W12 – trainees

O1 Unusual presentations in psychiatry and the pitfalls. A case review of Anti-

NMDA encephalitis

Dr Rowena Carter, Psychiatry trainee, South London and the Maudsley NHS trust

Background

In recent years a new category of encephalitis as been defined called Anti-N-Methyl-D-

aspartate receptor (NMDAR) encephalitis in which antibodies to NR1 and NR2 heteromers

of NMDAR are present in the CSF and serum of affected patients1

Patients typically present with psychotic symptoms that have an onset over days to

weeks and this can be easily mistaken for first presentation psychosis.

This distinction between the two can be difficult, particularly when the patient presents

as very behaviorally disturbed and physical investigations are therefore complicated.

Methods

The Author presents two very similar cases which highlight the importance of considering

a physical diagnosis when assessing a first presentation of apparent psychotic illness.

Results

Two case studies are compared and contrasted for onset, presentation, progression of

illness as well as investigations and overall outcome.

Although the two cases presented initially as indistinguishable, subtle differences in the

cases develop which will be highlighted and the importance of when to investigate with

CT/MRI/LP will be discussed.

One case had a diagnosis of bipolar affective disorder with psychotic features and

responded well to ECT, the second case had a diagnosis of Anti-NMDA encephalitis and

remains functionally impaired.

Conclusion

Anti-NMDAR encephalitis is severe and the progression of the illness is relatively fast.

Ultimately it can be fatal, however if it is identified and treated then the deficits can

potentially be reversible.

The decision of when to investigate psychotic patients is difficult and made more

complex when the behavior is challenging however it is important to reflect on potential

physical diagnosis when reviewing psychotic patients.

Category: Education and Training

O2 Trauma, Post Traumatic Stress Disorder and Psychiatric Disorders in a

middle income setting: prevalence and comorbidity in a Sri Lankan population

Dr Sarah Dorrington, Psychiatry trainee, King's College London; Dr Helena Zavos,

Researcher, King's College London; Dr Harriet Ball, Faculty of Medicine, Imperial College

London; Prof Peter Mcguffin, Professor, King's College London; Dr Fruhling Rijsdijk,

Researcher, King's College London; Dr Sisira Siribaddana, Endocrinologist and

Researcher, Institute of Research and Development, Colombo, Sri Lanka

Background; Most studies of post traumatic stress disorder (PTSD) in low and middle

income countries (LMI) have focused on ‘high risk’ populations defined by exposure to

trauma.

Aims; To estimate the prevalence of criterion A traumas and lifetime PTSD (DSM-IV) in a

LMI population, the conditional probability of PTSD given traumatic event and the

strength of associations between traumatic events and other psychiatric disorders.

Method; Our sample contained a mix of 3995 twins and 2019 non-twins, analysed as

individuals from the Colombo Twin And Singleton Study (CoTASS), a Sri Lankan

population-based study.

Results; Traumatic events were reported by 36.3% of participants. Lifetime PTSD was

present in 2.0% of the sample. Of people who had experienced 3 or more traumatic

events, 13.3% had lifetime PTSD and 40.4% had a non-PTSD psychiatric diagnosis.

Conclusions;

1) Despite high rates of exposure to trauma, this population was found to have much

lower rates of PTSD than high-income populations

2) There are high rates of non-PTSD diagnoses associated with trauma exposure that

could be considered in interventions for trauma-exposed populations.

Category: Research

O3 Brain Temperature, Cognition and Glutamate in Recent Onset Schizophrenia:

a 7T MRS study

Dr Sotirios Posporelis, Psychiatry trainee, Johns Hopkins University School of Medicine,

South London & Maudsley NHS Foundation Trust; Dr Teppei Tanaka, Post-Doc Fellow,

Johns Hopkins University School of Medicine; Dr Anouk Marsman, Johns Hopkins

University School of Medicine; Mr Mark Varvaris, Research Assistant, Johns Hopkins

University School of Medicine; Prof Peter B. Barker Barker, Professor of Radiology, Johns

Hopkins University School of Medicine; Prof Akira Sawa, Professor of Psychiatry and

Behavioral Sciences / Director, Johns Hopkins Schizophrenia Center / Director, Molecular

Psychiatry Program, Johns Hopkins University School of Medicine

Aims & Hypothesis: to elucidate the links between brain temperature, cognition and

glutamatergic function.

Background: Brain temperature (BT) is an important pshysiological parameter, reflecting

the amount of heat produced and sustained by bodily processes. Apart from its role as

an index of metabolism, it can be viewed as a factor that directly affects brain cells, their

activity and consequently function. In schizophrenia-although there is evidence of

dysfunctional thermoregulation, glutamate dysfunction, inflammation and oxidative

stress all of which can potentially affect BT- little is known about BT and this is mostly

due to the invasive nature of conventional measurement methods.

Methods: 11 recent onset DSM-IV schizophrenia patients and 9 healthy non-smoking

volunteers matched for age, sex, race, education status have been studied using 7 tesla

proton magnetic resonance spectroscopy. A combination of semi-LASER and STEAM

sequences were utilized to measure absolute brain temperature and identify the

following peaks of interest in the anterior cingulate: glutamate, glutamine, GABA, NAA.

All participants completed a broad neuropsychological battery, assessing a wide variety

of cognitive domains.

Results: Schizophrenia patients performed poorly in processing speed, attention/working

memory and ideational fluency. The schizophrenia group had higher levels of glutamate

but significance did not survive Bonferroni correction. BT has been consistently higher

than core body temperature (CBT) in every study participant. Only in the control group

did we find an inverse corelation between glutamate and BT. The level of glutamine

negatively correlated with CBT but significance did not survive Bonferroni correction. The

difference between BT and CBT in the schizophrenia group was positively correlated with

negative symptoms, adjusting for duration of illness.

Conclusions: to our knowledge, this is the first study to measure metabolite

concentrations and absolute brain temperature, in the anterior cingulate of recent onset

schizophrenia patients utilising a 7 Tesla system. Furthermore, it is the first to link brain

temperature to glutamate, cognitive function and negative symptoms. The results link

abnormal energy turnover to negative symptoms and highlight the importance of brain

temperature in schizophrenia research.

Category: Research

O4 Does having a common mental health problem predict Emergency

Department attendance?

Dr Amy Green, Psychiatry trainee, University of Bristol and the Severn Deanery; Prof

Chris Dickens, Professor of Psychological Medicine, University of Exeter; Dr Will Lee,

Plymouth University Peninsula Schools of Medicine and Dentistry; Prof Else Guthrie,

Professor of Psychological Medicine, Manchester University; Simon de Lusignan

Aims and hypothesis: Having a common mental health problem (CMHP), such as

depression or an anxiety disorder may be associated with increased Emergency

Department (ED) attendance. This study investigated the characteristics of individuals

associated with ED attendance using British primary care data.

Background: The use of urgent and unscheduled care in the UK has been increasing

steadily over recent years and the factors driving this are poorly understood. It is well

established that people with long-term physical conditions (LTCs) and depression,

frequently use urgent and unscheduled care. The independent contribution of having a

CMHP to this problem has not been previously explored using British data.

Methods: Data were gathered from primary care records of 117,317 adult patients from

two locations one in the North and one in the South of England over an 18 month period

(1/10/07-30/4/09). These patients’ data were linked to corresponding hospital episode

statistics to identify ED attendances. Multivariable logistic regression was used to identify

characteristics independently associated with subsequent ED attendance.

Results: ED attendees were more likely than non-ED attendees to suffer from 1 or more

LTC (29% vs 21%, p=<0.001 in the Northern centre and 25% vs 12%, p=<0.001 in the

Southern centre), and more likely to suffer from a CMHP (21% vs 13%, p<0.001 in the

Northern centre, and11% vs 5%, p<0.001 in the Southern centre). Using multivariable

logistic regression, after adjusting for age and distance from the ED, ED attendance was

associated with: having multiple LTCs [OR in the Northern centre=3.67, (95% CI

2.81,4.79) and OR in the Southern centre = 6.51, (95% CI 4.47,9.40)] and having a

CMHP [OR in Northern centre= 1.69 (95% CI 1.161,1.78) and OR in Southern centre =

2.27, (95% CI 2.05,2.05)].

Conclusions: In addition to the number of LTCs, ED attendance was independently

predicted by the presence of CMHP. Better treatment of CMHPs in primary care,

particularly among people with multiple LTCs, might reduce ED attendances.

Category: Research

O5 Suicide in students with mental illness, 1997-2010: A national clinical

survey

Dr Suhanthini Farrell, Psychiatry trainee, Centre for Suicide Prevention, Manchester; Dr

Kirsten Windfuhr, Project Manager, NCISH, Centre for Suicide Prevention, Manchester;

Prof Nav Kapur, 5, Centre for Suicide Prevention, Manchester

AIMS AND HYPOTHESIS We aimed to examine the socio-demographic, clinical, and

behavioural characteristics associated with university student suicide compared with

non-student suicide in a mental health patient population. We hypothesised that

students would be less likely to have enduring psychotic illness and more likely to have a

short history of contact with mental health services.

BACKGROUND: Entering Higher Education represents a transitional time in the life of

many young people, and coincides with the typical age of onset of some serious mental

illnesses. We believed awareness of the distinguishing characteristics of student suicide

would assist clinicians in managing risk in this group.

METHODS: Data collected by the National Confidential Inquiry into Suicide and Homicide

by People with Mental Illness for the period 1997 to 2010 for those aged 15-35 were

analysed. Univariate and multivariate conditional logistic regression were carried out to

identify factors independently associated with student suicide. Odds ratios were

calculated with 95% confidence intervals.

RESULTS: There were 243 student suicides in the clinical sample over the 14-year

period. Students who died were significantly less likely to be male** or living alone**,

and more likely to be from an ethnic minority**, than non-students. More students had

affective disorders** or eating disorders**, while psychotic disorders** and substance

misuse/dependence** were less likely. Psychological treatment was given to students

more often** and medication prescribed substantially less frequently*, even accounting

for diagnosis. Student suicides were characterised by shorter duration of illness**,

shorter history of contact with mental health services**, and reduced likelihood of

previous admission**. Fewer students fell into a recognised “priority group” of the

current UK suicide prevention strategy*. (* p<0.005, ** p<0.001).

CONCLUSIONS: Mentally ill students who die by suicide appear to be a clinically distinct

group in regard to diagnosis, treatment, and illness history. Medical under-treatment of

mental illness may be a particular feature of student suicides.

Category: Research

O6 Substance abuse patterns and ten-year outcome in FEP

Dr Melissa Weibell, PhD student, Stavanger University Hospital; Prof Jan Olav

Johannessen, Psychiatry consultant, Stavanger University Hospital, University of

Stavanger; Prof Tor Ketil Larsen, 6, Stavanger University Hospital, University of Bergen;

Dr Wenche ten Velden Hegelstad, clinical psychologist, Stavanger University Hospital; Dr

Inge Joa, professor, Stavanger University Hospital, University of Stavanger; Prof Svein

Friis, Psychiatry consultant, University of Oslo

Aims and hypothesis

The study aimed to investigate different patterns of substance use in an epidemiological

first-episode psychosis (FEP) sample, hypothesizing that persistent use would predict

poorer symptom outcomes compared to never users or stop users.

Background:

Substance use is common in FEP and has been linked to poorer outcomes. Patients may

use substances on-off or stop using. Little is known about the effect of different patterns

of substance use on outcomes.

Methods

301 patients aged 16-65 with first episode non-affective psychosis were included (1997-

2001) from three separate catchment areas in Norway and Denmark. We defined four

patterns of substance use; never used (N=153), persistent use (N=43), stop use

(N=36), and on-off use (N=48) during the first 2-years of follow-up.

114 patients were followed up at 10 years and compared on symptom levels (PANSS,

GAF) and remission status.

Results

Patients who stopped using had similar 10-year symptom outcomes as patients who had

never used with significantly lower symptom levels on PANSS positive and depressive

symptoms and GAF compared to patients with on-off or persistent use. There was a

trend for persistent users showing increasing negative symptoms over time. We found a

large and significant difference in remission rates, with 56.6% of never users and 63.3%

stop users achieving remission at 10 years compared to 32.2% for on-off users and

34.4% for persistent users.

Conclusions

Results clearly indicate that substance use cessation in FEP is associated with similar

outcomes to FEP patients who never used any substances; on-off use may be almost as

detrimental to mental health as persistent use. The harmful effects of substance use in

FEP can be substantially reduced if clinicians are able to assist patients to stop using

altogether.

Financial disclosure

Health West (#911369), National Research Council (#133897/320;#154642/320), the

National Council for Mental Health/Health and Rehabilitation (#1997/41;#2002/306),

Health South East (#2008001) and Health West #200202797-65; #911313, Norway;

the Theodore and Vada Stanley Foundation; NARSAD Distinguished Investigator Award.

Category: Research