Orthorexia nervosa (ON) is a recently proposed eating disordered behaviour characterized by an obsessional or exaggerated fixation on healthy eating. The published literature is scarce regarding its classification, clinical presentation, management and long-term outcomes. Herein, we present the clinical and follow-up findings of an 18-year-old woman with ON comorbid with depression, successfully treated with mirtazapine. The patient had a 12-month history of obsessional behaviours for "healthy food", characterized by suppression of sugar and fat from her diet, tightly counted meal calorie content, eating only self-made meals, avoidance of eating in public, unacceptance of other person's opinions on diet, social isolation and a weight loss of 15 kg (body mass index of 16.2 kg/m). A score of 19-points was initially obtained on the ORTO-15 questionnaire, suggesting the presence of orthorexic tendencies and behaviours. The patient also reported a 1-month history of depressed mood, anxiety, anhedonia, fatigue, insomnia with early morning waking, leading to the presumptive diagnosis of ON with comorbid depression. Treatment with mirtazapine for 11 months resulted in the remission of the disordered eating behaviour, a sustained regain of weight, a score of 41-points on the ORTO-15, and to the resolution of depressive symptomatology (including insomnia). To our knowledge, this is the first description of ON with comorbid depression successfully treated with mirtazapine. This case highlights the possible usefulness of mirtazapine as a treatment option for patients with ON. However, randomized controlled studies are warranted to confirm the current findings.

Choking phobia, also known as phagophobia or swallowing phobia is an uncommon clinical entity that has been underappreciated and is included in the new DSM-5 and upcoming ICD-11 diagnostic category of avoidant/restrictive food intake disorder. Phenomenologically distinct from other eating disorders, it is characterized by the phobic stimulus of swallowing that results in the avoidance of food or drinks, and ultimately to low weight, social withdrawal, anxiety and depression states. Its prevalence and long-term course on the general population still needs to be determined, probably reflecting years of indefiniteness regarding its nosology and by the absence of a clear set of diagnostic criteria. We present a clinical case of choking phobia in a 32-year-old male patient after an episode of choke when eating chicken. An early diagnosis and distinction from other eating disorders is important for proper treatment and fundamental for prognosis. We also make a thorough revision on literature in clinical features, differential diagnosis and treatment approaches, suggesting a conceptual approach for choking phobia as a clinical spectrum settled by different degrees of phobic subtypes, which may depend on a varied number of clinical variables.

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Introduction. Cognitive dysfunction as a core feature in the course of bipolar affective disorder (BPD) is a current subject of debate and represents an important source of psychosocial and functional burden. Objectives. To stand out the connection and clinical implications between cognitive dysfunction, dementia, and BPD. Methods. A nonsystematic review of all English language PubMed articles published between 1995 and 2011 using the terms “bipolar disorder,” “cognitive dysfunction,” and “dementia”. Discussion. As a manifestation of an affective trait or stage, both in the acute phases and in remission, the domains affected include attention, executive function, and verbal memory. The likely evolution or overlap with the behavioural symptoms of an organic dementia allows it to be considered as a dementia specific to BPD. This is named by some authors, as BPD type VI, but others consider it a form of frontotemporal dementia. It is still not known if this process is neurodevelopmental or neurodegenerative in nature, or both simultaneously. The assessment should consider the iatrogenic effects of medication, the affective symptoms, and a neurocognitive evaluation. Conclusion. More specific neuropsychological tests and functional imaging studies are needed and will assume an important role in the near future for diagnosis and treatment.

Background. Disulfiram, a drug used in the treatment of alcohol dependence, is an inhibitor of dopamine-β-hydroxylase causing an increase in the concentration of dopamine in the mesolimbic system. In addition to the physical symptoms associated with concomitant use of alcohol, disulfiram may lead to adverse events, when used alone, including psychosis. Aims. To report a case of a rare complication when using disulfiram for alcoholism treatment in a patient in alcoholic abstinence. Case Report. We describe the case of a 42-year-old male patient, who developed psychotic symptoms 3 weeks after initiating treatment with disulfiram for alcohol dependency. The patient had a history of chronic alcoholism for 12 years and was under disulfiram treatment (250 mg/day) for 1 month, with no other past history of psychiatric illness. The symptoms worsened after he initiated alcohol consumption, while taking disulfiram. The patient was hospitalized and disulfiram was suspended. After 4 days he was asymptomatic and at 6-week follow-up remained asymptomatic. Conclusion. Treatment with disulfiram can lead to the appearance of psychosis in patients with increased vulnerability. In clinical practice, psychosis in the context of alcoholism with disulfiram therapy is often neglected and should be taken into account.

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The appearance of palilalia induced by clozapine is a rare pharmacologic side-effect which physicians should be familiarised with when evaluating this symptom presentation.