285 A rare case of atypical, non-triggered takotsubo recurrence

Aims Takotsubo syndrome (TTS) is an acute and reversible heart failure syndrome that, at presentation, mimics acute myocardial infarction. The most common echocardiographic manifestation is the so-called ‘apical ballooning’, but other much less common wall motion patterns have been described. The pathophysiology of the syndrome is not fully understood, but there is considerable evidence that sympathetic stimulation plays a central role. The prevalence of this syndrome is higher in post-menopausal women and in most cases, but not invariably, precipitated by an emotional or physical triggering event. A close relation between brain and circulatory system has been observed and for this reason psychiatric and neurologic disorders are often recognized as precipitating conditions. Although many risk factor persist after the acute manifestation, Takotsubo recurrences do represent an exception, especially in the absence of a clear precipitating event. Methods and results A 70-year-old woman was admitted for anginal pain associated with ischaemic electrocardiographic alterations and elevation of cardiac biomarkers. The coronary angiography with left ventriculogram and the echocardiographic findings were consistent with a diagnosis of mid-ventricular Takotsubo. Cardiac magnetic resonance confirmed the absence of an ischaemic pattern or evidence of infectious myocarditis. This case represents a recurrence of TTS, in fact two years earlier the patient was hospitalized to our division for stress cardiomyopathy with typical apical ballooning. Also in the present occasion, she had a favorable clinical course, with a complete recovery of the cardiac function at subsequent evaluations. The unicity of this case lies above all in the absence of a clear trigger event. Although, an altered mental status was present because the patient suffered from anxiety and depression on pharmacological treatment, with periods of exacerbation but not in occasion of the recurrence. Conclusions TTS is not a benign condition, with recurrence being possible even in the absence of precipitating events. Based on registry data, annual rate of Takotsubo recurrence is 1.5–1.8% and is estimated to reach 4% in life. A variable TTS pattern at recurrence is common in up to 20% of cases. Our paper reports a unique case of recurrent Takotsubo syndrome with variable patterns of ventricular involvement, with neither physical nor psychological trigger. Nevertheless, for what concerns our case, the psychiatric condition the patient suffered from, could have played a role of permanent status of sympathetic activation, that in the end elicitates the occurrence of the syndrome. A better understanding of the pathophysiology of the syndrome is needed to find evidence-based therapeutic strategies that could prevent recurrence.

Female Genito-Pelvic Pain/Penetration Disorder: Review of the Related Factors and Overall Approach

Genito-pelvic pain/penetration disorder (GPPPD) can be an extremely bothersome condition for patients, and a tough challenge for professionals regarding its assessment and treatment. The goal of the present paper is to review the etiology, assessment, and treatment of GPPPD, especially focusing on the cognitive aspects of the disease and cognitive-behavioral treatment options, through a non-systematic review of articles indexed to the Medline, Scopus and Web of Science databases, using the following MeSH queries: pelvic pain; dyspareunia; vaginismus; vulvodynia; and cognitive therapy. Altogether, 36 articles discussing the etiology, diagnosis and management of GPPPD were selected. We provide an overview of GPPPD based on biological, psychological and relational factors, emphasizing the last two. We also summarize the available medical treatments and provide strategies to approach the psychological trigger and persisting factors for the patient and the partner. Professionals should be familiarized with the factors underlining the problem, and should be able to provide helpful suggestions to guide the couple out of the GPPPD fear-avoidance circle.

Reconceptualizing Self-Affirmation With the Trigger and Channel Framework: Lessons From the Health Domain

Self-affirmation—a theory-based technique to affirm the adaptive adequacy of the self—can promote positive behavior change and adaptive outcomes, although effects are variable. We extend a novel framework (Trigger and Channel), proposing three conditions that facilitate self-affirmation-induced behavior change: (a) presence of psychological threat, (b) presence of resources to foster change, and (c) timeliness of the self-affirmation with respect to threat and resources. Using health behavior as a focus, we present meta-analytic evidence demonstrating that when these conditions are met, self-affirmation acts as a psychological trigger into a positive channel of resources that facilitate behavior change. The presence of a timely threat and the availability of timely resources independently predicted larger self-affirmation effects on behavior change, and the two interacted synergistically to predict still larger effects. The results illustrate the conditionality of self-affirmation effects and offer guidelines for when, where, and for whom self-affirmation will be most effective.

Reconceptualizing self-affirmation with the Trigger and Channel Framework

Self-affirmation–a theory-based technique to affirm the adaptive adequacy of the self–can promote positive behavior change and adaptive outcomes, although effects are variable. We extend a novel framework (Trigger and Channel), proposing three conditions that facilitate self-affirmation-induced behavior change: 1) presence of psychological threat; 2) presence of resources to foster change; and 3) timeliness of the self-affirmation with respect to threat and resources. Using health behavior as a focus, we present meta-analytic evidence demonstrating that when these conditions are met, self-affirmation acts as a psychological trigger into a positive channel of resources that facilitate behavior change. The presence of a timely threat and the availability of timely resources independently predicted larger self-affirmation effects on behavior change, and the two interacted synergistically to predict still larger effects. The results illustrate the conditionality of self-affirmation effects and offers guidelines for when, where, and for whom self-affirmation will be most effective.

Delayed Onset of Neuropsychiatric Effects Associated with Montelukast

Montelukast (a leukotriene receptor antagonist) is a commonly prescribed medication used in the management of asthma in both children and adults. It has been associated with a possible increased risk of various neuropsychiatric events in post-marketing analyses of clinical trial data and surveillance studies. When establishing a link between a medication and side effects, it is usual to establish and enquire whether there is a chronological relationship between the commencement of the medication and the onset of the symptoms.We report a case where a number of unusual neuropsychiatric events were reported several years after commencement of montelukast in a young boy who may have a genetic predisposition and a likely psychological trigger. There was complete resolution of these symptoms upon the withdrawal of montelukast.

Phenomenology and psychiatric origin of psychogenic nonepileptic seizures

INTRODUCTION Psychogenic nonepileptic seizure (PNES) is a sudden change in a person's behavior, perception, thinking, or feeling that is usually time limited and resembles, or is mistaken for, epilepsy but does not have the characteristic electroencephalographic (EEG) changes that accompanies a true epileptic seizure [1]. It is considered that PNES is a somatic manifestation of mental distress, in response to a psychological conflict or other Stressors [2]. A wide spectrum of clinical presentation includes syncope, generalized tonic-clonic seizure, simple and complex partial seizure, myoclonic seizure, frontal lobe seizures and status epilepticus [3]. Coexistence of epilepsy and PNES is seen in approximately 9% of cases [5]. Between 25-30% of patients referred to tertiary centers and initially diagnosed as refractory epilepsy were on further examination diagnosed as PNES [6,7]. In DSM-IV [12] PNES are usually categorized under conversion disorder with seizures or convulsions. However, psychiatric basis of PNES may be anxiousness (panic attack), somatization or factitious disorder, simulation, dissociative disorders and psychosis [1]. AIM The aim of the study was to establish clinical phenomenology and EEG characteristics as well as basic psychiatric disorder in patients with PNES. METHOD In a retrospective study covering the period from January 1st 1999 till April 31 st 2003, 24 patients (22 female, 2 male) treated at the Institute of Neurology in Belgrade were analyzed. PNES were defined as sudden change in behavior incoherent with epileptiform activity registered on EEG. Possible PNES were determined on the basis of history data and clinical examination during the attack but definitive confirmation was established only by the finding of no ictal EEG changes during typical seizure of each patient. Patients with coexisting epilepsy were included in the study, too. At least two standard EEG (range 2-6, median 4) were performed at the beginning of diagnostic evaluation. Demographic data, clinical presentation (apparent loss of consciousness, type of convulsion and associated clinical signs) and placebo-induced seizures (administration of saline near the cubital vein) with EEG or video-EEG monitoring were analyzed. Basic psychiatric disorder was classified according to DSM IV classification criteria. RESULTS Duration of PNES was 4.7 years (range from 2 months to 30 years). The time from onset to the diagnosis of PNES was 4.5 years. Epilepsy comorbidity was diagnosed in 9 patients (37.5%). The average time of use of antiepileptic drugs (AED) in the group of isolated PNES was 2.4 years and 20% of patients were treated with two or more AED. The vast majority of patients presented with bilateral convulsions (54.16%) with apparent loss of consciousness found in 91.6% of cases. Ictal iwury (16.7%), tongue bite (4.2%) and premonition of the seizure (17.4%) were uncommon. Variability in clinical presentation of seizures was found in over half of patients (57%). Psychological trigger could be determined in over 60% of patients. EEG findings in a group with isolated PNES suggesting the existence of epileptiform activity was found in one case. EEG monitoring of placebo-induced seizure was performed in 20 patients, of whom 19 (95%) showed typical habitual attack with no electroclinical correlate. In 70% of cases conversion disorder DSM-IV criteria were fulfilled. Somatization disorder and undifferentiated somatoform disorder were found in 3 patients. The diagnosis of factitious disorder was made in one case and only two patients were undiagnosed according to DSM-IV. DISCUSSION Average delay from onset to diagnosis of PNES in larger studies was estimated to be approximately 7 years [8]. Even though diagnostic delay in our study was shorter, organizational reasons for this could not be found. Longer duration of a typical attack (compared to the epileptic seizure), apparent loss of consciousness, bilateral convulsion behavior and significant clinical variability in absence of typical epileptic elements such as tongue bite and ictal iwury could be the main clinical manifestation of PNES. We found rare interictal abnormalities (6.7%) in the group with isolated PNES and significant percentage (77.7%) in patients with coexisting epilepsy which is coherent with other reports [8]. The latest could lead to prolonged delay in appropriate diagnosis and suitable treatment. Clear psychological trigger wasn't noted in whole group of patients (61 %). This, however, is not unusual since PNES represents a chronic disorder with repeated triggering that could lead to less significant role of the same psychological trigger in developed PNES. Even insufficiently resolved in ethical terms, placebo-induced procedure was of huge sensitivity. In clinical practice conversion disorder is hard to differ from malingering or implementation of secondary gain. One could make the conclusion only on the basis of detailed and careful estimation of the symptoms developing context Conversion disorder is more prevalent among women (from 2:1 to 10:1) [4, 13] but modest percentage of affected men could be explained only by limited sample in this study. CONCLUSION PNES is often replaced with epilepsy and in number of cases clinical differentiation is not easy. One should be acquainted with clinical presentation of PNES as well as its psychiatric origin in order to adequately recognize and treat the disorder.