Introduction: The concept of delirium has developed historically from the prototype of acute confusion with psychomotor agitation. While the modern view of delirium recognizes four core features (disturbance of consciousness, disturbance of cognition, limited course and external causation), their operationalization can produce a misleading picture of the most common manifestations of delirium in elderly people. Objectives and Aims: Alert to the diagnosis of delirium in elderly patients. Methods: Review of relevant literature. Results: Delirium is a multifactorial syndrome, involving the interrelationship between patient vulnerability, predisposing factors at admission, and the noxious insults and aggravating factors during hospitalization. A significant proportion of elderly patients are either delirious on admission to hospital, or develop delirium at some point during their hospital stay. The clinic needs to be alert to the predisposing and precipitating factors, which have the potential to identify those at risk of delirium and to prevent it occurring, like age, sex, dementia, psychiatric disorders and physical illness. Another important phase of assessment is the differential diagnosis that includes most other organic and functional psychiatric disorders (but it´s necessary to remember that their presence does not exclude the possibility that the subject is delirious as well), especially depression, dementia or dysphasia due to a cerebrovascular accident. Conclusions: Complications arising from the delirious state in elderly patients prolong hospital admission and contribute to adverse functional outcomes, notably increased dependency and higher rates of institutionalization.

IntroductionThe suicide of a patient in ongoing treatment is surely among the most traumatic events in the professional life of a psychiatrist.ObjectivesAlert to the psychiatrist's reactions to patient suicide.MethodsReview of literature relevant in medline database.ResultsA substantial proportion, estimated to range from 15% to 68%, of psychiatrists has experienced a patient suicide. A significant proportion of psychiatrists show strong negative reactions, affecting professional and personal lives at levels of distress that are frequently comparable with those seen in clinical populations. Psychiatrists develop rather classic symptoms of anxiety, depression, or acute or posttraumatic stress symptoms, and their responses are typical: in the beginning occurs shock, disbelief, denial and depersonalization; and in the second phase takes place: grief, shame and guilt (“did I listen to him?”), anger (toward the patient who did not honor a therapeutic contract), relief (for example, after the suicide of a chronically suicidal patient), and the finding of omens that the psychiatrist considered signs of the coming suicide. But they are predictors of increased distress among psychiatrists who experienced a patient suicide, and the more consistent are age, experience, individual personality and psychiatric history. Recognition of all this combined with an avoidance of isolation is an effective coping mechanism that prevents the structuring of a pathological response to the patient's suicide.ConclusionsPsychiatrist's reactions to patient suicide are specific but not noted; its recognition is important to help them find appropriate coping mechanisms.

Objectives: Alert for the efficiency of the clozapina, in high doses, in refractory mania to pharmacological treatment. Methods: Review of literature relevant after the description of a clinical case example. Results: Description of a clinical case: Woman 30 years, ethnicity african, with bipolar disease type 1, with 12 years of evolution, and 11 treatments with around 1 year duration. Specifics took place with medication, such as intolerance to mood stabilizers, including lithium and valproate. Last inpatient care, with 5 months, it was for outbreak manic characterized by huge dysphoria and easy irritability with aggressiveness. There were administered antipsychotics, in high doses, and attempted electroconvulsive therapy, without success. Clinical remission has been achieved by the gradual increase of clozapina, in accordance with the patient tolerance, until 1400 mg daily without occurrence of agranulocytosis. The only intercurrence was a epileptic seizure, controlled with phenytoin. Conclusions: Refractory mania is treated with clozapina in high doses, which must be administered according to the patient tolerance and clinical improvement. The risk of agranulocytosis (1-3%) is low, and is the only formal indication to suspend the treatment. The extensive metabolizers do not respond to conventional doses of psychotropic substances, they need larger doses and are more frequent in african people.

IntroductionKnowing the impact that religious beliefs can have on the etiology, diagnosis and course of psychiatric disorders will help psychiatrists better understand their patients, assessing when the religious or spiritual beliefs are used to cope with mental illness and when they may be exacerbating this disease.ObjectivesAlert to the importance of religion in clinical practice.MethodsRelevant literature review.ResultsSeveral studies have demonstrated the influence of spirituality on physical, mental and health. In 1988, the World Health Organization (WHO) has given rise to the interest in further investigations in this area, with the inclusion of a spiritual aspect of the multidimensional concept of health. The spiritual well-being can be considered a protective factor for psychiatric disorders.Although it is not possible to determine with accuracy, the mechanisms of interaction of spirituality on health, especially mental health, several studies suggest that exercise can influence the spiritual activities, psychodynamically, through positive emotions. Furthermore, these emotions may be important for mental health in terms of possible psychophysiological and psychoneuroimmunological mechanisms.Anthropological sources suggest that beliefs in demons, black magic and evil spirits as cause of mental illness and distress are common. They may be less prevalent in western countries but even in Europe it's possible to see patients thought that their condition have been caused by evil and occult possession.ConclusionsClinicians should understand the negative and positive roles that religion plays in those with mental disorders and use this in clinical practice.

No abstract