatient Commitment is a controversial measure and it stirs up the concepts of stigma, coercion, care, patient autonomy and, globally, the values of humanization in psychiatry. Disclosure No significant relationships.

Introduction Trichotillomania is an obsessive-compulsive spectrum disorder characterized by recurrent and uncontrolled hair pulling. This behavior causes significant anxiety as well as low self-esteem in people who suffer from this disorder. There is still no therapy of proven efficacy in the treatment of trichotillomania. Psychotropic drugs and cognitive behavioral psychotherapy have been tried in the management of this disease, but the relapse rate is high. Narrative therapy is an innovative type of postmodern psychotherapy and in our literary search we have not found data related to its use in the treatment of trichotillomania. Objectives To present a novel therapeutic approach to a highly resistant disorder, trichotillomania. Methods Case report and literature review. Results We present a case of a 39-year-old woman diagnosed with trichoticolomania twenty years earlier. She tried several types of psychotherapies for manage her hair-pulling problem, all related with relapse only a few days after finishing the sessions. We have carried out a total of 5 narrative therapy sessions spread over 3 months. No relapses have been observed during the subsequent 9-month follow-up period. Conclusions Based on our experience, we believe that Narrative Therapy is a good and still unexplored alternative for people diagnosed with trichotillomania. Disclosure No significant relationships.

Introduction Suicide rates in people diagnosed with a psychotic disorder can be up to 50 times higher than in the general population, with the lethality of attempts being significantly higher in this group, compared to people diagnosed with other psychiatric disorders. Furthermore, it is known that being male is associated with more serious suicide attempts and higher rates of completed suicides. Objectives To reflect on the increased risk of suicide associated with psychotic disorders. Methods Case report and literature review. Results Case report 40-year-old male, recently diagnosed with Schizophreniform Disorder and currently with persistent positive symptoms. He was admitted to our psychiatric hospitalization unit due to a voluntary overdose of almost 100 tablets (antihypertensives, antiarrhythmics, and benzodiazepines) and alcohol. He admits taking the pills with the aim of committing suicide. Literature review: - Around 10% of people diagnosed with schizophrenia commit suicide. - In young patients diagnosed with schizophrenia, suicide is the leading cause of death. - Between 15 and 65% of patients diagnosed with schizophrenia have depressive symptoms such as hopelessness. - Depressive symptoms in these patients seem to be directly proportionally with awareness of the disease (stigma, awareness of its severity and a sudden decrease in quality of life and social integration). - The risk of suicide increases especially in the first 10 years of the disease. Conclusions Psychosis is an important risk factor of suicide and active preventive measures should be carried out in these patients. Disclosure No significant relationships.

Introduction Anorexia nervosa is an eating behavior disorder that is often related to various personality factors. The relationship between obsessive compulsive disorder and eating Disorders has been highlighted. Objectives To present a clinical case of a patient with eating disorder and gastric bezoar, secondary to compulsive hair ingestion. Methods Bibliographic review of articles published in relation to the comorbidity of these disorders, based on articles published in the last 5 years in Pubmed. Results 26-year-old female. Diagnosis of restrictive anorexia nervosa. She was admitted to the hospital on two occasions for nutritional disorders. In the last admission, she reported greater anxiety and significant weight loss. She reports that she has limited her food intake, but she does feel thin and is unable to eat for fear of gaining weight. Ruminative thoughts about her body image. During admission, the patient expressed a sensation of fullness, nausea and vomiting, later observing in abdominal X-ray and gastroscopy, the presence of a gastric trichobezoar, which was finally resolved conservatively. Conclusions Trichotillomania is observerd in 1 in 2000 people, trichophagia is even less frequent. According to DSM- V, these disorders are grouped within obsessive-compulsive spectrum disorders. A Trichobezoar is a conglomerate that can be found in the stomach or intestine, composed mainly of hair, previously ingested. Trichotillomania can be associated with anorexia nervosa, especially in patients with obsessive personality traits, which occurs frequently. The gastric slowing that patients with anorexia often present is a factor that favors the formation of the bezoar Disclosure No significant relationships.

Introduction Concerns about health and fitness during lockdown may serve as a trigger for eating disorders in vulnerable individuals. Other risk factors may also include increased use of social networks and comparison with beauty ideals. Isolation, loneliness and problems with emotional regulation may lead people to reduce food intake by giving them a greater sense of control. Objectives Emphasise the relevance of the increase in the incidence of Eating Disorders (ED) cases during the pandemic. Methods Review of the scientific literature based on a relevant clinical case. Results 14-year-old female, residing with her mother. She reports that from the beginning of COVID-19 confinement she became obsessed with leading a healthier life, starting to restrict food, limiting fats and carbohydrates, and having also started compulsive physical activity (approximately 4 hours of aerobic exercise per day), without associated purging behaviours. She also acknowledges eating small amounts (although she minimises this aspect) and controlling all calories, stating that food and practices aimed at “staying healthy” now dominate her life. Her previous BMI was 18, with a current BMI of 11.7. Conclusions Patients suffering from ED, who often have poor knowledge of their illness and find social-emotional communication difficult, may delay seeking help. Studies suggest the relevance of identifying specific vulnerability factors among ED patients in confinement in order to develop preventive strategies and personalised treatment approaches. Disclosure No significant relationships.

Introduction Electroconvulsive therapy (ECT) is a medical treatment for those patients with high suicide risk or refractory psychiatric disorders. It is currently a safe technique, and its effectiveness has been widely demonstrated. Objectives Presentation of a clinical case about a patient with drug-resistant delusional disorder and high suicide risk, who eventually received ECT treatment. Methods Bibliographic review including the latest articles in Pubmed about ECT procedure, effects and use. Results We present a 45-year-old man, who visited different doctors several times by reporting he had the feeling of “having a brain tumor or a vascular disorder”, so he requested imaging tests (computed tomography and magnetic resonance). These tests were absolutely normal, but he kept thinking something was wrong, and eventually attempted suicide by hanging (his family founded him before it was too late). The patient was admitted to hospital, and started psychopharmacological treatment, with minimal response. He desperately insisted that he had “something inside his head”. At this point, it was proposed to start ECT, and the patient accepted. After 6 bilateral ECT sessions, he was visibly more relaxed and less worried, and he no longer presented autolytic ideation. He was still a little bit suspicious about the feeling of having a neurological disease. Currently, the patient runs a follow-up consultation. Conclusions Electroconvulsive therapy is a safe and effective technique for those patients with high suicide risk. It may be useful to perform imaging tests in certain cases, for detecting intracranial pressure, acute hemorrhage, tumors… A follow-up of these patients must be performed Disclosure No significant relationships.

Introduction There are life events that may increase the possibilities of suffering some kind of Psychopathology. The most validated model for understanding the aetiology of psychosis is based on genetic and environmental risk factors and their interaction, likely involving epigenetic mechanisms. It is necessary to consider those events as risk factors for Mental Health. Objectives Study of risk and prognostic factors in psychosis. Methods Review of scientific literature based on a relevant clinical case. Results We present the case of a 28-year-old male patient from Peru, currently living in Germany. History of sexual abuse in childhood. He started taking drugs at the age of 8. In the emergency department, he reports that since the beginning of the pandemic, after listening to a speech by the Pope, he begins to interpret signals about situations occurring around him. He begins to read about mystical-religious subjects, changes the style of music he listens to and recognises changes in his personality. He says for months he has been feeling watched, persecuted and expresed someone wants to kill him. He says hears voices and that they communicate with him through bodily sensations. Conclusions Childhood trauma, immigration and cannabis use are significantly associated with an increased risk of functional psychosis. A neurotic personality also independently contributes to this risk. The accumulation of these factors increases vulnerability to mental disorders and leads to a worse prognosis and evolution of these pathologies. These findings could help to improve the prevention of psychosis and the development of specific treatment strategies in this particular population. Disclosure No significant relationships.

Introduction Traumatic brain injury (TBI) can cause changes in the personality and behaviors. History of TBI has been associated with violent behavior and substance abuse. Objectives Presentation of a clinical case of a patient with antisocial personality traits who suffered a TBI and abuses alcohol. Methods We conducted a bibliographic review by searching for articles published the last 5 years in Pubmed Results We present the case of a 48-year-old male patient with a history of myoclonic epilepsy, who suffered a TBI in a car crash. During his stay at ICU antisocial and borderline personality traits were found. When he came to consultations, he presented signs of alcohol intoxication (verbiage with hasty and dysarthric speech, and psychomotor incoordination). He acknowledges daily alcohol intake, although he minimizes it. During the interview he is irritable, prone to anger when contradicted and boasts of episodes of heteroaggressiveness and violence that he has carried out in the past. He reports morning sickness and tremors, but does not accept that they may be due to alcohol withdrawal. There is no motivation for change. Conclusions It has been determined that history of TBI is more frequent in individuals with antisocial personality. TBI has been linked to violent behaviors, poor inhibitory control, engaging in illegal acts and higher rates of substance abuse. However, the causal relationship between antisocial behavior and TBI has yet to be clarified, as the available evidence does not show which comes first. More research is needed in the future that takes into account the temporal sequence of events. Disclosure No significant relationships.

Introduction The main feature of body dysmorphic disorder (BDD) is impairing preoccupation with a physical defect that appears slight or non-existent to others. Objectives To draw an overview of BDD through a clinical case of a patient with BDD and autolytic ideation, which improved after an adequate diagnosis and an early pharmacological and psychotherapeutic approach. Methods Bibliographic review of the treatment and diagnosis of BDD, from articles published in the last 5 years in Pubmed. Results 18-year-old woman diagnosed with depression and obsessive ideation, which started at the age of 11, after a comment at school. The patient believes that she has intenseunder-eye bags or dark circles, this has caused her to abandon all activity and self-isolate at home. Symptoms included recurring obsessive and intruding thoughts related to the supposed defect, ritualized behaviors of hours of duration aiming toit through makeup, and autolytic ideation. Therapeutic approach combined psychopharmacological and psychotherapeutic treatments, obtaining gradual improvement of symptomatology and disappearance of the autolytic ideation. Conclusions The disorder is severe, which is reflected in high rates of suicide attempts. Differential diagnosis between obsessive and delirious dysmorphophobia is essential for improving outcomes; the egodystonic nature of the symptom, awareness of illness and obsessive personality traits facilitate the diagnosis. A multidisciplinary approach involving psychiatrists and clinical psychologists is necessary for a correct diagnosis and early treatment of this pathology, as well as recognition by dermatologists, surgeons and medical aesthetic professionals, where these patients go with the aim of finding solutions to their problem. Disclosure No significant relationships.

Introduction Cognitive depressive disorder (or depressive pseudodementia) is a condition defined by functional impairment, similar to dementias or other neurodegenerative disorders, in the context of psychiatric patients. It is important to consider a differential diagnosis in patients with cognitive impairment. Objectives Presentation of a clinical case of a patient with depression with psychotic symptoms who presents cognitive impairment. Methods Bibliographic review of the differential diagnosis between cognitive depressive disorder and real dementia by searching for articles in PubMed. Results We present a 51-year-old woman, previously diagnosed with adjustment disorder (with mixed anxiety and depressed mood) and unspecific anxiety disorder, who was admitted to the hospital due to delusional ideation of harm and Capgras syndrome, ensuring that her relatives had been replaced and the rest of the patients were not real patients, but actors who conspired against her. The MRI (Magnetic Resonance Imaging) was strictly normal (tumors or acute injuries as stroke or hemorrhage were discarded), and a MoCA (Montreal Cognitive Assesment) test was performed to screen any cognitive impairments (obtaining a score of 19/30, with language fluency and abstraction particularly affected). It would be convenient to repeat the test when this episode and the psychotic symptoms are resolved or improved. Conclusions 1. Some patients may have cognitive impairment in the context of a mood disorder. 2. A differential diagnosis and follow-up of these patients should be performed to assess prognosis, reversibility and treatment. 3. Depressive cognitive impairment may precede the development and establishment of a dementia or neurodegenerative picture. Disclosure No significant relationships.

Introduction Charles Bonnet syndrome (CBS) is characterized by the presence of visual hallucinations, generally complex, which occurs in patients with alterations in the visual pathway. The majority of affected patients are elderly. It appears in 15% of people with visual loss, predominantly in the 80-year-old female gender. Objectives To present a clinical case of a patient with visual hallucinations and a possible diagnosis of Charles Bonnet syndrome. Highlight the importance of an adequate differential diagnosis. Methods Bibliographic review of the treatment and diagnosis of CBS, from articles published in the last 5 years in Pubmed. Results Woman, 80 years old. No ophthalmological history except those associated with advanced age. She goes to the emergency room due to the presence of visual hallucinosis, in the form of “television presenters” of whom she makes partial criticism, being aware most of the time of their unreality. Hallucinations are not accompanied by anxiety or significant affective repercussions. Discarded delirium, intoxication by substances or drugs that cause the condition. Currently under follow-up to rule out other causes. Conclusions The diagnosis of SCB requires a multidisciplinary approach between neurologists, psychiatrists and ophthalmologists in order to avoid erroneous diagnoses. The differential diagnosis should be made with pathologies such as Lewy body dementia, Parkinson’s disease, delirium, substance intoxication, migraine aura, and metabolic encephalopathy, among others. It is important to involve the family in the treatment of the syndrome to reinforce the recognition of the unreality of these hallucinations in the patients. Antipsychotic treatment can be effective only if the condition is extremely distressing.

Introduction Mental retardation (RM) is defined as by a deficient intellectual capacity as well as by alterations of the adaptive capacity that are externalized in two or more functional areas (Personal autonomy, Communication, Orientation in the environment, Work and Free time). Objectives Present a patient with a severe behavioural disturbance with an associated intellectual deficit, who remained hospitalized for 2 months and after observing an oral alteration her symptoms improved. Methods A descriptive study of a clinical case Results 54-year-old woman, single. You have a moderate intellectual disability. In January 2019, she began mental health consultations with a diagnosis of adjustment disorder, on treatment with aripiprazole 5 mg/day, mirtazapine 15 mg/day, lorazepam 0.5 mg/day and dipotassium clorazepate 10 mg/day. Went to the emergency room with mutism, hyporesponsiveness and refuse to intake, having lost 25 kg in 6 months. Abdominal and thoracic CT and upper gastrointestinal endoscopy without significant findings. Consultation with otorhinolaryngology, dermatology, traumatology without significant findings. Odontostomatology consultation: Deep cavities are observed, so it is necessary to carry out extractions of the pieces in poor condition. After this intervention, the patient returns to accept oral intake. Conclusions People with intellectual disabilities have a wide range of medical problems that in many cases are directly associated with the underlying disease or syndrome and, in others, with poor physical health due to problems in basic self-care skills or the ability to express verbally. Usually, the first manifestation of pain is an alteration in behaviour, which must be taken into account when making a differential diagnosis. Disclosure No significant relationships.

Introduction Capgras syndrome, where patients have the conviction that one or more close people have been replaced by a “double,” is the most prevalent delusional misidentification syndrome. It appears in psychiatric illness and organic brain damage. It seems to be due to damage of bifrontal and right limbic and temporal regions, mainly in the right hemisphere. Objectives To review the pathologies associated to Capgras Syndrome and the relevance of the differential diagnosis Methods 53-year-old female was admitted due to great sadness, crying, social withdrawal and severe paranoid concerns over the last month. Follow-up in Mental Health since 2014, because of anxious depression. After her mother’s death, she felt being followed because of old faults. Since then, low dosis of antipsychotics were used. Now she is afraid of being harmed in relation to petty thefts she committed over 15 years ago. In recent days, she has been noticing small details indicating that her family members have been impersonated by strangers, showing anguish regarding their whereabouts. Results During her admission, high doses of antidepresants and paliperidone 6 mg/day were used with the complete disappearance of Capgras Syndrome and her anguish. Mild guilty thoughts were present after her discharge. That is why she was diagnosed with psychotic depression. Conclusions Capgras syndrome can be encountered in primary psychiatric diagnosis (particularly in schizophrenia and mood disorders) – where an organic element may exist in about a third of all cases – or secondary to organic disorders or medication-induced, through to overt organic brain damage, particularly in neurodegenerative disease.

Introduction Although schizophrenia and anorexia nervosa are very different disorders, when they occur in the same patient it can be difficult to distinguish whether the alterations in body image are due to psychotic symptoms or correspond to a comorbid eating disorder. It is also relevant to know how they can interact with each other. Objectives Presentation of a clinical case of anorexia nervosa in the context of a patient with a previous diagnosis of paranoid schizophrenia. Methods Bibliographic review of the relationship between schizophrenia and alterations in the perception of body image by searching for articles in Pubmed. Results We present a 48-year-old woman who resides with her mother and a sister. Diagnosed with paranoid schizophrenia and eating disorder. She had previously been admitted to hospital twice. Since 2004, she has been followed up in mental health consultations. The patient reports constant weight changes. A year ago she began to feel overweight and began to restrict her intake and to exercise, having lost 20 kg. She reports psychotic symptoms in the past, that she now denies. Various scales show moderate impact of weight on personal perception of psychosocial adjustment, an impulse to thinness and a significant distortion of body image, perceiving herself as heavier than she is and wishing she was lighter. Conclusions In schizophrenia, confusion in bodily experiences and states is not uncommon. The possible interactions between the symptoms of schizophrenia and anorexia nervosa complicate the adequate care of these patients. Further research on comorbidity of these two disorders is necessary.

Introduction Charles Bonnet syndrome (CBS) is characterized by the presence of visual hallucinations without other sensory-perceptual disturbances or evidence of organic mental disorder nor functional psychosis. Objectives Review differential diagnosis of BCS, searching articles in Pubmed. Methods 62-year-old woman, undergoing treatment with Sertraline and psychotherapy for three months because of anxious-depressive synthoms. Pathological myopia and retinal detachment in 2012, blind left eye, retaining 33% vision in the right eye. She comes to the emergency room feeling really anxious, she says that for a year now she has had the feeling that her husband is cheating on her with another woman, and she claims with certainty that she sees a woman in her bed at night, as well as flashes of light evidencing her presence. She has also begun to hear voices through the telephone wires. She and her family deny memory loss or other cognitive impairments. We performed a Nuclear Magnetic Resonance with normal results. Family claims good conygal relation until these synthoms began and no signs of cognitive impairment. Results The patient lives as real these hallucinations which haven´t appeared during admission. We started treatment with an antipsychotic and a benzodiazepine, with great improvement of anxiety and development of some insight. Executive impairment was observed. Conclusions The results obtained, make us think that, although our patient has an important visual loss, it is more a psychiatric pathology. Here lies the importance of a multidisciplinary approach among ophthalmologists, neurologists and psychiatrists in order to avoid misdiagnosis and that the patient can benefit from proper treatment. Disclosure No significant relationships.

Introduction Lithium is widely used in the treatment of the bipolar disorder. Once introduced, it is necessary to carry out an adequate control of the therapeutic range, since it is potentially toxic, and can affect various organs. Objectives To present the case of a patient suffering from lithium poisoning and to review the symptoms of lithium poisoning. Methods A descriptive study of a clinical case and review of the literature Results 49-year-old woman, married. Diagnosed with bipolar disorder. She went to the emergency room due to a low level of consciousness, kidney failure, trembling of the limbs, hyperthermia and leukocytosis. In the last two weeks, the patient has reduced her intake of food, not water, finding herself more and more shaky and less reactive. Lithium in blood at admission 1.71, so conventional dialysis was performed with a progressive decrease into 0.65. On examination, he is practically mutist, bradypsychia with a significant response latency. Clinical judgment: Accidental lithium poisoning. Conclusions The primary site of toxicity is the central nervous system and clinical manifestations vary from asymptomatic supratherapeutic drug concentrations to clinical toxicity such as confusion, ataxia, or seizures. Severe lithium neurotoxicity occurs almost exclusively in the context of chronic therapeutic administration of lithium and rarely results from acute ingestion of lithium, even in patients currently taking lithium. As such it is an iatrogenic illness, occurring in patients who have identifiable clinical risk factors: nephrogenic diabetes insipidus, older age, abnormal thyroid function and impaired renal function. Disclosure No significant relationships.

Introduction: Multiple sclerosis (MS) is a autoimmune disorder which preferentially affects young women of childbearing age. During pregnancy, the annualised relapse rate (AAR) is modified, but pregnancy has no harm effect on the long-term course of the disease. We aimed to study the clinical course of our MS patients during pregnancy, and compare their obstetrics outcomes with a control group of non-MS patients. Methods: A single centre prospective observational study was conducted. We assessed the reproductive history, MS history, pregnancy course and new-born outcome of a cohort of MS patients who had had a pregnancy between January 2007 and July 2012. We compared the global outcomes with a control cohort of 58 age-matched healthy pregnancies. Results: Complete data from 35 consecutive women were analysed, 40 deliveries. Control groups: 58 patients, 60 deliveries. EDSS at pregnancy 0.7. ARR before pregnancy 0.5. During pregnancy 0.3, after pregnancy 0.4. Twelve patients were on disease-modifying drugs (DMD) before pregnancy, 4 prenatal exposure occurs. The comparison between relapse rate and EDSS before, during and after delivery showed no statistically significant difference. In addition, compared to control group, there were also no differences in the obstetric outcomes. In MS cohort, we found a higher incidence of assisted reproductive treatments and lower breastfeeding rate, both statistically significant. Conclusions: Our series confirms that pregnancy has no negative long term impact on the progression of MS and also suggest that there is no additional morbidity in the pregnancy, comparing to the rest of the population. Resumen: Introducción: La esclerosis múltiple (EM) es una enfermedad autoinmune que afecta preferentemente a mujeres en edad fértil. Durante el embarazo y puerperio, cambia la tasa anual de brotes (TAB) de EM, sin modificar la evolución a largo plazo. Analizamos la repercusión del embarazo en pacientes con EM, y comparamos sus resultados obstétricos con embarazos de mujeres sanas. Métodos: Estudio unicéntrico, observacional descriptivo, de diseño longitudinal prospectivo. Se analizan los datos globales de una cohorte de pacientes con EM que han dado a luz entre enero de 2007 y julio de 2012, con un seguimiento de 2 años posparto. Los resultados obstétricos se compararon con un grupo control de 58 embarazadas sanas, elegidas al azar de nuestro centro durante el mismo período de tiempo. Resultados: Un total de 35 pacientes con EM, 40 partos. Grupo control: 58 mujeres, 60 partos. EDSS preembarazo: 0,7. TAB 2 años preembarazo: 0,5. Durante el embarazo: 0,3, a los 2 años posparto: 0,4. Doce pacientes recibían FME previo al embarazo, 4 iniciaron la gestación con FME. No hubo diferencias estadísticamente significativas en la TAB ni en la EDSS entre períodos preembarazo, embarazo y posparto. Al comparar con grupo control, no hubo diferencias en edad materna, semanas de gestación, peso al nacer, porcentaje de cesáreas, ni complicaciones obstétricas. En pacientes con EM hubo mayor porcentaje de tratamientos por infertilidad y menor porcentaje de lactancia, ambos estadísticamente significativos. Conclusiones: Nuestro trabajo confirma que el embarazo no repercute negativamente en el curso de la EM y que no existe mayor morbilidad obstétrica comparado con mujeres sanas. Keywords: Multiple sclerosis, Pregnancy, Immunomodulatory therapy, Breastfeeding, In vitro fertilisation, Artificial insemination, Palabras clave: Esclerosis múltiple, Embarazo, Terapia inmunomoduladora, Lactancia, Fecundación in vitro, Inseminación artificial

Resumen: Introducción: La esclerosis múltiple (EM) es una enfermedad autoinmune que afecta preferentemente a mujeres en edad fértil. Durante el embarazo y puerperio, cambia la tasa anual de brotes (TAB) de EM, sin modificar la evolución a largo plazo. Analizamos la repercusión del embarazo en pacientes con EM, y comparamos sus resultados obstétricos con embarazos de mujeres sanas. Métodos: Estudio unicéntrico, observacional descriptivo, de diseño longitudinal prospectivo. Se analizan los datos globales de una cohorte de pacientes con EM que han dado a luz entre enero de 2007 y julio de 2012, con un seguimiento de 2 años posparto. Los resultados obstétricos se compararon con un grupo control de 58 embarazadas sanas, elegidas al azar de nuestro centro durante el mismo período de tiempo. Resultados: Un total de 35 pacientes con EM, 40 partos. Grupo control: 58 mujeres, 60 partos. EDSS preembarazo: 0,7. TAB 2 años preembarazo: 0,5. Durante el embarazo: 0,3, a los 2 años posparto: 0,4. Doce pacientes recibían FME previo al embarazo, 4 iniciaron la gestación con FME. No hubo diferencias estadísticamente significativas en la TAB ni en la EDSS entre períodos preembarazo, embarazo y posparto. Al comparar con grupo control, no hubo diferencias en edad materna, semanas de gestación, peso al nacer, porcentaje de cesáreas, ni complicaciones obstétricas. En pacientes con EM hubo mayor porcentaje de tratamientos por infertilidad y menor porcentaje de lactancia, ambos estadísticamente significativos. Conclusiones: Nuestro trabajo confirma que el embarazo no repercute negativamente en el curso de la EM y que no existe mayor morbilidad obstétrica comparado con mujeres sanas. Abstract: Introduction: Multiple sclerosis (MS) is a autoimmune disorder which preferentially affects young women of childbearing age. During pregnancy, the annualized relapse rate (AAR) is modified, but pregnancy has no harm effect on the long-term course of the disease. We aimed to study the clinical course of our MS patients during pregnancy, and compare their obstetrics outcomes with a control group of non-MS patients. Methods: A single centre prospective observational study was conducted. We assessed the reproductive history, MS history, pregnancy course and new-born outcome of a cohort of MS patients who had had a pregnancy between january 2007 and july 2012. We compared the global outcomes with a control cohort of 58 age-matched healthy pregnancies. Results: Complete data from 35 consecutive women were analyzed, 40 deliveries. Control groups: 58 patients, 60 deliveries. EDSS at pregnancy 0,7. ARR before pregnancy 0,5. During pregnancy 0,3, after pregnancy 0,4. Twelve patients were on disease-modifying drugs (DMD) before pregnancy, 4 prenatal exposure occurs. The comparison between relapse rate and EDSS before, during and after delivery showed no statistically significant difference. In addition, compared to control group, there were also no differences in the obstetric outcomes. In MS cohort, we found a higher incidence of assisted reproductive treatments and lower breastfeeding rate, both statistically significant. Conclusions: Our series confirms that pregnancy has no negative long term impact on the progression of MS and also suggest that there is no additional morbidity in the pregnancy, comparing to the rest of the population. Palabras clave: Esclerosis múltiple, Embarazo, Terapia inmunomoduladora, Lactancia, Fecundación in vitro, Inseminación artificial, Keywords: Multiple sclerosis, Pregnancy, Immunomodulatory therapy, Breastfeeding, In vitro fertilization, Artificial insemination

Resumen: Antecedentes: La neuromielitis óptica (NMO) es una enfermedad predominantemente humoral mediada por anticuerpos IgG-NMO/AQP-4. Sin embargo, no se conoce bien la contribución de las diferentes subpoblaciones de células B y T en su patogenia o en la respuesta a los tratamientos. Objetivos: Describir los cambios clínicos e inmunológicos asociados al tratamiento con inmunoglobulinas intravenosas (Ig-IV) y rituximab (RTX) en una paciente con un brote grave de NMO y síntesis intratecal de IgG-NMO/AQP-4 que no había respondido a metilprednisolona y recambio plasmático. Métodos: Se analizaron, de forma secuencial en el LCR y en la sangre periférica (SP), las subpoblaciones linfocitarias mediante citometría de flujo multiparamétrica y los IgG-NMO/AQP-4, antes y después del tratamiento con Ig-IV y RTX. Resultados: En el LCR antes del tratamiento, y comparado con la SP, predominaban las células T CD4+ y estaban menos representadas las T CD8+ y las B CD19+. Tras el tratamiento, el porcentaje de células T CD4+ se mantuvo alto, el de T CD8+ aumentó y el de B CD19+ disminuyó, aunque menos que en la SP. Al comparar los LCR se vio que tras la terapia el porcentaje de células T CD8+ memoria efectoras y efectoras había aumentado, y el de células B memoria IgM y el de células B con cambio de isotipos, disminuido. Los cambios observados fueron paralelos a la negativización de los IgG-NMO/AQP-4 y a la mejoría clínica. Conclusiones: Nuestros hallazgos confirman que, además de una respuesta inmunitaria humoral intratecal durante el brote de NMO, subpoblaciones específicas de células B y T participan en la modulación de la inflamación dentro y fuera del sistema nervioso central. Abstract: Background: There is increasing evidence supporting that neuromyelitis optica (NMO) is an inflammatory humoral mediated disorder associated with NMO-IgG/AQP-4 antibodies. However, little is known about the subsets of B cells and T cells that contribute to the pathogenesis or therapy response. Objectives: To describe the clinical and immunological changes associated with intravenous immunoglobulins (IV-Igs) plus rituximab (RTX) in a patient with a severe acute attack of NMO and intrathecal synthesis of NMO-IgG/AQP-4, who previously did not respond to intravenous methylprednisolone and plasma exchange. Methods: We sequentially analysed the levels of NMO-IgG/AQP-4 by immunohistochemistry, and B and T cells subsets by multiparametric flow-cytometry, in the CSF and peripheral blood (PB), before and alter IV-Igs plus RTX therapy. Results: In the CSF before treatment, and compared with PB, there was a higher percentage of CD4+ T cells and a lower percentage of CD8+ T cells and CD19+ B cells. After therapy, the percentage of CD4+ T cells remained high, and that of CD8+ T cells increased. The observed decrease in the percentage of CD19+ B cells was lower than in the PB. When the CSF was compared, it was found that the percentage of effector-memory and effector CD8+ T cells had increased after therapy, and that of IgM memory B cells and switched-memory B cells decreased. The observed changes paralleled the decrease of NMO-IgG/AQP-4 results to negative and the clinical improvement. Conclusions: Our findings confirm that, besides intrathecal humoral immune response against AQP4, B and T cell subsets are involved in the modulation of inflammation within and outside the central nervous system. Palabras clave: Neuromielitis óptica, Líquido cefalorraquídeo, Autoanticuerpos Anti-acuaporina-4, Subclases de células B CD19+ y T CD8+, Keywords: Neuromyelitis optica, Cerebrospinal fluid, Anti-aquaporin-4 autoantibodies, CD19+ and CD8+ T cell subsets

Background: There is increasing evidence supporting that neuromyelitis optica (NMO) is an inflammatory humoral mediated disorder associated with NMO-IgG/AQP-4 antibodies. However, little is known about the subsets of B cells and T cells that contribute to the pathogenesis or therapy response. Objectives: To describe the clinical and immunological changes associated with intravenous immunoglobulins (IV-Igs) plus rituximab (RTX) in a patient with a severe acute attack of NMO and intrathecal synthesis of NMO-IgG/AQP-4, who previously did not respond to intravenous methylprednisolone and plasma exchange. Methods: We sequentially analysed the levels of NMO-IgG/AQP-4 by immunohistochemistry, and B and T cells subsets by multiparametric flow-cytometry, in the CSF and peripheral blood (PB), before and after IV-Igs plus RTX therapy. Results: In the CSF before treatment, and compared to PB, there was a higher percentage of CD4+ T cells and a lower percentage of CD8+ T cells and CD19+ B cells. After therapy, the percentage of CD4+ T cells remained high, and that of CD8+ T cells increased. The observed decrease in the percentage of CD19+ B cells was lower than in the PB. When the CSF was compared, it was found that the percentage of effector-memory and effector CD8+ T cells had increased after therapy, and that of IgM memory B cells and switched-memory B cells decreased. The observed changes paralleled the decrease of NMO-IgG/AQP-4 results to negative and the clinical improvement. Conclusions: Our findings confirm that, besides intrathecal humoral immune response against AQP4, B and T cell subsets are involved in the modulation of inflammation within and outside the central nervous system. Resumen: Antecedentes: La neuromielitis óptica (NMO) es una enfermedad predominantemente humoral mediada por anticuerpos IgG-NMO/AQP-4. Sin embargo, no se conoce bien la contribución de las diferentes subpoblaciones de células B y T en su patogenia o en la respuesta a los tratamientos. Objetivos: Describir los cambios clínicos e inmunológicos asociados al tratamiento con inmunoglobulinas intravenosas (Ig-IV) y rituximab (RTX) en una paciente con un brote grave de NMO y síntesis intratecal de IgG-NMO/AQP-4 que no había respondido a metilprednisolona y recambio plasmático. Métodos: Se analizaron, de forma secuencial en el LCR y en la sangre periférica (SP), las subpoblaciones linfocitarias mediante citometría de flujo multiparamétrica y los IgG-NMO/AQP-4, antes y después del tratamiento con Ig-IV y RTX. Resultados: En el LCR antes del tratamiento, y comparado con la SP, predominaban las células T CD4+ y estaban menos representadas las T CD8+ y las B CD19+. Tras el tratamiento, el porcentaje de células T CD4+ se mantuvo alto, el de T CD8+ aumentó y el de B CD19+ disminuyó, aunque menos que en la SP. Al comparar los LCR se vio que tras la terapia el porcentaje de células T CD8+ memoria efectoras y efectoras había aumentado, y el de células B memoria IgM y el de células B con cambio de isotipos, disminuido. Los cambios observados fueron paralelos a la negativización de los IgG-NMO/AQP-4 y a la mejoría clínica. Conclusiones: Nuestros hallazgos confirman que, además de una respuesta inmunitaria humoral intratecal durante el brote de NMO, subpoblaciones específicas de células B y T participan en la modulación de la inflamación dentro y fuera del sistema nervioso central. Keywords: Neuromyelitis optica, Cerebrospinal fluid, Anti-aquaporin-4 autoantibodies, CD19+ and CD8+ T cell subsets, Palabras clave: Neuromielitis óptica, Líquido cefalorraquídeo, Autoanticuerpos Anti-acuaporina-4, Subclases de células B CD19+ y T CD8+

Resumen: La terapia de la esclerosis múltiple está en rápida evolución. En un plazo próximo, se prevé la incorporación de nuevos fármacos que pueden modificar las pautas actuales de tratamiento. Mientras tanto, el Grupo de Enfermedades Desmielinizantes de la Sociedad Española de Neurología encargado del consenso sobre la utilización de medicamentos para la EM, ha considerado necesaria una puesta al día de las indicaciones actuales y de los principios de tratamiento de esta enfermedad. Abstract: Treatments for multiple sclerosis therapy are rapidly evolving. It is believed that new drugs will be approved in the near future, thereby changing current indications for treatment. In this context, the Spanish Society of Neurology's study group on demyelinating diseases, which evaluates medication use in MS, has decided to draw up a consensus statement on the current indications and guidelines for multiple sclerosis treatment. Palabras clave: Esclerosis múltiple, Tratamiento, Fármacos, Líneas de tratamiento, Fracaso terapéutico, Keywords: Multiple sclerosis, Treatment, Drugs, Lines of therapy, Drug failure

Treatments for multiple sclerosis therapy are rapidly evolving. It is believed that new drugs will be approved in the near future, thereby changing current indications for treatment. In this context, the Spanish Society of Neurology's study group on demyelinating diseases, which evaluates medication use in MS, has decided to draw up a consensus statement on the current indications and guidelines for multiple sclerosis treatment. Resumen: La terapia de la esclerosis múltiple está en rápida evolución. En un plazo próximo, se prevé la incorporación de nuevos fármacos que pueden modificar las pautas actuales de tratamiento. Mientras tanto, el Grupo de Enfermedades Desmielinizantes de la Sociedad Española de Neurología encargado del consenso sobre la utilización de medicamentos para la EM, ha considerado necesaria una puesta al día de las indicaciones actuales y de los principios de tratamiento de esta enfermedad. Keywords: Multiple sclerosis, Treatment, Drugs, Lines of therapy, Drug failure, Palabras clave: Esclerosis múltiple, Tratamiento, Fármacos, Líneas de tratamiento, Fracaso terapéutico