Iranian Journal of Psychiatry and Behavioral Sciences
Volume:11 Issue: 3, Sep 2017

Context: Several studies have controversial results regarding the association between Borna disease virus (BDV) and chronic fatigue syndrome (CFS). The present systematic review and meta-analysis investigated the association between CFS and BDV.
Evidence Acquisition: The present study was conducted based on the PRISMA guidelines for systematic review and meta-analysis studies. To avoid bias, all procedures of the study were performed by two researchers independently. A comprehensive search was performed using online databases, including PubMed, Scopus, Embase, PsycINFO, science Direct, Cochrane Library, web of science, and Google scholar using the MeSH keywords until December 12th, 2016. Heterogeneity among studies was evaluated using Cochran's Q test I2 Index. Finally, the random effect model was used for combined Odds Ratio (OR) using Review Manger software version 5.3.5.
Among 9 eligible studies comprising 610 cases and 2176 controls, the total OR for association between BDV and CFS was estimated to be 10.41 (95% confidence interval [CI]: 4.24 - 25.55, P This study supports the association between BDV and CFS and shows the role of viral agents in etiology of CFS. Therefore, viral agents may play a role in the etiology of neuropsychiatric disorders.

Context: Coronary heart disease (CHD) is the most common cause of death and disability in the world. While the relationship between depression and CHD is well documented, anxiety remains understudied, despite its common cooccurrence.
Evidence Acquisition: A PubMed (MEDLINE) search was conducted in order to find articles published between January 2000 and December 2015, using the following keywords: “coronary heart disease” and “anxiety”. In total, 79 out of 1138 articles were considered relevant by consensus between the authors and were reviewed.
According to previous studies, anxiety is suggested to increase the risk of CHD. Anxiety is associated with an increase in cardiac complications, morbidity and mortality. Also, a lower quality of life has been described among patients after acute coronary syndrome, with a few studies reporting contradictory findings. Although studies on anxiety management in CHD are sparse, selective serotonin reuptake inhibitors have been shown to be relatively safe for patients. On the other hand, psychological interventions have not been adequately evaluated, although some studies have revealed their advantages.
Evidence suggests that anxiety is associated with the development and course of CHD. Awareness and appropriate training in cardiology settings need to be prioritized to improve early identification and initiation of effective management.

Nowadays, outcome prediction models using logistic regression (LR) and artificial neural network (ANN) analysis have been developed in many areas of healthcare research.
In this study, we have compared the performance of multivariable LR and ANN models, in prediction of psychological symptoms six months after mild traumatic brain injury.
In a prospective cohort study, information of 100 mild traumatic brain injury patients, during a six months period between 2014 and 2016 were included. Data were divided into two training (n = 50) and testing (n = 50) groups, randomly. 300 ANNs and LRs were studied in the first group and then the predicted values were compared in the second group using the two final models. The receiver operating characteristic (ROC) curve and accuracy rate were used to compare these models.
The results showed that accuracy rate for the neural network model was 90.65%, while it was 75.96% for the LR model.
The ANN models appeared to be more powerful in predicting psychological symptoms versus the LR models.

Despite the widespread studies demonstrating the role of emotion regulation in social anxiety and distress symptoms, its mechanism and its relation to more biological basis like motivation is not well known.
Based on emotion dysregulation model, the present study aimed to assess mediation role of emotion regulation strategies on the relationship between, emotional intensity, safety and reward motivations with social anxiety symptoms, rumination and worry.
Using Quota sampling, 524 participants were recruited from community sample and filled in questionnaires. Data were analyzed using structural equation modeling.
The results of SEM supported the mediating role of emotion regulation strategies (attentional control, decentering, awareness, reappraisal, and non-acceptance) in the relationship between motivation (reward and punishment) and emotion dysregulation symptoms (social anxiety symptoms, worry, and rumination). Model examination indicated the good fitness of the proposed theoretical model especially after omitting emotion intensity, as χ2=61.94, df=26, χ2/df=2.38, P These findings emphasize the possible important role of emotion regulation strategies and temperamental traits like motivation in the etiology of social anxiety disorder and their correlate distress symptoms.

Therapeutic community program (TCP) is available for opioid users in Iran (Persia), the most populous Persian Gulf country. TCP can reduce opioid use and some associated harms. However, there are few studies about TCP in Iran.
The current qualitative study aimed to explore the self-perceived positive and negative aspects of TCP among a group of Persian opioid users in Tehran.
The study was conducted at a large men-only TC center between December 2010 and July 2011. Overall, 50 opioid users were interviewed in eight roundtable meetings. Nine key informants were individually interviewed. NVivo 10 was used to thematically analyze the data.
The mean age of the participants was 38 (SD = 9) years. Participants were dependent on opioids. The thematic data analyses indicated that peer support, group meetings, and the lack of medications were the most frequently self-perceived positive aspects of TCP. Untreated withdrawal symptoms, long duration of residence, anxiety, and depression were the most frequently reported negative aspects of TCP.
The identified positive treatment aspects should be considered to improve the TCP quality. The identified negative treatment aspects should be managed in the provision of TCP.

The acceptance and commitment therapy (ACT) is a novel method for resolving interpersonal problems.
This study aimed at determining the effectiveness of ACT on interpersonal problems and difficulties in emotion regulation among female students with interpersonal problems.
In this randomized clinical trial, the study population consisted of 70 female students, who were selected via purposive sampling from Azad University of Gorgan, Iran. The study population was randomly categorized to intervention (ACT group) and control groups. The intervention group consisted of ten 90-minute ACT sessions, held by a trained clinical psychologist, according to a study by Mckay, Lev and Skeen (2012). The data collection tools included two short-form questionnaires, including the inventory of interpersonal problems (IIP-32) and difficulties in emotion regulation scale (DERS). Pre-test and post-test scores were analyzed, using covariance methods.
Generally, the findings showed a significant difference in the post-test scores between the control and ACT groups following the intervention.
Based on the findings, acceptance and commitment therapy (ACT) can be effective in improvement of interpersonal problems and emotional dysregulation.

People with epilepsy (PWE) are at risk of domestic violence; either towards others or being the victim.
This study surveyed the prevalence of violence problems in people with epilepsy (PWE) and the characteristics of violence and possible health outcomes.
There were 350 PWE treated at Khon Kaen University, Srinagarind Hospital’s epilepsy clinic who were enrolled. Data were collected from January 2013 to July 2013 by self questionnaires from 350 persons providing epilepsy reliability by Cronbach’s alpha at 0.86.
There were 206 females (59.7%) and 141 males (40.3%) with the mean age of 37.1 years (range 18 to 85 years). The prevalence of violence towards others was 51.4% (180 patients), and being the victim of violence was 40.0% (140 patients). There was a significant correlation between being the recipient of violence and being the perpetrator (r = 0.58, P The prevalence of domestic violence in PWE is high and has negative consequences on the individual, family, and community.

Cosmetic surgery became increasingly popular in recent years. In some cases, cosmetic surgery caused some complications and did not create a durable improvement of quality of life.
The current study aimed at determining the predictive factors for cosmetic surgery in Iranian females.
The current case-control study was conducted on 98 females admitted to the plastic surgery clinics (the case group) and 102 females admitted to other clinics as the control group. The simple random sampling method was used. The inclusion criteria were no obvious physical defects and known mental disorders. Duplicates and the ones not interested to cooperate with the study were excluded. Study data were collected using demographic, the multidimensional scale of perceived social support (MSPSS), and the Cohen perceived stress scale (PSS). The Chi-square test was used to assess the categorical variable. The logistic regression model was applied to measure odds ratio.
The relationship between educational level as well as occupation, and cosmetic surgery were statistically significant. The social support from friends and others was significantly associated with tendency toward cosmetic surgery. While family support and perceived stress showed no differences between the females with and the ones without cosmetic surgery. The logistic regression analysis showed that higher education level, being a housewife, and external supports had a significant relationship with cosmetic surgery.
Factors including higher education level, being a housewife, and external supports were the important factors affecting the tendency toward cosmetic surgery among females in Ilam, Iran. Identifying the risk factors of unnecessary cosmetic surgery is needed in every society, to plan counseling programs and reduce unnecessary surgeries.

Loneliness is commonly experienced during adolescence and has been associated with negative health outcomes.
The present study aimed at assessing the factors associated with loneliness and investigating the relationship between loneliness and health risk behaviors among adolescents in the association of southeast asian nations (ASEAN).
This cross-sectional study included 30 284 schoolgoing adolescents (aged 13 - 15 years, mean age = 14.1 years, SD = 0.8) from 7 ASEAN countries, who took part in the global school-based student health survey (GSHS) between 2007 and 2013. The measure inquired about loneliness, health risk behaviours, and protective factors.
Across the 7 ASEAN countries, 7.8% of the adolescents reported mostly or always being lonely and 31.3% reported sometimes being lonely in the past 12 months. In multivariable logistic regression, female gender, older age, living in a low or lower income country, not having close friends, bullying victimization, and lack of parental or guardian support were associated with mostly or always feeling lonely in the past 12 months. After adjusting for sociodemographic and social supportive factors, it was found that loneliness was associated with poor mental health, substance use, aggression, and other health risk behaviours.
A significant proportion of adolescents were experiencing loneliness, which was found to be associated with various health risk behaviours. Thus, it is important to recognize lonely adolescents early in to prevent more serious poor mental health and other health risk behaviours.

The prevalence of undernourishment or hunger is 9.6% in the association of southeast asian nations (ASEAN).
The purpose of this study was to examine the prevalence of hunger and its psychobehavioural correlates among adolescents in ASEAN member countries, including Cambodia, Indonesia, Malaysia, Myanmar, Thailand, Philippines, and Vietnam.
The analysis was based on a cross sectional survey of 30 197 school-aged children (13 - 15 years) from 7 ASEAN countries participating in the global school-based student health survey (GSHS) during 2007 - 2013.
Regarding the overall prevalence of hunger, 56.9% of the subjects experienced hunger over the past month (rarely to always), while 4.2% were hungry most of the time or always (high hunger status). The prevalence of high hunger status ranged from 0.9% in Vietnam to 7.9% in Cambodia. In the adjusted multivariate logistic regression analysis, increased frequency of hunger in the past month was associated with psychological distress (loneliness, OR: 2.96, CI: 2.16 - 4.04; suicidal ideation, OR: 1.51, CI: 1.13 - 2.03; anxiety, OR: 3.42, CI: 2.54 - 4.62), substance use (tobacco use, OR: 1.90, CI: 1.34 - 2.41; alcohol use, OR: 1.76, CI: 1.32 - 2.35), behavioural problems (truancy, OR: 2.54, CI: 1.94 - 3.32; bully victimization, OR: 2.31, CI: 1.77 - 3.01; involvement in physical fights, OR: 2.57, CI: 1.97 - 3.35), and serious injury in the past year (OR: 2.61, CI: 2.00 - 3.41).
In order to improve psychobehavioural health among adolescents in ASEAN member countries, the possible contribution of hunger or food insecurity should be taken into account.

Various cognitive dysfunctions are reported in children and adolescents with bipolar disorder (BD) in manic, depressed, and euthymic phases. Among these deficits, the findings related to visual memory are more inconsistent.
Given the limitations and inconsistencies, we aimed to compare visual memory in the euthymic phase of BD with a typically developing group.
Thirty 11 to 18 year old inpatients with bipolar manic episode were compared with 30 normal youths regarding their visual memory. The Kiddie schedule for affective disorders and Schizophrenia-Present and lifetime were used to confirm the diagnosis and comorbidities. Conners Parent Rating Scale (CPRS), Young Mania Rating Scale (YMRS), Children Depression Inventory (CDI), and Raven’s Progressive Matrices (RPM) were conducted to evaluate attention-deficit hyperactivity, manic, depressed symptoms, and IQ respectively. Paired Associates Learning (PAL) and Pattern Recognition Memory (PRM) taken from the Cambridge Neuropsychological Test Automated Battery (CANTAB) were used to assess visual memory for both groups. Adolescents with BD performed these tasks when entered the euthymic phase of the disorder.
The 2 groups did not have any differences in their age, gender, and IQ. Most PAL and PRM scores were poorer (nonsignificant) in the BD group compared with the TD participants. The PRM mean correct latency score was higher in the BD individuals with ADHD compared with both the non-ADHD and the Typically Developing (TD) adolescents (P = 0.01 and P = 0.02, respectively).
Youths with euthymic phase of BD suffer from some visual memory problems. These deficits may be related to comorbid attention deficit hyperactivity disorder.

Migraine is one of the main reasons for primary and secondary headaches worldwide and has significant effects on patients’ life. Based on recent studies, psychological factors may affect the severity, frequency, and the duration of migraine attacks.
The aim of this study was to investigate the relationship between defensive style and early maladaptive schemas in the patients with migraine headaches.
The sample size consisted of 75 (male and female) patients which was based on Cochran’s formula. Among the clients who referred to neurology clinics, patients with migraine headaches were selected by convenience sampling, they completed defensive styles questionnaire (DSQ-40), Young’s early maladaptive schemas (YSQ-SF), and Ahvaz migraine questionnaire (AMQ). Statistical analyses were conducted by correlation coefficient and stepwise regression.
The results showed that there was a positive and significant relationship between immature defense style with the components including abandonment, mistrust, social isolation, emotional inhibition, defectiveness, failure, vulnerability, obedience, entitlement, insufficient self-control, enmeshment, and dependent and unrelenting standards. In addition, there was a negative and significant relationship between mature defensive style with the components namely social isolation and defectiveness. Neurotic defensive style was not compatible with any of the component schemas.
The results obtained from the current research indicate that early maladaptive schemas can act as the foundation of emotional and behavioral tendencies and defensive styles in the patients with migraine headaches.

Executive dysfunction has been proposed as a fundamental impairment in children with autism spectrum disorder (ASD), however, existing findings are inconsistent.
The present study aimed at evaluating the behavioral profile for executive functions (EF) in adolescents compared to healthy individuals using the Farsi translation of the behavior rating inventory of executive function (BRIEF).
In this study, 34 participants (aged 5-16) with ASD were compared to 36 age and gender matched typically developing (TD) children using the BRIEF and childhood autism rating scale (CARS), and raven progressive matrices (RPM).
All subscales of the BRIEF were significantly higher in children and adolescents with ASD. Working memory was impaired in 88% of the ASD group, and the inhibition subscale had the highest mean score. The visual response subscale of CARS correlated significantly with the metacognition index (MCI) and global executive composite (GEC) of the BRIEF. A slight negative significant correlation was found between the BRIEF planning/organization T- score and age in the group with ASD.
Adolescents with ASD have difficulties in every day executive functioning, mostly in working memory and inhibition. These deficits are related to some aspects of social and sensory impairments seen in ASD.

Coronary heart disease leads to negative consequences, diminished health-related quality of life, and increased mortality.
This study aimed at predicting the quality of life of patients with coronary heart disease based on defense mechanisms and alexithymia with the mediating role of psychological distress.
In a cross-sectional descriptive study, 300 patients with coronary heart disease, who had referred to the specialized heart center of Ayatollah Madani governmental hospital in Khorramabad city of Lorestan were selected by the convenience sampling method from February to July 2015. Depression, anxiety, and stress scales, the mac-new health-related quality of life questionnaire for patients with heart disease, the Toronto alexithymia scale, the defensive styles scale and a demographical checklist were used for data collection. Descriptive indices were analyzed by SPSS-19 and structural equation model with AMOS was used for analysis of the inferential statistics.
According to the structural equation model, the path coefficient related to the effect of defense mechanisms on alexithymia (β = 0.65), alexithymia on the quality of life (β = -0.26), alexithymia on psychological distress (β = 0.51), and psychological distress on the quality of life (β = -0.58) were statistically significant (P 0.05).
Defense mechanisms and alexithymia had a significant role in predicting the quality of life of patients with coronary heart disease. It is recommended that clinical specialists should design appropriate clinical trials or modify the current and future interventions on the basis of the results of such studies.

Executive function of the brain consists of organizing, shifting attention, monitoring, self-regulating, inhibition and working memory, which are diversely affected in attention deficit/ hyperactivity disorder (ADHD). Parent management training (PMT) is a major intervention for ADHD with significant impact on clinical symptoms. However, little is known about its effect on cognitive aspects of ADHD.
The aim of this study was to assess the effects of parent management training (PMT) on attention, response prevention, impulsivity, and vigilance of males with ADHD as well as their clinical symptoms.
In this clinical trial, 32 subjects were recruited from a child and adolescent psychiatric clinic in Tabriz, Iran. Participants (all males) were divided to 2 groups. One group received routine clinical care plus 8 sessions of PMT and the other group only received routine clinical care as a control group. Clinical symptoms were evaluated by Conner’s rating scale and performance of children in terms of executive function was tested by the continuous performance test (CPT) and Go/ no Go test before and after the intervention. A follow-up measurement was performed at week 12. Using SPSS 17.0 statistics, chi-square and independent-sample t tests were used to compare sample means. A two-way repeated measures analysis of variance (time-treatment interaction) was also performed.
Parent management training had a higher effect on hyperactivity (P = 0.032) and oppositional (P = 0.007) symptoms of children. Commission errors (reflecting impulsivity and response prevention), omission errors (reflecting inattention), and reaction time (reflecting vigilance) in Go/no Go test were not significantly different between the 2 groups. Omission errors in CPT and the reaction time significantly improved in PMT and routine clinical care (RCC) group (P = 0.032).
Parent management training may improve executive functions in children with ADHD in terms of reaction time and omission errors.

Rheumatoid arthritis (RA) is a systemic and immunologic disorder, which is characterized with feet, wrist and knee inflammatory destruction and morning stiffness. It mainly results in joint deformity and reduced ability, which can propagate into low quality of life (QOL). Recently, QOL has been demonstrated as one of the most important factors in male’s life and studies have showed the negative effect of physical and emotional stress on QOL.
This study aimed at evaluating the effect of stress management on QOL in females with RA referring to Baqiyatallah hospital during years 2012 to 2013.
Fifty female patients with RA that had referred to Baqiyatallah hospital between March 2012 and March 2013 were evaluated in 2 equal groups, matched by age. The patients were enrolled conveniently. The intervention group members were trained with a 10-session stress management program and the control group did not undergo any intervention. The world health organization quality of life (WHOQOL-BREF) questionnaire was filled-out by both groups (α = 0.641) and the results were compared by suitable statistical tests.
Significant difference was observed in QOL between the intervention and control groups (effect size of ɛ2 = 0.845). No significant difference was seen in mean QOL results in early post-test and late follow-up test; however, a significant difference was seen between post-test and pre-test in the intervention groups (P This study demonstrated that stress management could benefit QOL in RA patients. The results suggest that the stress management package can be beneficial in these patients along with other medications.

Burn damages are important causes of mortality and morbidity. They are also associated with many physical, psychological, social, and economic consequences.
The present study was conducted to assess the effect of guided imagery on reducing anxiety and pain due to dressing change in burn patients.
The statistical population of this clinical trial included all burn patients (grade 1 and 2 but not self-immolation) who admitted to the burn department of Imam Reza hospital in Mashhad (the second largest city in Iran) between September 2012 and March 2013. 40 patients selected non-randomly through convenience sampling method were divided randomly into two equal groups of intervention and control. The intervention group received guided imagery treatment (15 minutes per day for 8 days) in addition to the routine care, while the control group only received the routine care. Data were gathered through a demographic form, Beck anxiety inventory, and McGill pain inventory. The data were analyzed by descriptive statistics such as frequency, mean, and standard deviation and inferential statistics such as independent t-test in SPSS software.
The comparison of anxiety and pain between the two groups in pre-test showed no significant differences (P = 0.310 and P = 0.120, respectively). However, there were significant differences in the scores of anxiety and pain between the groups in post-test (P = 0.001 and P = 0.001, respectively).
It seems that guided imagery can reduce the level of anxiety and pain due to dressing change in burn patients.

Mental illness stigma has undesirable consequences for patients with psychiatric disorders.
The current study aimed at understanding the lived experiences of patients with psychiatric disorders on the consequences of stigma.
Hermeneutic phenomenology was conducted on 12 patients. They were selected from psychiatric hospital clinics in Mashhad.
Black shadow of stigma is one of the main themes in the present work. It consists of seven subthemes including taking refuge in secrecy, academic deadlock, marriage bumps, glass fence of job, the bitter taste of death, cocoon of loneliness, and the narrow circle of friends.
These results call for actions to tackle the stigma in mentally ill people in Iran. The results of this study can help develop interventions and policies to prevent the stigma against people with mental disorders.

Forgiveness is associated with many psychological and personality factors such as severe and clinical personality patterns.
The aim of this study was to determine the role of severe and clinical personality patterns in prediction of forgiveness in a sample of university students.
A cross-sectional study was conducted on 375 students (175 female, 200 male) from university of Mohaghegh Ardabili in 2012-2013. The subjects were asked to fill out Millon clinical multiaxial inventory-III and interpersonal forgiveness inventory. The data were analyzed by SPSS version 22 using Pearson correlation coefficient and stepwise multiple regression analysis at 95% significance level.
The results showed that schizoid (r = -0.28), avoidant (r = -0.38), depressive (r = -0.38), dependent (r = -0.37), negativistic (r = -0.44), masochistic (r = -0.52), schizotypal (r = -0.43), borderline (r = -0.41), and paranoid (r = -0.55) personality patterns were negatively associated with forgiveness. The results of stepwise multiple regression analysis showed that paranoid and borderline personality patterns among severe personality patterns, and masochistic, antisocial, narcissistic, and negativistic personality patterns among clinical personality patterns were significant predictors of forgiveness (P The findings of the present study identified individuals’ ability and capacity in relation to forgiveness; accordingly, it gave a realistic vision for experts and consultants in resolving interpersonal conflicts and therefore, developed the existing knowledge in the area of forgiveness.

Some studies show that a low level of emotional intelligence (EI) is associated with self-destructive behaviors such as deviant behavior or smoking.
The current study aimed at determining the effects of EI on the illicit drug use potential among nurses.
The current quasi-experimental study was conducted in 2015 on 70 hospital nurses. Samples were randomly selected and divided into 2 groups (35 nurses in each group). Then, the experimental group subjects attended EI training sessions.
Illicit drug use potential in the experimental group had significant negative changes in comparison with that of the control group (P Given the importance of EI to help nurses to avoid risky behaviors, holding training sessions on EI for nurses and nursing students appears necessary.

Anxiety during pregnancy is one of the major women’s health concerns all over the world. Marital satisfaction is a common factor affecting women’s anxiety.
The aim of this study was to investigate the association between marital satisfaction and anxiety in women during pregnancy.
In this cross-sectional study, 147 nulliparous women in the second trimester of pregnancy were selected using a single stage cluster sampling from Sari city, Iran, between March and July 2015. Data were collected using the demographic checklist, Spielberger anxiety inventory and enrich marital satisfaction questionnaire. Data were analyzed using descriptive and inferential statistics (ANOVA, t-test, Pearson coefficient correlation and liner regression) by the SPSS v.18 software. The P value less than 0.05 was considered as statistically significant.
The mean scores of state anxiety, trait anxiety and marital satisfaction of the participants were 39.01±8.71, 39.12±8.42, and 176.61±27.38, respectively. According to the results of regression analysis, marital satisfaction could predict 21% and 17% of variations of state anxiety and trait anxiety of the pregnant women, respectively (P The assessment of marital satisfaction should be considered during the evaluation of pregnant mothers who suffer from anxiety and vice versa. When marital dissatisfaction exists, the psychological assessment of maternal status is recommended.

Quetiapine is an effective and well-tolerated atypical dibenzothiazepine antipsychotic with higher affinity for 5-hydroxytryptophan than D2 dopamine receptors. It is a generally well-tolerated drug, yet, is remotely associated with urinary incontinence. Urinary incontinence is an embarrassing and distressing side effect of antipsychotic drugs. This paper reports on 2 patients with bipolar disorder, who developed urinary incontinence after treatment with quetiapine, and suggests dose reduction as the proper method for addressing this side effect. Nocturnal enuresis should be enquired through direct yet sensitive questions. The inevitable corollary is that patients treated with quetiapine should be properly monitored for nocturnal enuresis. A proper response to this side effect does not necessarily cease the antipsychotic medication.

Sturge-Weber Syndrome (SWS) is a rare neurocutaneous syndrome that is manifested by overt neurological and covert psychiatric features. Although the syndrome is known to be neurocutaneous, multiple organs and systems are involved.
A 45-year-old male, with type I SWS was admitted to the psychiatric ward with manic-like symptoms. The case had a history of repeated psychiatric admissions due to seizures, mood and behavioral disorders. Upon admission, he had elevated mood, talkativeness, increased libido along with ictal aggression with psychic aura. The symptoms remitted with anticonvulsants. Other required diagnostic and treatment workups were also conducted.
A holistic approach should be adopted to manage these patients. Left brain involvement, the associated stigma, seizure disorder, adverse effects of antiepileptic medications along with coping with a chronic condition might have been the underlying mechanisms for mood and behavioral changes in this patient.

Delirium, also known as acute Confusional state, is a common presentation in geriatrics. It is characterized by an acute and a fluctuating disturbance of consciousness, and a deficit in cognitive functions. Delirium that occurs in demented people is referred to as delirium superimposed on dementia.
The patient presented here was a challenging case of an elderly female with 86 years of age that was diagnosed with delirium superimposed on dementia (DSD). The patient developed DSD in parallel with venous thrombosis (VT) affecting her right leg. Venous thrombosis was initially superficial, affecting the great saphenous vein (GSV), which later progressed to deep venous thrombosis (DVT). The therapeutic approach for this patient was literally a dilemma, and a distressing situation to the patient, medical and paramedical staff, and the caregivers. The patient refused feeding, and had refractory insomnia. Additionally, the patient became frequently hyperactive throughout the day in association with frequent delirium attacks. The hyperactivity was difficult to control, despite her leg condition (DVT) that required cautious immobilization to prevent the catastrophe of a superimposed episode(s) of thromboembolic phenomenon. Luckily, a pulmonary thromboembolism never happened.
The patient resisted, and sometimes completely rejected diagnostic or therapeutic intervention, and medical consultations. A multidisciplinary approach was mandatory, and the DSD was eventually successfully well-managed, with an adjusted dose of haloperidol, a high potency first generation antipsychotic drug. Subsequently, her medical and surgical complications were also successfully managed. Finally, the patient was discharged from the hospital, and later scheduled, for a reconstructive surgery, using autologous mesh skin grafting under regional anesthesia, to cure her refractory venous leg ulcer. The venous ulcer occurred as a complication for the venous thrombosis.