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Issue 5 – 2018

This is the fifth issue of the International Journal of Clinical Neurosciences and Mental Health. The journal aims to provide high-quality publications in the areas of Psychiatry and Mental Health, Neurology, Neurosurgery, and Medical Psychology. This publication is intended to provide a forum for experts from all around the world to share their knowledge, expertise, and research efforts. The journal operates under an Open Access model, and therefore everyone is invited to join this initiative.

Issue Nr:


|    Issue date: 2018-02-13


Persisting use of physical restraint: Knowledge Translation vs. Attitudes - read full article

By: Nicole Walker, Theresa Scott, Nadeeka N. Dissanayaka, Fiona Kate Barlow, and Nancy A. Pachana

Physical restraint in residential aged care (RAC) 
The use of physical restraint in residential aged care (RAC) is relatively common [1]. Existing research suggests that the proportion of residents physically restrained in RAC facilities ranges from 12% to 47% [2]. The last two decades have seen much research discussing both the potential benefits and adverse consequences of physical restraint [3]. While at a global level, there are distinctive factors that determine both the prevalence and justification for employing physical restraint on a case by case basis rather than an umbrella explanation [4], the prevalence of physical restraint use in RAC is concerning. If knowledge about the negative impact on quality of care and quality of life could be presumed to decrease the use of physical restraint in RAC, then additional factors could also be presumed to be simultaneously (and strongly) promoting the use of physical restraint. In this paper, in the moment affective processes (e.g., emotions, negative attitudes) are suggested as one such likely factor, potentially overriding knowledge-based interventions and thus maintaining the use of physical restraint. Specifically, negative attitudes towards residents residing in RAC may exist in many populations, and these, in addition to the unique environment associated with working in RAC (including high levels of one on one care, frailty and decrease mobility), perhaps promotes behaviour that is driven by affect, rather than knowledge. Multiple studies reveal that physical restraint harms residents [2]. In particular, serious injury and mortality are often directly related to both proper and improper use (selection and application) of physical restraint on residents [1], and physical restraint is likewise associated with reduced psychological well-being, and mobility [2]. Further, residents who are managed via physical restraint exhibit rapid cognitive decline compared to those who are not restrained [2, 5]. Despite this evidence, physical restraint is frequently referenced as a protective measure [6]. For example, it is argued that physical restraint reduces the risk of personal injury to residents and employees [2], controls wandering, and facilitates medical treatment [7, 8]. However, the literature suggests that such justifications are not evidence-based and in fact are not supported by the data [8, 9]. (Continues)

International Journal of Clinical Neurosciences and Mental Health 2018; 5:1
DOI: https://doi.org/10.21035/ijcnmh.2018.5.1

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Original Article

Hit or Miss? Diagnostic contributions of neuropsychological assessment in patients with suspected dementia - read full article

By: Donna Pinsker, Ada H. Y. Lo, Catherine Haslam, Nancy A. Pachana, and Hayden Pinsker

Objectives: Accurate early diagnosis of dementia has important implications for prognosis, treatment, and management. In hospital settings, neuropsychological assessment is frequently included in the diagnostic work-up for dementia, particularly in clinically ambiguous cases. However, the diagnostic contributions of neuropsychological testing in this population are not well established. This paper reports the findings from a preliminary study examining the diagnostic utility of such assessment in patients with suspected dementia. 
Methods: A retrospective review of hospital medical records was performed for 84 patients who underwent neuropsychological assessment for diagnostic purposes within a five-year time frame. A proxy measure of diagnostic accuracy was obtained using the level of agreement between the neuropsychologist’s opinion and the most recent working diagnosis of the medical treatment provider, allowing a minimum follow-up period of twelve months.
Results: Using defined clinical coding criteria to account for differences between clinical conditions (e.g., mild neurocognitive disorder) and underlying pathology (e.g., Alzheimer’s disease), the baseline diagnosis of the neuropsychologist concurred with the most recent diagnosis of the treatment provider in 88% of cases with an exact match in 77% of cases. Follow-up neuropsychological assessments over time did not lead to a significant improvement in diagnostic accuracy.
Conclusion: A high level of diagnostic agreement emerged between neuropsychology and treating medical consultant opinions, independent of available neuroimaging evidence. The findings highlight the contribution of neuropsychological testing in the diagnosis of dementia in hospital settings. Replication of these results is required using prospective designs, larger samples, multiple sites, and autopsy confirmed diagnoses.

Keywords: Alzheimer’s disease, Dementia, Diagnostic accuracy, Neuropsychological assessment.

International Journal of Clinical Neurosciences and Mental Health 2018; 5:2
DOI: https://doi.org/10.21035/ijcnmh.2018.5.2

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Review Article

Parent training for parents of children on the autism spectrum: a review - read full article

By: Joana Prata, Wenn Lawson, and Rui Coelho

Autism is a neurodevelopmental condition with biological, genetic, environmental and developmental causes, which are still not clearly understood. Parents are usually the primary caregivers for their children and the essential link between home and school environments. Often they also take on a coach or therapist role across a variety of interventions, which demands a great amount of time, dedication, energy and financial resources. Increased parent skills allow for continued opportunities for the child to learn in a range of different situations and environments, and parent training is now considered an important component of successful intervention programs. This paper is a review of current research regarding parent training for parents of children on the autism spectrum.

Keywords: Autism, Parent training, Parent education programs, Parent stress.

International Journal of Clinical Neurosciences and Mental Health 2018; 5:3
DOI: https://doi.org/10.21035/ijcnmh.2018.5.3

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Review Article

Late-onset schizophrenia: from Manfred Bleuler to the present - read full article

By: Ana Dias-Amaral, Maria João Peixoto, Alzira Silva, and Rui Coelho

Background: For Bleuler, late-onset schizophrenia (LOS) was characterized by onset after age 40, symptoms similar to the classic form and absence of signs of organic brain disease. We aim to describe the current aetiology, diagnosis and treatment of LOS, emphasizing the differences between LOS and classic schizophrenia. 
Methods: Non-systematic review of original articles and systematic reviews regarding late-onset schizophrenia aetiology, diagnosis and treatment indexed to Pubmed, ISI – Web of Knowledge, Scopus and EBSCO published between January 1980 and December 2017, using the MeSH query: schizophrenia AND late onset disorders. Altogether, 62 articles were deemed relevant by two independent reviewers and included in the final selection. 
Results: 23% of the cases of schizophrenia have late- (> 40 years) or very late-onset (> 60 years), with higher incidence in females. Genetic factors, menopause, sensory deficits, vascular and neurodegenerative lesions, and age per se are risk factors. Higher educational levels and marital rates and greater cognitive reserve stand out. Well systematized persecutory and jealousy delusions and auditory hallucinations are common. On the contrary, negative symptoms are uncommon. Cognitive functions are well preserved in the first year, but high rates of dementia are described after five-year follow-up. Due to the protective effect of oestrogen, LOS appears to have a worse prognosis in postmenopausal women. Despite the anti-psychotic drugs available, most patients remain symptomatic. 
Conclusion: There is a significant overlap between early-onset schizophrenia and LOS/very-late onset schizophrenia-like psychosis (VLOSLP), but there are important differences mainly regarding risk factors and symptoms that cannot be overlooked. Seventy-five years after the first description, it is necessary to better define LOS/VLOSLP as a debate identity.

Keywords: Schizophrenia, Psychosis, Late-onset.

International Journal of Clinical Neurosciences and Mental Health 2018; 5:4
DOI: https://doi.org/10.21035/ijcnmh.2018.5.4

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Review Article

Efficacy of transcranial magnetic stimulation in the treatment of Obsessive-compulsive disorder - read full article

By: Nuno Sousa and Ricardo Moreira

Background: Obsessive-compulsive disorder (OCD) is a chronic and debilitating disease characterised by obsessions and compulsions that cause anxiety to the patient and his family. Its prevalence is around 2 to 3% in the general population, and despite being responsive to treatment, 40-60% of patients are not full responders and remain refractory. Therefore, new therapeutic options like transcranial magnetic stimulation (TMS) have been gaining interest recently due to their non-invasive nature and potentially promising results. However, there is not yet a consensus about its efficacy in this disease. The aim of this review is to assess the efficacy of TMS in the treatment of OCD, discussing some of the clinical trials available. 
Methods: A search was made in MEDLINE, through Pubmed, using the query: "Obsessive-Compulsive Disorder"[Mesh] AND "Transcranial Magnetic Stimulation"[Mesh]. 
Results: Several demographic, clinical and technique-related variables of 16 clinical trials were analysed, along with their outcome. Most of the trials revealed promising results in three cortical areas: dorsolateral pre-frontal cortex, supplementary motor area and orbitofrontal cortex. However, their statistical power is affected by their small sample size and heterogeneity of parameters, which limits critical analysis and comparison of results. Depression was also identified as a possible confounding factor, which could predispose to positive results. 
Conclusion: The distinct characteristics of the clinical trials make it impossible to generalise the effects of this technique in OCD. More robust studies, preferably without comorbid psychiatric disorders, are necessary to better evaluate the efficacy of this technique.

Keywords: Transcranial magnetic stimulation, Obsessive-compulsive disorder.

International Journal of Clinical Neurosciences and Mental Health 2018; 5:5
DOI: https://doi.org/10.21035/ijcnmh.2018.5.5

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Review Article

Family systems, offspring and eating disorders: Can perfectionism close the gaps? - read full article

By: Tiago Santos, Cristiana Marques, Ana Telma Pereira, Sandra C. Soares, and António Ferreira Macedo

Research on the etiology and risk factors of Eating Disorders (ED) combines several dimensions in complex interactions. Classical and more modern theoretical approaches are consistent in acknowledging a web of cultural, family and neurobiological aspects, at both inter and intrapersonal levels. Although such approaches have contributed to a deeper comprehension in this domain, a robust conceptual framework that fully integrates all the different elements is still lacking. Herein, we aim at tackling such integrative account, by presenting a review of past and current research based on three major dimensions: perfectionism, parenting and family dynamics, and offspring’s behavior and characteristics. Given their critical role in ED across different conceptual frameworks, these dimensions have been consistently pointed out as associated with ED. The available data suggests that perfectionism may be taken not only at an individual level but also as a family phenotype. Furthermore, it may be the link between intrapersonal factors in the onset and development of ED, and interpersonal factors, particularly parenting styles and family dynamics. The current integrative framework may aid in the disclosure of some of the underlying processes by which personal and contextual factors interact and translate into illness and, therefore, contribute to new insights regarding the role of families and parents-child interaction in the etiology of ED and to more effective therapeutic interventions at both individual and family level.

Keywords: Eating Disorders, Parenting Styles, Perfectionism, Offspring.

International Journal of Clinical Neurosciences and Mental Health 2018; 5:6
DOI: https://doi.org/10.21035/ijcnmh.2018.5.6

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From gender binarism to gender... binarism: gender identity and new expressions of gender stereotypes - read full article

By: Orlando von Doellinger

The concept of gender, established in the mid-20th century, is still often confused with the notion of sex. Despite great developments and profound deepening in gender studies, gender identity and sexual orientation, two distinct notions, are also confused and frequently taken as synonymous or as presenting a unequivocal relationship. The problem lies, in our opinion, in masculinity and femininity stereotypes and, above all, in the maintenance of a gender binarism perspective. If (biological) sex is not dichotomous (there are male sex and female sex, but there are also different forms of intersex), gender and gender identities, are individual and even more complex constructions to which countless factors (biological, social, developmental, and relational, among others) contribute. In this viewpoint we try to restate the perspective that each human being will always present a composite of specific and individualized complex combination of masculine and feminine traits, and that even some more recent “classifications” that try to overcome stereotyped binarism end up repeating and reinforcing them, promoting the pathologization of gender identities that are not in line with social stereotypes.

Keywords: Sex, Gender, Gender stereotypes, Gender identity, Gender bynarism.

International Journal of Clinical Neurosciences and Mental Health 2018; 5:7
DOI: https://doi.org/10.21035/ijcnmh.2018.5.7

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Case Report

More than meets the eye: an unusual Parkinson’s disease mimic - read full article

By: Verónica Cabreira, Eva Brandão, and João Massano

Introduction: Fragile X-associated tremor/ataxia syndrome (FXTAS) is a rare, X-linked adult-onset neurodegenerative disorder affecting carriers of the fragile X mental retardation 1 (FMR1) gene premutation, a 55-200 cytosine-guanine-guanine [CGG] repeat expansion in the 5' untranslated region of the gene. Intention tremor and ataxia are usually the core features of the syndrome, while parkinsonism has also been described, but less frequently seen. FXTAS probably remains underdiagnosed, possibly mistaken for essential tremor, various degenerative ataxias, and atypical parkinsonian syndromes. Hyperintensity of the middle cerebellar peduncle (MCP) detected in T2 or FLAIR MRI, a highly specific sign of this disorder, is present in approximately 60% of men with FXTAS. 
Case report: We present the unusual case of a patient with previously undiagnosed FXTAS who was referred for deep brain stimulation (DBS) surgery, as the phenotype resembled Parkinson’s disease (PD). An MRI scan requested in 2006 had revealed symmetrical T2 hyperintensity in the middle cerebellar peduncles. Genetic testing disclosed FMR1 premutation with 90 CGG repeats expansion confirming the diagnosis of FXTAS. 
Discussion: This case highlights the relevance of considering FXTAS as a possible diagnosis in these cases, even if the clinical picture resembles PD. MCP hyperintensity seen on MRI should therefore trigger genetic testing and subsequent appropriate management.

Keywords: Parkinsonism, Parkinson’s disease, Fragile X-associated Tremor/Ataxia Syndrome, differential diagnosis, FMR1.

International Journal of Clinical Neurosciences and Mental Health 2018; 5:8
DOI: https://doi.org/10.21035/ijcnmh.2018.5.8

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Case Report

Scurvy in Anorexia Nervosa: a case report - read full article

By: Maria João Peixoto, Patrícia Nunes, Raquel Melo, and Sertório Timóteo

Introduction: Anorexia nervosa (AN) is associated with numerous medical complications and almost every body system can be adversely affected. There may be multiple skin signs, most of them a direct consequence of malnutrition due to starvation. Humans require exogenous vitamin C (ascorbic acid) and they must obtain it from dietary intake through vegetables and fruits. Clinical manifestations occur after vitamin C has been eliminated from the diet for 1-3 months. 
Case Report: This case report illustrates a 21-year-old woman, diagnosed with AN restriction subtype who developed ecchymosis and petechiae on the torso and legs. The diagnosis of scurvy was made based on clinical findings and dietary history, with therapeutic evidence as soon as vitamin C supplementation begins. After two weeks of treatment the cutaneous signs fully disappeared. 
Discussion: In many patients with AN adequate intake of fruits and vegetables is preserved, so the diagnosis of scurvy is counterintuitive. The best confirmation of the diagnosis of scurvy remains a complete clinical recovery following vitamin C supplementation. Although scurvy is regarded as a disease from the past, we should be aware of its existence in developed countries as a complication of AN.

Keywords: Anorexia Nervosa, Scurvy, Ascorbic Acid Deficiency..

International Journal of Clinical Neurosciences and Mental Health 2018; 5:9
DOI: https://doi.org/10.21035/ijcnmh.2018.5.9

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