P.8.a.024 Case-report of acute intermittent porphyria presenting with behavioral disturbances

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for pregabalin 300, 450, 600 mg/d, respectively), with no significant by-region interactions (P=.250). The most common allcause, treatment-emergent AEs were dizziness (pregabalin, 43.0%; placebo, 15.2%) and somnolence (17.2%; 6.0%). Incidence, by region, of most AEs was similar; however, somnolence was reported more frequently in RoW (23.2% pregabalin, 9.3% placebo) than in Europe (11.8%, 3.1%). 103 (18.7%) pregabalin and 12 (6.5%) placebo patients discontinued because of AEs considered related to study medication; among pregabalin-treated patients, dizziness (6.2%), vertigo (2.9%), and somnolence (2.7%) were the most common of these. Conclusions: Patients with FM in Europe and RoW countries shared common demographic and baseline disease characteristics. Treatment with pregabalin was associated with improvements in pain, patient global assessment, and sleep, and the responses were similar across regions. Pregabalin treatment was generally well tolerated. There were some differences between regions in incidence of somnolence as an AE. References [1] Crofford, L.J., et al, 2005, Pregabalin for the treatment of fibromyalgia syndrome: results of a randomized, double-blind, placebo-controlled trial. Arthritis Rheum 52, 1264–1273. [2] Mease, P.J., et al, 2008, A randomized, double-blind, placebocontrolled, phase III trial of pregabalin in the treatment of patients with fibromyalgia. J Rheumatol 35, 502–514. [3] Arnold, L.M., et al, 2007. A 14-week, randomized, double-blind, placebo-controlled, monotherapy trial of Pregabalin (BID) in patients with fibromyalgia syndrome [poster]. Presented at the 26th Annual Scientific Meeting of the American Pain Society, May 2−5, 2007, Washington DC.

P.8.a.023 The effect of milnacipran on tenderness in fibromyalgia: a psychophysical and fMRI analysis R.H. Gracely1 ° , K. Jensen2 , E. Kosek2 , M. Ingvar2 , P. Fransson2 , H. Marcus3 , E. Choy4 , S.C.R. Williams5 , Y. Mainguy6 , 1 University of Michigan, Mechanistic Studies, F. Petzke3 . Ann Arbor Michigan, USA; 2 Karolinska Institute, Department of Neurosciences, Stockholm, Sweden; 3 Klinikum der Universitaet zu K¨oln, Schmerzambulanz, K¨oln, Germany; 4 King’s College Hospital, Academic Department of Rheumatology Clinical Trial Unit, London, United Kingdom; 5 King’s College Hospital, Centre for Neuroimaging, London, United Kingdom; 6 Institut de Recherche Pierre Fabre, Clinical Research, Lab`ege, France Purpose: Milnacipran, a norepinephrine and serotonin reuptake inhibitor, with preference for norepinephrine over serotonin reuptake inhibition has previously demonstrated efficacy in the treatment of the fibromyalgia syndrome (FMS) in the US patient population. FMS is a chronic and debilitating condition, with a real need for a therapy that not only relieves pain but addresses the functional and physical aspects of the illness that can have a significant impact on a patient’s quality of life. FMS is characterized by both widespread pain and tenderness. The link between tenderness and widespread spontaneous pain is not known. Tenderness (i.e., pressure allodynia) is often regarded as an indication of pain amplification in FM and thus pathophysiologically related to spontaneous pain. Alternatively, tenderness could be mediated by different mechanisms that may or may not be related to the perception of spontaneous pain. The present study evaluated the association of tenderness and spontaneous pain in FMS using psychophysical ratings and func-

tional magnetic resonance imaging (fMRI) measures of brain activity before and after treatment with milnacipran. Methods: Ninety-two right-handed female patients with FMS participated in a 13-week, multicenter, double-blind, placebo controlled, randomized trial of 100 mg b.i.d. milnacipran or placebo. After a wash out of all medications, participants rated the intensity of non-painful and painful 2.5s blunt pressure stimuli applied to the left thumbnail. These ratings were used to calculate subjectively equal pain sensations (scored as 50 mm on a visual analogue scale) for each subject that was delivered during fMRI scanning to the same location before and after treatment. Summary of results: Baseline fMRI analysis showed significant pressure-evoked brain activity in regions previously identified in pain studies, including primary (S1),and secondary (S2) somatosensory cortex, insular and cingulate cortex, cerebellum, thalamus, and amygdala. In comparison to placebo milnacipran reduced VAS ratings of painful pressure in all patients (p = 0.055, one-tailed). Milnacipran treatment resulted in significant increases in brain activity in S1, the caudatus nucleus, anterior insula, anterior and posterior cingulum, and amygdala. Placebo treatment increased activity only in a parietal region and in mid insular cortex. These differences did not reach statistical significance in a comparison between the effects of milnacipran and placebo. However, this statistical comparison identified a large region of posterior cingulate/precuneus in which pain-evoked activity was significantly greater after milnacipran in comparison to placebo (p < 0.05). Milnacipran was well tolerated. Conclusions: Milnacipran exerted a normalizing effect in patients with FMS, reducing tenderness and producing patterns of pressure evoked activity that have been observed in healthy control subjects. These effects of milnacipran on tenderness suggest an association between the mechanisms mediating tenderness and the unknown mechanisms mediating pain and related symptoms of FMS. Increased knowledge of these mechanisms may help to improve the development of milnacipran as a treatment for the problematic syndrome of fibromyalgia and related disorders.

P.8.a.024 Case-report of acute intermittent porphyria presenting with behavioral disturbances C.N. Marginean1 ° , B.I. Dragomir1 , F. Moldovan2 , L. Fodoreanu1 . 1 UMF Iuliu Hatieganu, Psihiatrie, Cluj-Napoca, Romania; 2 Spitalul Clinic Judetean, Neurologie II, Cluj-Napoca, Romania Introduction: Acute intermittent porphyria is an autosomal dominant disorder caused by the reduction in the activity of hydroxymethylbilane synthetase – also reffered to before as porphobilinogen deaminase, to half of its potential [1]. Exogenous factors can trigger the disease and precipitate the attacks: certain porphyrinogenic drugs, steroids, infections, and excessive dieting [2]. The enzyme defects can be proven in most of the heterozygous subjects, but the clinical expression of this type of porphyria is very heterogenous: from abdominal pain to neurological symptoms including peripheral neuropathy and psychiatric symptoms like anxiety, depression, insomnia, hallucinations, paranoid delusions, finishing with seizures caused by hyponatremia, autonomic neuropathy symptoms and difuse pain syndrome [3]. Case history: A 28 years-old caucasian male, having a two years younger sister deceased one year ago: encephalo-polyradiculoneuritis with paraplegia, presented during the last year periodic attacks of intense abdominal pain, meteorism, nausea, vomiting, difuse muscle pain, low fever, symptoms that mimic

P.8.a Other topics (clinical) an accute inflammatory abdominal disease. The patient was hospitalized four times in local and regional surgical departments, undergoing three surgical procedures: acute appendicitis, abdominal wall and pericaecal abscess, bowel subocclusion and the laboratory findings demonstrated leucocytosis, mild anaemia, unspecific inflamatory syndrome. The imaging studies, showed important pneumocolon as unique finding. The patient received antibiotics, antiinflammatory and prokinetic drugs. During the last surgical hospitalization he develops episodes of psychomotor agitation, insomnia, behavioral disturbances comprising irritability, low frustration tolerance, inappropriate conduct (throwing himself on the floor, hitting the other patients) in a patient with no history for beahvioral issues, for these reasons he was reffered to a psychiatric service. During the two days of treatment with 400 mg a day of carbamazepine as behavioral regulator, he starts complaining of intense muscle pain, asthenia and presenting severe tetraparesis, urinary incontinence, constipation, tachicardia, high blood pressure, fever (38ºC). The laboratory findings showed hyponatremia (Na = 121mEq/l), uroporphyrine = 1563 mg/24 h, coproporphyrine = 229.4 mg/24 h, PBG ++++. The diagnosis of acute porphyria is confirmed by the clinical and laboratory findings, as well as by the EMG. The patient was transferred to the ICU and intubated. After initiating treatment with hem IV (Human Hemine) the patient’s status significantly improved, detubation was possible within 10 days and the patient was stable both physicaly and mentally. At the present time the patient continues to be stable respecting the restrictions imposed by the diagnosis. Discussion: The peculiarity of this case report consists in the association of acute intermittent porphyria with psychiatric symptoms comprising behavioral disturbances symptoms which initially raised the suspicion regarding a personality disorder – borderline type on axis II, according to DSM IV, not confirmed by the patient’s history, the psychiatric examination and the psychological evaluation made in our service. Conclusion: We presented this case in order to point the importance of a complete differential diagnosis in psychiatry, in a case report which was a challenge for our team. Therefore, we encourage a high index of suspicion for acute intermittent porphyria in psychiatric patients in order to prevent false psychiatric diagnosis. References [1] Anderson, K.E., Bloomer, J.R., Bonkovsky, H.L., et al., 2005, Recommendations for the diagnosis and treatment of the acute porphyrias. Ann Intern Med 142: 430−50. [2] Peters, T.J., Sarkany, R., 2005, Porphyria for the general physician. Clin Med 5, 275:81. [3] Thomas, G., De Longhery, 2006, available on U.R.L.: www.emedicine.com/med/topic 1880.htm; pages 20.

P.8.a.025 Therapeutic contact through Internet. Discussion of the theoretical and technical possibilities of realization therapy J. Przybylo1 ° , K. Krysta1 , A. Kwiatkowska2 , I. KrupkaMatuszczyk2 . 1 Medical University of Silesia, Department of Psychiatry, Katowice, Poland; 2 Medical University of Silesia, Department of Internal Diseases, Bytom, Poland In our paper the problem of theoretical understanding of the problem of therapeutic relationship through internet, as well as technical possibilities given by this medium with the consideration of specificity of particular communication technologies. Therapy

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through the internet may be very useful as there is a growing number of patients using, and even abusing it. The users of Internet, through increasing hours spend on-line go through subsequent phases: from a fascination and relax, through a feeling of reducing discomfort, a need to keep a relationship with other users of the net for keeping the life balance, escape from everyday problems, to a deepening of depression because of neglecting everyday problems. Studies show that internet overuse is a reason for family conflicts, due to long term stay on-line young people have problems in learning, work and family duties, on-line stay above 5 hours a day may be followed by increased risk of addiction. Prolonged internet use influences reduction of contacts with real friends. Because of a long time spent in the Internet, young people neglect their responsibilities concerning school, work and family life. The above data show that there are many negative results of abusing the internet. It is then a very interesting idea to use internet in a positive, therapeutic way. This offer may especially be addressed to patients, who have a grater experience of internet use, who perhaps already had efforts to find a solution of their problems in the global net. Following the above analysis of these phenomena the authors made an attempt to find solutions to use electronic media for a therapeutic purpose. The reason for dealing with this issue was a number of technical possibilities existing within the internet, spreading of new forms of contacts and subcultures, a growing supply of therapies using internet und lack of ethical-theoretical clarity. Authors present different forms of understanding of the therapeutic contact existing in the literature, models of this contact and theoretical descriptions of therapeutic relationship. Authors described different lines of characteristics of the electronic contact enumerating 6 of these lines: off-line, on-line, anonymous-open, local-unlimited, with and without open go-between, text-paratext, multimedial, elusivefirm. Analyzed were technologies of electronic contact with the inclusion of the described division, like: SMS, MMS, e-mail, IRC, chat, discussion forums, Usenet, IM-communicators. In the presented paper authors analyze also reasons of a lack of publications regarding the importance of physical therapistpatient contact, they also ask questions concerning the definition and identification of the patient in the internet contact. They also wonder what predispositions must have the therapist in order to effectively work in this type of contact. In the second part of the paper presented were results of a longterm therapy of 2 patients who had a contact with the therapist only with the use of above methods.

P.8.a.026 Pharmacokinetics of (S)-zopiclone and (S)-desmethylzopiclone following dosing with zopiclone and eszopiclone N. Brunello1 ° , P. Bettica2 , D. Amato3 , G. Maier4 , D. Nutt5 . 1 University of Modena, Department of Biomedical Sciences, Modena, Italy; 2 GlaxoSmithKline, GlaxoSmithKline, Verona, Italy; 3 Sepracor Inc., Biostatistics, Marlborough, USA; 4 Sepracor Inc., Clinical Pharmacology, Marlborough, USA; 5 University of Bristol, Psychopharmacology Unit, Bristol, United Kingdom Introduction: In examining the pharmacokinetic profile of a hypnotic drug, the time taken to reach peak concentration (Tmax ) and the half life (t1/ 2 ) are important determinants of the clinical profile. The Tmax affects the time to onset of action and, therefore, sleep onset latency, while the t1/ 2 determines the duration of activity and