Symposium Oral Presentations

Objective: It has been proposed that anything does not kill you make you stronger. Although it might be true in adult cases, children whose psychological life begin in the parental mind and shaped by the experiences during the early period of life are not as strong as adult against adverse effects of stressful events. Internalization of objects and emerging of internally working models, concept of normality and abnormality that will be the main ground for the understanding of the world in later life are emerged during childhood. That is why anything does not kill a child will shape its mind that might have everlasting effects on child.

genomic variants have been associated with ADHD risk. These variants include common DNA sequence variantssingle nucleotide polymorphisms (SNPs). Although many studies have been conducted, there is no precise single-nucleotide polymorphism mainly associated with ADHD, rather a composite risk based upon these nucleotide polymorphisms could be discussed. Whole-genome investigations represent specific single dopaminergic, serotonergic, and noradrenergic candidate genes. Each of these genes was assumed to be associated with ADHD. However, according to current knowledge, variants in single genes associated with ADHD should be investigated with caution as some of these variants reveal false-positive results. Various nutritional factors, toxins, dietary factors, and exposures to stressful life events in childhood and poor attachment with parents, are also blamed for the development of ADHD. Low birthweight and maternal smoking during pregnancy are the two major prenatal factors in pathogenesis of ADHD. In utero exposure to maternal stress, cigarette smoking, alcohol, prescribed drugs (e.g. paracetamol), and illicit substances are also other factors. Environmental toxins, especially in utero exposure to lead, organophosphate pesticides, and polychlorinated biphenyls, are other factors for ADHD. Nutritional deficiencies (e.g. zinc, magnesium, and polyunsaturated fatty acids) could not be shown systematically to cause ADHD evidence based. Sugars and artificial food additives and food colourings were also blamed and discussed further Feingold Diet with restriction of sugar and artificial additives and food colourings yielded negative results. Psychosocial risk factors, low socioeconomic status, and parental conflict have been found not casual rather correlated with ADHD. Studies regarding mother-child relation and attachment showed that the problems regarding child and parent relation is not a cause rather a result of ADHD. Whereas early parental and social deprivation have been shown for a causal relationship with ADHD. Animal studies also interestingly showed that some environmental factors could interact with genetic material and even change the genetics through methylation of DNA-epigenetic factors. These show that there is complex and intricate environmental and genetic factors which interact each other at each level.
References [1]  Autism Spectrum Disorder (ASD) is an early onset neurodevelopmental disorder marked by impairments in reciprocal social interaction and communication, and the presence of repetitive or restricted interests and behaviours. ASD had great phenotypic heterogeneity and aetiologic diversity. This presentation focuses on understanding the proposed aetiologies in ASD by reviewing the conceptual background and highlighting some recent advances. Autism is thought as the most heritable disorder in psychiatric diseases. Genetic studies have revealed that the risk to siblings of children with autism is approximately 3-6%, which is about 50-100 times greater than the risk appearing in the population at large. Although twin studies support a strong genetic contribution to the aetiology of ASD, the estimates of heritability varieties such as susceptibility genes. GWAS studies found that rare genetic variants are more likely to cause most cases of ASD than common variants. Rare single gene disorders such as fragile X, tuberous sclerosis, neurofibromatosis, and certain chromosomal abnormalities are important examples of rare genetic variants associated with ASD. Copy number variants (CNVs) are another important example of genetic variants. Although each CNV was <1% in ASD, cumulatively it may account for 15-20% of ASD. A large number of ASD-linked genes are also associated with broad processes such as metabolism, chromatin remodelling, mRNA regulation, protein synthesis, and synaptic function. Moreover, ASD-related brain pathologies indicate that abnormal acceleration of brain growth in early childhood accompanied by impaired neuron morphological development and brain cytoarchitecture are common features in ASDs. Impairments in synapse formation and synaptic plasticity ultimately lead to functional and cognitive impairments in ASD. In addition to the genetic component, impairment of the neurotransmitter system (serotonin, GABA, glutamate, dopamine, etc.) was also suggested in the underlying mechanism of ASD. Oxytocin also plays a key role in social reward systems and might modulate the dopamine reward pathway during social interaction. Dysfunction in brain systems subserving social perception was focused on autism research. The social motivation hypothesis builds upon this framework and suggests that reduced social drive leads to inattention to people and consequent failure of developmental specialization in experience-expectant brain systems, such as the face perception system. Interconnectivity theories of ASD, in contrast to social information processing theories, have been put forward as an alternative account for the clinical impairments observed in ASD. Complex and distributed information processing is impaired in ASD due to poor long-range connectivity, while simple, low-information processing demands are intact. Several studies have demonstrated atypical patterns of connective tissue in ASD via direct imaging of white matter tracts connecting different brain regions. Despite inconsistent trends across studies, including underconnectivity, overconnectivity, and typical patterns of connectivity, there is a debate on the role connectivity plays in ASD. Heterogeneity in brain function and the behavioural phenotype in ASD is the rule rather than the exception. Integrated research approach will extend the strengths of each investigative method to enable profiling of function across levels and at individual stages of processing to inform the development of specific treatment modalities.
considering possible negative consequences are widely accepted components of addiction. Yet current treatment strategies are only partially effective. Therefore, there is a grave need to better understand the neurobiology and pathophysiology of addiction in order to take the first step of finding more effective treatments [1]. Various brain pathways were demonstrated to be involved in addictive pathologies. Midbrain structures, particularly dopaminergic signals from ventral tegmental area and nucleus accumbens, are the key elements of reward pathways, which control a person's responses to environmental and internal reward-related stimuli [2]. Alcohol and drugs activate these circuits, much stronger and more persistent than natural stimuli, which in turn decreases the person's ability to activate it with natural stimuli and causes loss of motivation and hedonic experiences. Other structures associated with these pathways include hippocampus, hypothalamus, amygdala, and prefrontal cortex [3]. This talk aims to provide an overview of neurobiology of addiction and how it affects memory, motivation, hedonics, and decision-making processes.
[ The neurobiology of cognitive behavioural therapy in addiction therapy

Kinyas Tekin
Moodist Hospital, Istanbul, Turkey E-mail address: kinyastekin@gmail.com ABSTRACT Addiction is a chronic, relapsing disorder in which individuals typically cycle between periods of sustained, compulsive drug use, and abstinent periods of varying durations. Therefore, addiction is appropriately considered a neurobehavioural disorder of maladaptive learning that results from chronic drug use. In recent years, interdisciplinary research in the field of neuroscience has expanded our knowledge about neurobiological correlates of mental processes and changes occurring in the brain due to therapeutic interventions. It is accepted that cognitive and behaviour theories are important approaches in psychological treatment of addiction. Cognitive behaviour therapy stressed that addition can be changed and learned behaviour. The goal of cognitive approach is to change maladaptive thinking and addicted individuals' behaviours. Commonly, this approach is an essential treatment for relapse prevention and motivation. Cognitive-behavioural therapies (CBT) which are short-term, collaborative, problem focused on therapeutic methods aimed at reducing symptoms and improving the quality of life of people. CBT has been refined, elaborated, and evaluated in numerous empirical studies. CBT has brought key mechanisms of addiction into much sharper focus. This has allowed for the development of more precise therapeutic interventions that target aspects of the dynamic interaction between person, situation, and appetitive impulse. Cognitive-behavioural therapies combine two different theoretical and therapeutic approaches resulting from two different paradigms of human nature and psychopathology. First one is the behavioural paradigm which is based on the learning theory and models of experimental psychology. Its basic idea is that every behaviour, either adaptive or maladaptive, has been learned. The other one is the cognitive paradigm which claims that mental disorders arise from altered cognitive processes. The goal of cognitive behaviour therapy is to prevent the consumption of detrimental substance for patients and to provide them with new life abilities. CBT contributes clients to gain self-sufficiency and helps decrease their life stress. Thus, the goal of CBT is a curial method for decreasing occurring addiction problem and preventing relapse in their future life. The neuroscientific investigations of basic CBT hypotheses have shown that (i) functional and non-functional behaviours and experiences may be learned through lifelong learning due to brain KEYWORDS Brain; therapy; cognitive behaviour therapy; neurobiology of psychotherapy; substancerelated disorders neuroplasticity that continues across the entire lifespan; (ii) cognitive activity contributes to dysfunctional behaviour and emotional experience through focusing, selective perception, memory and recall, and characteristic cognitive distortion; on a neurobiological level, there is a relationship between top-down and bottom-up regulation of unpleasant emotional states; and (iii) cognitive activity may be changed, as shown by therapeutic success achieved by metacognitive and mindfulness techniques, which also have their neurobiological correlates in the changes occurring in the cortical and subcortical structures and endocrine and immune systems. Neurobiology of mindfulness therapy

Zehra Olcay Tuna
Moodist Hospital, Istanbul, Turkey E-mail address: zehraolcaytuna@gmail.com ABSTRACT Addiction has generally been characterized as a chronic relapsing condition. Across numerous investigations of relapse precipitants in both animal and human models, two factors have emerged as the most commonly endorsed relapse risk factors: craving and negative affect. Mindfulness-based relapse prevention (MBRP) was designed to target experiences of craving and negative affect and their roles in the relapse process. A developing research area that is promising for addiction treatment is that of mindfulness-based therapies. Findings and the theoretical framework obtained from studies, together with anecdotes from clinical applications, support the efficiency of this innovative treatment for substance abuse disorders in general. MBRP offers skills in cognitive-behavioural relapse prevention integrated with mindfulness meditation. The mindfulness practices in MBRP are intended to increase discriminative awareness, with a specific focus on the acceptance of uncomfortable states or challenging situations without reacting "automatically." Neurobiological findings support the efficiency of awareness education in identifying triggers of strong desire and developing alternatives for compulsive behaviours done unawares. Recent neurobiological, cognitive, and behavioural data support two specific components of mindfulness, attention and acceptance, that may target the common intermediary phenotypes of rumination and stress directly, highlighting their potential utility in the treatment of substance use disorders. A recent efficacy trial found that those randomized to MBRP, as compared with those in a control group, demonstrated significantly lower rates of substance use and greater decreases in craving following treatment. Furthermore, individuals in MBRP did not report increased craving or substance use in response to negative affect. It is important to note, areas of the brain that have been associated with craving, negative affect, and relapse have also been shown to be affected by mindfulness training. In this section of the panel, recent studies on the neurobiological mechanisms and efficiency of mindfulness-based approaches in addiction treatment will be conveyed.  (2):351-365. determinants. Support for the implication of genetic risk factors in suicidal behaviour is provided by studies of families, twins, and adoption cases. Studies of adoption have also shown that there is a higher risk of suicide for the individuals who are biologically related to suicidal probands, but not for non-biologically related members of adoptive families. The recent findings of a large body of studies suggest significant heritability of completed suicide, with an aggregate estimate of heritability = 45%. The heritability appears to depend in part on psychiatric disorders such as mood disorders and substance abuse, with ∼90% of suicide attempters having a psychiatric disorder, and, importantly, to also be partly independent of them. The independent factor has been hypothesized to influence impulsive aggression, with individuals who have both these personality traits and a major mental disorder having the greatest risk of suicidal behaviours. Understanding of the precise genetic system that causes vulnerability to suicidal tendencies is largely incomplete, and efforts to identify the precise molecular mechanisms that are involved have been hampered by the large heterogeneity that is found within groups of suicidal behaviours. The generally accepted and regarded model for the genetic determinism of the suicidal behaviour is a polygenic model that involves a large number of genetic variants, each of which contributes a small modulation of risk. Over the last decade, many teams from around the world have attempted to identify associations between genetic markers and suicidal behaviours. It is recognized by all that single genes might not explain the full risk of developing suicidal behaviours. In summary, we have identified several studies that have shown an association of genetic polymorphisms with suicidal behaviours, in line with previous reviews. The strongest results from meta-analyses support the combination of suicidal behaviours with variants in TPH1-rs1800532, SLC6A4-5-HTTLPR, COMT-rs4680 or BDNF-rs6265. Results to date from Genome-Wide Association Study are unsatisfactory, with most studies showing no evidence of association at a genome-wide significant level or only marginally. Studies that did show an association failed to replicate the results.

KEYWORDS
Self-harm behaviour; genetics; heritability; 14-25 age group; suicide a one-sided mirror and a video-recorder. There should be no chair or any furniture, and the parent-toddler couple is asked to sit and play on a carpet on the floor. There should be a toy box, a desk to write on, and several toys (esp. cars, dolls, balls, toy animals, lego, kitchen goods, toys that generate musical sound, a piece of paper and a pencil, etc.). Both the mother and the toddler are scored on 10 items on five-grade (1: very bad to 5: obviously sufficient) Likert-type scale in MTI-MAXA by professional assessors (preferably at least two blinded assessors). Ten items are physical involvement, affective expressiveness, pleasure, responsiveness, reciprocity, joint attention, non-intrusiveness, adaptive flexibility, support, and acceptance. In the reliability and validity study, the interrater reliability of the MTI-MAXA scores was good to excellent [1]. MTI-MAXA-maternal scores were significantly correlated with Bayley mental and motor scores, and inversely correlated with Brief-Infant & Toddler Social-Emotional Assessment Scale (BITSEA)-problem scores of the children. In addition, MTI-MAXA-toddler scores were significantly correlated with BITSEA-competence and Bayleymental scores of the children. Further studies that will use MTI-MAXA to assess the mothertoddler interaction in different clinical settings and ages (e.g. 2-4-year-old) may accumulate the findings on MTI-MAXA in terms of reliability, validity, and utility.   [1]. This syndrome is characterized by craniofacial dysmorphisms, including midface prominence, sparse lateral eyebrows, severe telecanthus, lacrimal-salivary apparatus agenesis, fronto-nasal abnormalities, thin upper vermillion border, protruding ears, myopia, mental retardation, sensorineural hearing impairment, congenital heart anomalies with intraventricular conduction delay, hypochromic microcytic anaemia, and skeletal abnormalities of the long bones with recurrent fractures [2]. Mutations in a single gene, IRX5 homeobox cause a recessive congenital disorder affecting face, brain, blood, heart, bone, and gonad development which suggests that IRX proteins may be crucial for the ontogeny and function of many organs in human.

References
Case presentation: A 14-year-old male patent diagnosed with Hamamy Syndrome will be presented. He has been followed by our child psychiatry department since 2016. His primary complaints are his touching behaviour to objects multiple times, counting, checking, hygiene and symmetry. His mother reports that patient spends almost the entire day with activities regarding his obsessions and compulsions. He constantly touches mother and sister's hair and wants to touch inappropriate areas. He has sensational issues with taste, smell and touch. He also does not talk in public, is more comfortable speaking with his family at home. His main medical problems are lacrimal agenesis, hearing loss, feeding problems (only eats liquid or pureed foods), and bone fractures (a total of 58 fractures and 14 operations regarding the fractures). History of psychiatric illness in the family was positive with his sister with Obsessive Compulsive Disorder. His mother and father are cousins. Similar touching behaviour and sensational problems appear in the first-degree relative members.
The patient is diagnosed with Obsessive Compulsive Disorder after our psychiatric examination with a total score of 34 in Yale-Brown scale. He also has Social Anxiety Disorder, Selective Mutism, and Enuresis Nocturne. We evaluated hypersensitivity levels to touch, smell, sound, and tactile stimulation and he had high score compared to his age group in Dunn Sensory Profile. His IQ total score is 41 (considered as an underachievement and did not reflect his actual performance). We started Fluoxetine 20 mg per day and increase the dose to 40 mg day. He became irritable and had sleep problems with this treatment. Then we started KEYWORDS Genetic syndrome; sensory; compulsive; psychopharmacology; treatment Sertraline 100 mg day which is also caused irritability. Then we switched to Clomipramine 75 mg per day and we increase dose up to 200 mg, but it did not help. Then we added Risperidone 1 mg day. Risperidone caused severe sedation, so we stopped it and we added Haloperidol 15 mg day. This treatment did not change symptoms. We also referred him to sensory integration therapy which also did not work. Discussion: We will discuss psychopharmacological management of this case with its neuropsychiatric and neurobiological aspects.
References [1]  Transformative effect of neuroscience on psychotherapies

Melike Nebioglu
Health Sciences University, Haydarpaşa Numune Research and Training Hospital, Istanbul, Turkey E-mail address: melikenb@gmail.com ABSTRACT We can use the applicable neuroscience knowledge to help individuals to understand and cope with depression and anxiety. Twenty-first-century therapies can remove the mask from secret and private knowledge, and form a sounder alliance by sharing the relevant knowledge with the client. Many of the recent developments in neuroscience are very closely related to psychotherapy. The most exciting aspect of neuroscience is brain's potential to generate new cells. Discovery of neurogenesis (Cell Birth) reversed everything we thought we knew until the 1980s. We used to assume that all the brain cells we would possess throughout our life were there from the moment we were born. However, now we are aware of the possibility of generating new neurons in certain parts of our brain during our lifetime. Factors, which may cause neurogenesis to decrease, are ageing and high level of cortisol induced by chronic stress or recurring depression. It is not a coincidence that a theory attributes depression to the suppression of neurogenesis. Serious impacts, such as radiation and traumatic brain damage, suffered by brain cells, are other factors causing neurogenesis to decrease. The relevant process, which is known as neuroplasticity, shows that the brain does not function in a manner, which cannot be modified after birth, and that it is instead re-programmable through experiences. Since neurons are social beings, there are in average 10,000 connections between them. As it may be understood from its name, neuroplasticity explains that neurons are soft and easily mouldable, just like plastic; in other words, they may be modified through what is learned from experiences. As for learning, it both establishes and strengthens synaptic relations. Neurochemical activity between synapses increases the firing power of neurons, which, in turn, is called action potential. Two main neurotransmitters in the brain are glutamate and GABA. While glutamate initiates neuron activity, GABA inhibits, or in other words, restricts it. The emergence of the neuroplasticity concept goes back to one of the founders of the field, Donald O. Hebb . Hebb proved that mental stimuli caused actual structural changes in the brain. Hebb, who brought lab mice home for his children to play, found out that mice, upon their return to the laboratory environment, had become faster learners, when compared to mice, which never left their cages in the laboratory. It was observed that the former's brains were bigger and heavier. Hebb's following words became some kind of a mantra: "Neurons that fire together, wire together." In other words, when you fire neurons together to support a new behaviour and to display the relevant behaviour again and again, the neurons in questions will wire together to make a permanent habit of the behaviour. Patients/clients should be informed of the necessity to feel some discomfort, in order to understand how they can be assured of the restructurability potential of their brain. At the relevant stage, it may be useful to use an old vinyl record metaphor. During the vinyl's rotation, the stylus used to find the microscopic changes on groove traces. If the vinyl was damaged, the stylus gets caught up in the same groove, and the vinyl kept playing the same short section of the same song over and over again. In order to remove the stylus from the deep groove it was caught in, the listener had to leave his seat. The situation is similar in anxiety and depression. In order for individuals to make a new behaviour KEYWORDS Transformative; effect; neuroscience; psychotherapies; experience permanent, they have to display it, even if they do not feel comfortable. The possibility of restructurability depends on the clients' understanding of the necessity to leave their comfort zone, just like removing a phonography stylus caught in the groove. The relevant process requires intense and recurring behaviour change. Neuroplasticity covers many changes in the brain, arising from learning; these may be summarized as follows: establishment of new synaptic connections, strengthening of connections through LTP (long-term potentiation), dendritogenesis (formation of new dendrites, neurogenesisbirth of new neurons -Buonomano and Merzenich, 1998). Our goal in therapies is to achieve long-term potentiation (LTP) in neural circuits relevant to anxiety and depression. To explain LTN, we can state that neurons, which are not fired simultaneously, lose their connections. When teaching your clients how practising is the main thing that matters, give them impressive examples with regard to neuroplasticity. The purpose of giving this example is to show that, when any part of the brain gets used to the "use it or lose it" approach, the relevant part will further grow due to neuroplasticity.  [1]. From these, it derives five postulates about the properties required of physical mechanisms to support consciousness. A healthy and awake person usually perceives the external world as a seamless whole. Our perception of the external world depends on the integration of information from different senses [2]. The human brain, which integrates these information, cannot be considered a passive, stimulus-driven device or a passive transformer, but rather as an extraordinary integrative organ, which not only perceives but also creates new realities [2]. On the other hand, we strongly believe that we have a mind as Rene Descartes stated "cogito ergo sum." The mind that can be assumed as the gatekeeper of inner world (the human body) is the interface between internal and external worlds. One fascinating characteristic of human nature is our ability to consciously use our imagination to simulate reality as well as fictional worlds. We could assume that thought, language, memory, decision making, emotions, self-awareness, and comportment are formed by the coincidental processing of inputs driven from environmental context (social or external facts, necessities, etc.) and demands of internal milieu (personal urges, desires, values, targets, memory, etc.). Identical stimulus can trigger vastly different responses depending on situational context, past experience, and present needs. Since consolidation of the imaginative representations of "self" concept or emotions (e.g. autism) or the differentiation of the source of information and/or stimulus either from internal milieu or from external may never develop enough (e.g. ASD) or it becomes significantly disturbed (e.g. schizophrenia) and cognition, consciousness, and self-awareness are all formed by integrative functions of brain (especially association areas), we may assume that several integrative functions are not sufficiently developed in particular psychiatric disorders. Specifically, the inferior parietal lobule are responsible for representing one's own mental states, superior temporal sulcus is specialized in the representation of the mental states of others [3]. The structures including amygdala, the anterior cingulate gyrus, ventral and dorsal medial prefrontal cortex are involved in both [3]. The goal of this presentation is to review particular areas in brain that have role in differentiation of the source of information and/or stimulus either from internal milieu or from external.

KEYWORDS
Autism; integrative processing; mentalizing; theory of mind; consciousness schizophrenia and bipolar disorder.ADHD is a familial disorder with a relative risk risk about 5-9 in first-degree relatives of individulas with ADHD. Various different genomic variants have been associated with ADHD risk These variants include common DNA sequence variants -single nucleotide polymorphisms (SNPs)-Although many studies have been conducted, there is no precise single nucleotide polymorphism mainly associated with ADHD rather a a composite risk based upon these nucleotide polymorphisms could be discussed.Whole-genome investigations represent specific single dopaminergic, serotonergic, and noradrenergic candidate genes. Each of these genes were assumed to be associated with ADHD.However according to current knowledge, variants in single genes associated with ADHD should be investigated with caution as some of these variants reveale false positive results. Various nutritional factors, toxins,diateary factors and exposures to stressful life events in childhood and poor attachement with parents are also blamed for development of ADHD Low birth weight and maternal smoking during prgenancy are two major prenatal factors in pathogenesis of ADHD.in-utero exposure to maternal stress, cigarette smoking, alcohol, prescribed drugs (eg, paracetamol),illicit substances are also other factors. Environmental toxins, especially in-utero exposure to lead, organophosphate pesticides, and polychlorinated biphenyls, are other factors for ADHD. Nutritional deficiencies (eg, zinc, magnesium, and polyunsaturated fatty acids) could not be shown systematically to cause ADHD evidence based. Sugars and artificial food additives and food colourings were also balmed and discussed further Feingold Diet with restriction of sugar and artificial additives and food colourings yielded negative results. Psychosocial risks factors low socioeconomic status, parental conflict have been found not casual rather correlated with ADHD. Studies regarding mother-child relation and attachement showed that the problems regarding child and parent relation is not a cause rather a result of ADHD.Wheras early parental and social depriavtion has been shown for a casual relationship with ADHD.Animal studies also interestingly showed that some environmental factors could inetract with genetic material an deven change the genetic through methylation of DNA -epigenetic factors. These show that there is complex and intericate environmental and genetic factors which inetract each other in each level. Anticholinergic drugs are known as muscarinic receptor antagonists, parasympatholytics, and cholinolytics. They inhibit the effect of acetylcholine on the parasympathetic nervous system (more on M1, M2, and M3 receptors, less on nicotinic receptors). They block transmission by inhibiting postganglionic nerves. They are divided into two groups as natural (atropine, scopolamine) and synthetic/semisynthetic (tolterodine, amitriptyline). Antidepressants: Amitriptyline is not preferred in the elderly due to its strong sedative properties with hypotension and arrhythmia potential. Paroxetine is the most effective anticholinergic SSRI, and the risk of hyponatremia in the elderly is high. Venlafaxine is low in anticholinergic activity, but increases hypertension and predisposition to hyponatremia and is required dose adjustment in renal failure. The sedative effect of trazodone is high, may be preferred in sleep disorders with low dosage (25-150 mg) due to effects on H1 receptors. Clinical trials on the effects of fluvoxamine, bupropion, imipramine, desipramine, and cholimipramine (high anticholinergic effect and hypotension) in elderly are limited.
As an alternative to these drugs, sertraline and citalopram may be preferred in the treatment of depression. Non-pharmacological approaches can be applied in the treatment of insomnia, and trazodone can be given if necessary. Gabapentin may be appropriate for neuropathic pain and depression.
Benzodiazepines: Alprazolam should be used for a limited period of time, which can cause rebound anxiety and withdrawal syndrome. Diazepam is not preferred due to its long half-life. Alternatively, psychotherapy, exercise, yoga, aromatherapy, music, etc. are recommended. SSRIs and lorazepam are more suitable for medical treatment. Antipsychotics: They are mostly prescribed for behavioural disorders in the treatment of delirium and dementia. Their long-term use is risky. They cause increases in falls, fractures, confusion, somnolence, extrapyramidal side effects, and mortality. Success rate in the treatment of agitation is close to 20%. Alternatively, citalopram or trazodone may be used as an antidepressant in dementia behaviour disorder. In the treatment of delirium, non-pharmacological treatment should be considered firstly, and haloperidol should be added when necessary. Antiepileptics: Carbamazepine and oxcarbazepine are the most risky drugs in terms of anticholinergic load. Alternatively, levetiracetam and lamotrigine may be preferred. Gabapentin or levetiracetam may be considered in neuropathic pain. Anti-spasmolytic: The anticholinergic activities of drugs used in the treatment of urinary incontinence (tolterodine, trospium, solifenacin, propiverine, oxybutynin, fesoterodine, darifenacin, and flavoxate) are very high. Alternatively, the patient may be given frequent WC visits (at least 2 h intervals), pelvic muscle strengthening exercises (Kegel), fluid restriction in the evening, and cloth diaper. Antihistamines: Chlorpheniramine, diphenhydramine, doxylamine, clemastine, hydroxyzine, and meclizine have high anticholinergic activity in these groups of drugs. Cetirizine, loratadine, desloratadine, and levosetirizine should be preferred because they are low anticholinergic drugs. It is not recommended to use in the treatment of insomnia and trazodone is more suitable in this case.

KEYWORDS
Drugs; anticholinergics; elderly; antidepressants; benzodiazepines; antipsychotics Side effects can lead to adverse outcomes associated with ageing. These include cognitive impairment, delirium, functional impairment, falls, and mortality. Cognitive impairment: Cognitive impairment and dementia due to anticholinergics are more likely to occur in patients over 80 years of age, with multiple comorbidities (>2) and psychiatric illness. A possible reduction in the effect of cholinesterase inhibitors used in patients with dementia using anticholinergics may be seen. In addition, anticholinergics in Alzheimer patients also trigger the onset of psychosis. In elderly individuals and dementia patients, anticholinergic burden should be kept at minimum or eliminated. Alternative applications and drugs (especially those not crossing the blood-brain barrier) should be tried instead of anticholinergics. Delirium: As known, delirium is a syndrome that is often overlooked in the elderly, untreated, and has high morbidity and mortality risk. Drugs are the cause of 12-39% of delirium cases in the elderly. Anticholinergics-induced delirium may be present as a hypoactive or hyperactive type. In studies investigating the relation between anticholinergics and delirium in the elderly, the results are inconsistent due to existing many confounding factors and different measurement methods. Falls: Due to carelessness of the individual, it is called "falling" in order to become immobile below the level that you are in. Fall is a common condition in old age. Anticholinergics are preparing for falling due to weakness, fatigue, confusion, blurred vision, and cognitive impairment, incontinence and functional impairment, which are side effects specific to ageing. It has been reported that the use of anticholinergics increases the risk of falling in community dwelling and hospitalized elderly. Physical performance and functionality: Advanced age and decrease in acetylcholine levels are the main reasons for negatively affecting function. Anticholinergics disturb functionalism (basic and instrumental activities) in the elderly by central and peripheral side effects such as confusion, dyskinesia, lethargy, insomnia, dizziness, headache, nausea, vomiting, diplopia, mydriasis, and cycloplegia. This situation is even more serious if there are polypharmacy and high anticholinergic burden. Mortality: There are no randomized controlled trials that could provide risky populations as well as observational studies on the effects of anticholinergics on mortality in the elderly. The results of the studies so far vary, but it is thought that the risk of mortality may be increased in patients on anticholinergics, particularly those with advanced age, frailty, cardiovascular diseases. Conclusions: Side effects of anticholinergics are more frequent and more serious in the elderly. Anticholinergics may increase functional and cognitive impairment, morbidity and mortality in the elderly. The relationship seems likely to be based on the pharmacologic properties of the drugs. as "a disease disguised as a virtue." Although prompted by a desire to achieve optimum health, orthorexia may lead to nutritional deficiencies, medical complications, and poor quality of life. Despite its being a distinct behavioural pattern that is frequently observed by clinicians, orthorexia has received very little empirical attention and is not yet formally recognized as a psychiatric disorder. An examination of diagnostic boundaries reveals important points of symptom overlap between orthorexia and anorexia nervosa, obsessive-compulsive disorder (OCD), obsessive-compulsive personality disorder (OCPD), somatic symptom disorder, illness anxiety disorder, and psychotic spectrum disorders. Neuropsychological data suggest that orthorexic symptoms are independently associated with key facets of executive dysfunction for which some of these conditions already overlap. Discussion of cognitive weaknesses in set-shifting, external attention, and working memory highlights the value of continued research to identify intermediate, transdiagnostic endophenotypes for insight into the neuropathogenesis of orthorexia. An evaluation of current orthorexia measures indicates a need for further psychometric development to ensure that subsequent research has access to reliable and valid assessment tools. Optimized assessment will not only permit a clearer understanding of prevalence rates, psychosocial risk factors, and comorbid psychopathology but will also be needed to index intervention effectiveness. Though the field lacks data on therapeutic outcomes, current best practices suggest that orthorexia can successfully be treated with a combination of cognitive-behavioural therapy, psychoeducation, and medication.

Drugs
Although not yet officially recognized as a psychiatric diagnosis, orthorexia is often associated with significant impairment, as what starts as an attempt to attain optimum health through attention to diet may lead to malnourishment, loss of relationships, and poor quality of life. Relative to other styles of unhealthy eating, orthorexia has been largely neglected by the scientific community even though its behavioural pattern is frequently observed by eating disorder specialists. In this presentation, I describe what is known about the symptoms, epidemiology, and assessment of orthorexia, including a discussion of its diagnostic boundaries and neuropsychological profile. in alleviating different aspects of psychiatric symptoms involved in different psychopathologies such as cognitive impairments, anxiety spectrum disorders, addiction, and auditory hallucinations. In addition to its treatment roles, TMS has been used as a diagnostic tool in several neuropsychiatric conditions. In considering its favourable side effects profile, and regarded as an easily applicable method, rTMS has been one of the most preferred treatment options in neurology and psychiatry. Although studies compared the rTMS and electroconvulsive therapy (ECT), which is the most famous stimulation method in psychiatry, in terms of impact on depression showed the superiority of ECT, rTMS has some advantages involving an application without anaesthesia and an inpatient treatment procedure as well as with regard to cost effectiveness. Additionally, rTMS is considered to have an obvious advantage in terms of safety and tolerability than ECT. Furthermore, rTMS has been reported to have no cognitive side effects but has been associated with improvements in cognitive KEYWORDS TMS; depression; mechanism; application; parameters functions. The principle behind TMS includes the stimulation of the regional cortical neurons by a magnetic field generated by direct electric current through a circulatory coil placed over the scalp. This magnetic stimulation generates an electric current in the cortical neurons, which affects the cortical neuronal transmembrane potential and leads to depolarization or hyperpolarization in the stimulation area and the interconnected regions. The frequency of the stimulus is fundamental as a high-frequency (HF) (>1 Hz) stimulus induces cortical excitability and has an activating/depolarizing effect, while a low-frequency (LF) (1 Hz or less) stimulus inhibits transmembrane potential and has an inhibitory/hyperpolarizing effect. Both HF-rTMS applied to the left dorsolateral prefrontal cortex (DLPFC) and LF-rTMS applied to the right DLPFC have been reported to be efficacious in the treatment of depression as rTMS has been thought to address the possible contrasting roles of the left and right hemispheres in treating that disease. rTMS, which is the most widely used form of TMS in psychiatry, yields long-lasting effects in cortical neuronal activity in long-term potentiation (LTP) and long-term depression (LTD). Although the underlying mechanism of TMS is not yet well elucidated, modulation of neuronal activity by increasing or decreasing cortical excitability, neuroplasticity, modulation in the secretion of endogenous dopamine, and some neurotrophic factors, like brain-derived neurotrophic factor (BDNF), and alteration of serotonergic and dopaminergic receptor levels are the main components that are possibly involved in the mechanisms of action. Studies that have emphasized alterations in cortical excitability and dopaminergic pathways by TMS have recommended that additional studies be conducted to assess the efficacy of rTMS in psychiatric disorders related to altered cortical activity and dopaminergic dysfunction. In this course, we will discuss the theoretical and practical aspects of the rTMS applications involved in the current treatment protocols conducted in psychiatric conditions, as well as review the suggested mechanisms of action for rTMS presented in the literature and will highlight the advantages of this novel promising therapeutic stimulation method. Schizophrenia is a chronic illness that affects 1% of the population, leading to a significant loss of functioning. The disease is seen with positive and negative signs throughout the course. It is a disease that starts at an early age and is a long-lasting and important public health issue with the loss of power it creates. For this reason, many new researches and data on treatment and follow-up are mentioned. When we look at the aetiology of schizophrenia, genetic factors play an important role. But, other factors such as inflammation, environmental factors, neuromediators and neurodegenerative processes, and chemicals are also involved in aetiology.

References
In recent years, the prevalence of biomarkers has increased steadily in the diagnosis and followup of schizophrenia. Biomarkers are isolated and workable data for that disease. Identification and evaluation of biomarkers is very important. Today, however, there are many limitations. In studies conducted for biomarkers, the data are not always consistent and there are no significant differences between groups in all studies. But, in today's literature, biomarkers are becoming increasingly important.
There are many neurotransmitters in the pathophysiology of schizophrenia. Over the years, however, these studies and hypotheses have mostly focused on dopamine. Dopamine imbalance is the main cause of schizophrenia. However, dopamine dysfunction alone is not enough to explain the pathophysiology of schizophrenia. Many recent surveys have shown that they are involved in this process in different neuromediators. For this reason, the search for new mediators has increased due to the fact that other neuromediators other than the dopamine process may also be present. It is known that only 20-25% of people, who have been exposed to major adverse life events, develop symptoms of major depressive episode (MDE) and although almost 70% of the population are exposed to traumatic life events, 5-10% of them are diagnosed with posttraumatic stress disorder (PTSD). MDE and PTSD are mainly investigated to understand the underlying neurobiology; however, biological aspects of health and resilience are mostly ignored. In addition, studies about stress mainly focus on MDE and PTSD, but resilience for stress-related somatic disorders and other psychiatric disorders. In addition to these gaps, resilience is a broad term, which has various definitions by different authors, as they suggest that mechanisms of resilience may be dysfunction specific, general or global. Genetic predisposition is one of the most investigated global resilience mechanisms and investigation of genetic polymorphisms shows many pathways related to resilience; however, studies on systems neuroscience and molecular neuroscience also produce a lot of information about dysfunction specific and general biology of resilience. Regulation of the hypothalamus-pituitary-adrenal axis at the optimum level, stress-related release ratios of KEYWORDS Stress; resilience; cognitive reappraisal; hippocampus; social support dehydroepiandrosterone to cortisol and neuropeptide Y to noradrenaline levels, levels of brainderived neurotrophic factor and other neurotrophic factors such as galanin, the ability to restore hippocampus and ventromedial prefrontal cortex volume, level of inflammatory factors as IL-6 and IL-1 released in response to stress and testosterone levels are one of the most replicated findings. On the other hand, people who have good emotional regulation capability, good coping skills, and high social support are among the most resilient individuals. Current studies support this fact by showing that brain networks related to cognitive flexibility, cognitive reappraisal, and emotional regulation are important modulators of resilience. The way social support affects neurobiology as increasing oxytocin levels and changing amygdala activation also guides the pathways for resilience. The role of microbiota in resilience is also being investigated lately with promising findings.
Pica is called the constant eating of non-nutritive substances. This should continue for at least one month. The eating of non-food items should not be appropriate to the level of development. This eating behaviour should not be part of a culturally approved practice. Typically, small children can eat paint, plaster, yarn, hair, and fabric parts; older children may eat soil, animal faeces, stone, eraser, and paper. Specific behaviour of the pica is seen in children aged 12-24 months. Biological, psychological, and socio-cultural factors are involved in the appearance of the pica. For this reason, iron deficiency and anaemia tests should be requested in all cases. In some pica cases, parental neglect or abuse has been reported. In differential diagnosis, developmental retardation, autism spectrum disorder, and schizophrenia should be considered. The most serious medical complications are lead poisoning, intestinal obstruction, intestinal parasitosis, and severe iron deficiency. Psychoeducation is important in therapy. Techniques such as positive reinforcements, role modelling, and over-correction can be applied in behavioural approaches. Increasing the amount of mother-child interaction and stimuli can give positive results. There are studies suggesting that pica should be included in obsessive-compulsive disorder and that SSRI use is effective in treatment. Rumination disorder is the repetitive and voluntary ingestion of food that has been swallowed for at least 1 month after a period of normal functioning. After the food is brought back into the mouth, it is swallowed or thrown out. This behaviour cannot be better explained by gastrointestinal disease, psychiatric, or medical conditions. Often seen in infants 3-12 months old. The frequency of male infants is higher. It is known that the negative psychosocial environment plays a major role in the development of the rumination disorder. Central nervous system lesions, gastrointestinal system diseases and infections that cause vomiting should be excluded. Malnutrition may develop due to regurgitation despite adequate intake of food. Medical complications include dental caries, esophagitis, dehydration and weight loss. The primary goal in the treatment of rumination disorders is to maximize mother-baby interaction. Behavioural approaches are also important for rumination syndrome. Habit reversal using relaxation and diaphragmatic breathing are the behavioural approaches used. Atypical olfaction pattern in autism: a possible first clue in early diagnosis

Mahmut Çakır
Child Psychiatry Clinic, Health Sciences University, Amasya Research and Training Hospital, Amasya, Turkey E-mail address: mahcakiroglu@gmail.com ABSTRACT Olfaction behaviour is important in living beings to communicate and bond with the mother. In humans, it can be said that infants get attached to the mother to the extent that they perceive the clues of mother's scent and the function of scent can be said to have a significant role in mother-infant bonding. It has been determined that autistic children can recognize people frequently by smelling the clothes or body odours of family members repetitively and that this situation has a significant effect in autistic individuals' bonding with primary care-givers. In autistic individuals, extraordinary responses in sensory input such as auditory, visual perception, and increased olfactory sensitivity have frequently been defined. It has been thought that these different sensory perception symptoms including olfaction are distinctive, stimulative, and descriptive for autism and they have taken their place in the diagnostic algorithm for autism. In studies about autistic children and adults, different results have been found about olfactory perception threshold, odour discrimination, and olfactory sensitivity. While it has been shown in studies with normal adults and children that anxiety and depression decrease sensory olfactory sensitivity and functionality of odour discrimination, in children with High Functioning Prevalent Developmental Disorder (HFPDD), it has been reported that sensory hypersensitivity is associated with anxiety and depression; however, it has also been reported that sensory hypersensitivity can be the core finding of HFPDD independently. It has also been reported that as a result of olfactory hypersensitivity, autistic children are more disturbed and uneasy about different odours and this situation has been reported to influence the functioning and determination of "odour identification" negatively. On the other hand, it has been predicted that lower olfaction functioning in the form of odour threshold and odour discrimination in autistic children when compared to healthy controls can be explained with relative insufficiency of learning, perception, attention, and focusing levels of these cases in addition to cognitive functions when compared with healthy controls. Interestingly, it has been argued that damaged olfactory detection thresholds in autistic individuals can create insensitivity against some odours and can positively contribute to behaviour and hypersensitivity. Olfactory function is a well-known early biomarker of neuron functioning in neurodevelopmental disorders in young children and neurodegenerative disorders in adults. In neurodevelopmental disorders such as autism, atypical sense, primarily olfactory processing is known to exist in very early periods of life. It has been emphasized that future studies about olfactory processing in autism will be important in terms of finding out significant associations between brain function, clinical behaviour, and treatment; and that, finding out different or atypical olfaction patterns very early will improve and accelerate this process. Most importantly, realizing atypical olfactory behaviour early is very important in terms of early detection of "autism spectrum disorder" and it could make clinical contribution in creating a point of view toward being maybe the "first clue," especially in early diagnosis.

KEYWORDS
Atipic; autism; early diagnosis; first clue; olfaction Introduction to Acceptance and Commitment Therapy (ACT)

Hasan Turan Karatepe
Department of Psychiatry, Istanbul Medeniyet University, School of Medicine, Istanbul, Turkey E-mail address: htkaratepe@yahoo.com ABSTRACT Acceptance and Commitment Therapy (ACT) is a psychotherapy approach that is based on functional contextualism as a philosophy and Relational Frame Theory (RFT) as a theory. ACT has been shown to be effective in a wide variety of clinical problems, including depression, anxiety, posttraumatic stress disorder, substance use, chronic pain, and even psychosis. It does not aim to eliminate symptoms, rather to improve psychological flexibility which is defined as "the ability to contact the present moment more fully as a conscious human being, and to change or persist in behavior when doing so serves valued ends." Pyschological flexibility underlies the ACT approach to psychological health and psychopathology and is established through six core processes that consist of acceptance, defusion, being present, self-as-context, values, and committed action. At this workshop, we aim to introduce general principles of the ACT model based on six core processes using experiential exercises, to teach how to apply basic ACT techniques and to improve clinical skills. Depression and the depressive spectrum disorders represent one of the most frequent outpatient psychiatric complaints in the world. Current prevalence rates for major depression are twice as high for women (21.3%) as for men (12.7%) and appear to have been increasing steadily over the past half-century. Over this same time span, the median age of onset, now the late teens to the early twenties, has become progressively lower. Although 30% of patients with major depressive disorder have failed response to antidepressant medications or psychotherapy, at least three main psychological approaches to treatment of depression -Cognitive Therapy, İnterpersonal Therapy, and Behavioural Activationhave recognized as interventions with "well-established" empirical support for their efficacy based upon favourable research findings comparing them with antidepressant medication. Besides these approaches, mindfulness-based components within cognitive therapy have also enjoyed empirical support in the alleviation of depression and/or prevention of its reoccurrence. One of the prominent forms of the third-wave behavioural therapies, Acceptance and Commitment Therapy (ACT) can be a powerful alternative to the approaches that mentioned above, because of the different handle of psychopathology, especially in the treatmentresistant group. ACT, which aimed at increasing psychological flexibility rather than symptom reduction, suggests that the internal negative experiences such as sadness, worry, or blues are not the parts of human internal live that need to be removed from; on the contrary, these experiences are the valued component of human nature. ACT reveals that the painful parts of human experiences carry the strong meaning for us at the same time. Like the two facets of a medallion; valued sides are always with the painful sides. Because of this reason if you want to release from the negative part of the experience, then the valued part of the experience will be faced with the risk of disappearing. ACT therapists try to clarify the meaning of this unwanted internal experience for the clients live and use some behavioural strategies to the cognitive components of this experience during the sessions. Attention-deficit/hyperactivity disorder (ADHD) is a major public health issue. It is one of the most frequent childhood-onset psychiatric conditions, with an estimated prevalence exceeding 5% in school-age children. It is well known that ADHD is often associated with other disorders. Whereas the comorbidity between ADHD and psychiatric disorders has been extensively explored, the association with somatic conditions has received much less attention. Obesity associated with ADHD has been quite overlooked in researches as well as in clinical practice. However, increasing empirically based evidence has suggested a significant association between ADHD and obesity. Although research suggests that there is a possible link between obesity and ADHD, the mechanism of this association remains uncertain. Appetite is controlled by many organs and tissues at the central and peripheral levels and regulated by complex processes, in which various hormones (leptin, ghrelin, adiponectin, insulin, cholecystokinin, etc.) and neuromediators (neuropeptide Y, agouti gene-related peptide, proopiomelanocortin, cocaineamphetamine-regulated transcript, etc.) play a role. Leptin has a significant role in food consumption and energy balance regulation as it reduces appetite and increases energy consumption. Ghrelin is a potent orexigenic (appetite stimulant) systemically. Ghrelin reduces leptin's effect of reducing food consumption and body weight by modulating the release of several hypothalamic peptides. In this presentation, up-to-date information on the relationship between leptin, ghrelin and ADHD will be reviewed. We know that peptide hormones act as neurotransmitters on neurological systems, as well as neuromodulator effects. Ghrelin and leptin are the best known of these hormones. However, how it effects on the neural system and affects the psychiatric clinic are still open to discussion. Ghrelin started to be released from the placenta in the mother's womb, and also released from thyroid glands, kidney, lung, lymph tissue, as well as many organs including gastric neuroendocrine cells [1]. Ghrelin and leptin not only regulate our hungertoughness but also help in regulating many hormonal axes such as growth hormone, thyroid hormones, follicle-stimulating hormone, and luteinizing hormone [2]. Several studies have been carried out on Ghrelin about neurodegenerative diseases, addiction, schizophrenia, mood disorders, anxiety disorders, OCD, depression, eating disorders, and insomnia [1,3]. Similarly, it has been emphasized that leptin hormone influences the release of steroid hormones by acting on the pituitary axis. It is mentioned that the leptin level may be a prognostic marker for treatment response in depressed patients [4]. The leptin hormone was found to be related to brain development and neuroplasticity. In our talk, we are planning to make a horizon speech by trying to emphasize the structure, mechanism and functions of these hormones. Bigorexia is a mental disorder characterized by excessive mental and physical activities that accompany a perception of person's general body structure or a particular region of his body (particularly the arm muscle groups) being not sufficiently built or muscular enough. Muscle dysmorphism, reverse anorexia, Adonis complex, Arnold syndrome are other common names for this phenomenon. Muscle dysmorphism and Bigorexia terms began to be widely used at the end of the 1990s. In contrast to anorexia nervosa, the male-to-female ratio is assumed to be about 1/10, around 100,000 people worldwide are affected by the disease, and a significant portion of them are thought to be professional bodybuilders and other athletes. It is thought that roughly 10% of those who are engaged in bodybuilding sports have muscle dysmorphism. However, epidemiological studies in this area are insufficient. In DSM-5, it is mentioned as a subtype of body dysmorphic disorder in the disorders associated with the obsessive-compulsive disorder section. In those affected by this disorder, there are extreme mental preoccupations as not being muscular enough in an obsessive pattern. As an extension of this, compulsions occur like spending long hours in the gym for more weightlifting, spending excessive money incompatible with economic conditions for sports equipment and protein supplements, abnormal diet patterns, and abuse of anabolic substances. Since the physical health problems generally do not appear at the early stage in bigorexia, the rate of treatment seeking is very low compared to anorexia nervosa. While there is no specific treatment programme currently developed for this disease, good results have been obtained with the combination of fluoxetine and cognitive-behavioural therapy. Often, it is even more beneficial to carry out a multidisciplinary treatment programme with the relevant departments for patients who continue to intensify their training programme, even though they are injured, or for patients who worsen their health by abuse of anabolic or other substances.

KEYWORDS
Bigorexia; bodybuilding; diagnosis; dysmorphia; treatment Addictions, particularly smoking, alcohol, and substance use, are major health problems both in Turkey and around the world. There is a myth that addictions are not a serious health problem for women and as a truth in global studies, both substance use and addiction is seen less in women when compared to men as a supporting data to this idea. But as a reality women use cigarettes, alcohol and substances (no matter more or less, they actually use) and a key problem identified is that substance use is more prevalent in women of childbearing age. As a second myth, it is accepted that women cut off using cigarette, alcohol, or other addictive substances suddenly when they learn they are pregnant. Actually, studies on pregnant women demonstrate that while the frequency of substance use decreases during other times, but as a truth; it is still an important health problem. Smoking during pregnancy is related to poor birth outcomes as low birthweight, intrauterine growth restriction placental abruption and previa. Using alcohol during pregnancy can have destructive consequences for the developing foetus, including foetal alcohol syndrome and alcohol-related effects. Illicit drug use in pregnancy may have undesirable consequences on the foetus including higher rates of prematurity, intrauterine growth restriction, placental abruption, neonatal withdrawal syndrome, and cognitive impairment. Despite these harmful effects, use of these substances in pregnancy is escaped from attention by most psychiatrists, gynaecologists, and other physicians. We conducted a study in 2016 at Sakarya, Turkey, and found that the substances most frequently used by pregnant females in their previous pregnancies and current pregnancies were cigarettes/tobacco products. Alcohol and synthetic cannabinoid use during pregnancy was also determined. Daily tobacco smokers continued to smoke during pregnancy, with a rate of 42.5% and 26.8% of them went on to use cigarettes almost every day. These are striking rates that recall the importance of awareness and education substance use disorders during the perinatal period. Treatment approaches are still conducted under the shadow of myths during pregnancy and postpartum period. Women are naturally expected to quit all addictions when they learned that they have a foetus. But indeed addicted women still have a "disorder" despite pregnancy and they need updated treatment approaches during these periods. Current treatment approaches suggest hope for a better management of the period of pregnancy, lactation, and relationship between mother and baby. Talking about contraception with addicted women, encouraging planned pregnancies, also talking about quitting methods for substance use before and during pregnancy, using medications if needed, encouraging lactation at the postpartum period are important headings. Also increasing social support, psychoeducation of the patient and family, psychotherapies as cognitive behavioural therapy, motivational psychotherapy, interpersonal psychotherapy, and others should be provided.

ABSTRACT
In recent years, chronic medical diseases have been more prevalent since medical problems have been managed more effectively. This increased prevalence is also associated with the combination of harmful behaviours for health and absence of health beneficial behaviours.
With the increase in life expectancy comes a set of psychological challenges that face the chronically ill. Chronic diseases are associated with high levels of uncertainty and patients should change their behaviours according to their new life patterns. Some of them have to endure debilitating and demanding treatments. These are some of the factors that cause psychological difficulties in people with chronic medical problems. Approximately one in four patients with chronic medical problems is considered to have psychological problems. Chronic medical problems are often associated with fatigue and mood problems for which KEYWORDS Chronic; disease; medical; organic; psychotherapy cognitive therapy has proven efficacy. It aims that one develops the ability to manage himself adapting to the new situation and establishes a better relationship with healthcare professionals. The creation of a new repertoire of skills for the management of psychological problems in cognitive therapy can also be applied in the acquisition of self-management skills in chronic illness. Psychological and behavioural variables play an important role in the cause, course, and prognosis of chronic illness. Factors such as the onset of the disease, coping with the new situation, pre-medical psychiatric status, and current level of social support are some of the determinants of the psychological condition in chronic medical diseases. Substance use and sleep relation appears to be bidirectional, in that substance use may directly cause sleep disturbances, and difficulty sleeping may be a risk factor for relapse to substance use [1]. Substance use and/ or abuse may cause disturbance in sleep stages, circadien rhythms, daytime sleepness and/ or alertness. It can be seen in practice like as insomnia, hypersomnia, parasomnia, circadian disturbances. Alcohol effects on sleep reduced sleep latency in the first half of the night, but increased them in the second half of the night and cause sleep disruptions like increased night awakenings, due to acute withdrawal effects of substance [1,2]. Insomnia is especially frequent among individuals with alcoholism [3]. The most consistently reported finding in detoxified uncomplicated alcoholism is a reduction in slow wave sleep, defined by the presence of delta EEG activity [4]. Recently studies have shown that presence of delta activity at polisomnography can associated with sleep disturbance such as parasomnia and insomnia [5]. Cannabis may make better subjective sleep complaints particularly when used over short periods of time. However chronic cannabis use is associated with negative subjective effects on sleep that are manifested most prominently during withdrawal such as strange dreams, insomnia, and poor sleep quality [6]. There was credible evidence of a strong relationship between opioids and sleep disordered breathing like hypersomnia. Acute intoxication with heroin, morphine, or methadone resulted in dose-dependent enhancements in arousal during sleep-wake periods. Heroin use demonstrated a stronger effect particularly on reduction of theta waves and REM sleep. Nevertheless, abnormal PSG findings are commonly reported in chronic opioid users despite development of tolerance. These abnormalities include increased sleep latency, increased awakening, decreased total sleep time, and decreased sleep efficiency. Slow-wave sleep time and REM sleep are decreased compared to baseline, while duration of stage 2 sleep is increased similar to acute use [7]. Stimulant-dependent sleep disorder consists of reduction in sleepiness or suppression of sleep by central stimulants such as amphetamine, cocaine, thyroid hormone, and various xanthine derivatives (caffeine, theophylline) with alterations in wakefulness following abstinence [8]. Both recent cocaine administration and acute cocaine withdrawal have been reported to adversely affect objective measures of sleep quality. Both recent cocaine administration and withdrawal prolong sleep onset latency, reduce total sleep time and decrease sleep efficiency [9]. Similarly, both recent methamphetamine administration and withdrawal have also been reported to adversely affect objective measures of sleep quality. Indeed, recent methamphetamine administration has been reported to increase sleep onset latency and markedly decrease total sleep time while acute methamphetamine withdrawal prolongs sleep onset latency, increases night-time and daytime total sleep time, increases awakenings during the night and reduces sleep quality (10). Benzodiazepines (BZDs) are the most commonly prescribed compounds in insomnia. A long term of BZDs use may cause dependence and abuse. The long term use of high doses of BZDs for chronic insomnia induces a marked depression of slow wave activity and of its physiological instability (11). Understanding the sleep problems related to substance use disorders requires characterizing them both subjectively and objectively while considering how sleep responds to periods of use and abstinence. Schizophrenia as a chronic psychiatric disorder presented with positive and negative symptoms and cognitive impairment. There are various ways and scales for evaluating positive and negative symptoms but it is hard to evaluate cognitive decline and there is a need for practical tools for such assessments. The present neuropsychiatric test batteries are usually expensive, need long application durations and additionally certified and experienced practitioners for use. It is generally hard to bring all these parameters together so there is a need for a more practical, and applicable way. At 2008 Ventura et al developed a cognitive assessment interview (CAI) for patients with schizophrenia [1,2]. The Turkish validity and reliability of the interview was conducted by Bosgelmez et al. (2015) with the name CAI-TR [3] and showed that the interview is applicable for Turkish patients. The cognitive assessment interview is carried out with the patients with schzophrenia and their caregivers if necessary. It a way of making an expert judgment and evaluation about the patient's cognitive functioning but that is not only based on self-report or the patient's perception of his or her cognitive functioning. During the interview interviewer researches the links between the patient's cognitive functioning and daily living activities such as school performance, success in employment, home making tasks, social interactions and other activity that requires cognition. CAI assessment also includes educating the patient about understanding the link between thinking skills and functioning. If the patient is not currently attending school, working, or socializing; information is provided about the last time thinking skills were required to function and further information about his or her current performance ability. Also the separation of the possible influence of positive and negative symptoms or depression on daily functioning from the effects of poor cognitive functioning is conducted. CAI-TR includes 10 questions, structures an interview with the patient and his/her relative, scores the cognitive impairment of the patient and provides an additional scale for global assessment of cognitive functionality. It takes 10-20 minutes for interview and 30-40 minutes for total assessment. As a conclusion Turkish CAI is a practical test that can be used to measure cognitive functions of patients with schizophrenia with its short administration time, easy application and validity and reliability. Approach to medication in epilepsy is for control of chronic symptoms with antiepileptic medication and repression of seizures rather than eliminate the actual reason of the epilepsy. This is because there is no specific etiologic approach and the pathophysiologic mechanisms are not understood enough. While making a choice among current antiepileptics, concerns should be as follows: effect spectrum of the drug, overall or at least life quality enhancing-level of seizure control, side effects in long and short term, ease of use and dose titration, cost, its effects on reproduction cycle, sex and age of the patient. Furthermore, it is crucial to pay attention to seizure type and epilepsy diagnosis is up-to-date. In the use of antiepileptic medication which is base of current epilepsy treatment, there are some principles to take into consideration. In the present presentation antiepileptic medications, their indications and side effects will be explained in the course of epilepsy treatment EEG changes in ADHD and EEG as a diagnostic tool

Figen Yavlal
Department of Neurology, Bahcesehir University School of Medicine, Istanbul, Turkey E-mail address: figenyavlal@hotmail.com ABSTRACT Attention-deficit hyperactivity disorder (ADHD) is a common psychiatric disorder affecting children, adolescents, and adults. The prevalence of ADHD in children is around 5% and varies from 3% to 16% in adults depending on the diagnostic criteria. Despite the debate on the significance of EEG on cognitive and behavioural development, it is commonly accepted that EEG discharges have a high incidence in several neurodevelopmental disorders, including ADHD. Although various EEG alterations have been described in patients with ADHD, their pathological significance has not been determined. It has been suggested that there is a close relationship between ADHD and epilepsy. A recent large-scale study revealed that ADHD in children is often accompanied by epilepsy. Based on this background, reappraisal of EEG findings in children with ADHD is important in order to detect indications of potential comorbid epilepsy and to investigate the developmental mechanisms of the neurophysiological manifestations in patients with ADHD. Several studies have estimated increasing and, particularly, high rates of ADHD in childhood in contrast to the constant comorbidity rate of epilepsy in childhood. About 70% of patients with frontal lobe epilepsy (FLE) have ADHD and there is an especially high affinity between ADHD and FLE. Children with childhood absence epilepsy (CAE) are prone to the comorbidity of inattentive-type ADHD. Moreover, it has been reported that symptoms of ADHD have a close relationship with benign epilepsy of childhood with centrotemporal spikes (BECT), rolandic discharges (RD), or Panayiotopoulos syndrome. EEG is a useful noninvasive screening tool for brain KEYWORDS ADHD; EEG abnormalities; epilepsy; comorbidity; diagnosis function and seizure susceptibility. Several reports showed a high incidence of interictal drugs and alcohol, have developed a physiological dependence on these substances, and who discontinue or reduce the use of it. Alcohol, benzodiazepines, and most of the drugs have well-known withdrawal syndromes. For example, opioid withdrawal is very important and has conspicuous clinical symptoms so clinicians feel obliged to interfere immediately with disturbing symptoms. Also, alcohol discontinuation can cause serious medical and behavioural problems. As a myth, it is expressed that particularly cannabis plants and sometimes psychostimulants do not have withdrawal syndrome and do not cause addiction syndrome. Use of cannabis for medication and relaxing legal enforcements on cannabinoids use is always a part of agenda. Before DSM 5 cannabis considered that can cause only psychological addiction thus DSM has not included cannabis withdrawal syndrome until the 5th version. According to DSM 5, Cannabis Use Disorder and the other cannabis-related disorders include substances derived from the cannabis plant and chemically similar synthetic compounds. Synthetic cannabinoids (SCs) are included in a group of drugs called new psychoactive substances. Effects of SCs on the central nervous system are similar to other cannabinoids with 2-100 times more potent pharmacological effects. There are a growing number of reports about SCs withdrawal symptoms. Thus, addiction and withdrawal symptoms are more severe than natural cannabinoids. These symptoms include agitation, irritability, mood swing, vivid dreams, seizures, tachycardia, tremor, chest pain, cramping palpitations, dyspnoea, cravings, headache, severe anxiety, insomnia, nausea and vomiting, loss of appetite, and diaphoresis. There are many cases in the literature about withdrawal syndrome synthetic cannabinoids including cases of delirium. Some times SCs withdrawal can be severe and cause medical and behavioural problems. Many of substance users apply to the hospital urgently or use the SC again and sometimes this clinical condition confused with intoxication. It is important to get the right treatment approach in such cases. Another heading that withdrawal syndrome is overlooked is psychostimulants. The dependence potential of psychostimulants is well established. For many years, the dependence was considered to be entirely psychological. According to a common approach, psychostimulants produce insignificant, unimportant symptoms even no discontinuation syndrome. However, the existence of a withdrawal syndrome is now well recognized and includes hypersomnia, increased appetite, severe dysphoria, depressed mood, and craving As a conclusion, withdrawal syndromes of cannabinoids and psychostimulants need to be discussed and recognized as well as alcohol, heroin, and other substance withdrawals. Differences in psychopharmacology of peadiatric bipolar disorder and adult bipolar disorder

Halil Kara
Department of Child and Adolescent Psychiatry, Aksaray University Research and Training Hospital, Aksaray, Turkey E-mail address: drhalilkara85@gmail.com ABSTRACT Childhood-onset bipolar disorder is more common than thought and in many adult bipolar patients, many researches have been made that the first mood disorder attack is seen during childhood and adolescence [1]. Due to the difficulty of performing placebo-controlled studies in children and adolescents, a small number of controlled trials investigating bipolar disorder treatment are available. Bipolar disorder treatment differs in children and adolescents in terms of pharmacokinetic and pharmacodynamic changes and comorbid situations being different from adults in children and adolescents [2]. One of the reasons behind bipolar disorder becoming symptomatic in early ages may be the increased genetic load [3]. This can lead to closer follow-up and longer treatment medication in our treatment plan. Working with a developing brain can also lead to changing treatment needs in the treatment KEYWORDS Bipolar disorder; child and adolescent psychiatry; psychopharmacology; pharmacokinetic; pharmacodynamic protocols. It causes us to bring the psychosocial approaches to the forefront. It also forces us to seek new treatments. Up to now, we have applied similar approaches to the treatment of adult bipolar disorder in the treatment of childhood bipolar disorder. In this seminar, we will try to touch on the difference between the two. Post-traumatic stress disorder is characterized by a history of exposure to trauma (actual or threatened death, serious injury, or threats to the physical integrity of the self or others) with a response of intense fear, helplessness, or horror; with the later development of intrusive symptoms (such as recollections, flashbacks, or dreams), avoidance symptoms (for example efforts to avoid activities or thoughts associated with the trauma), negative alterations in cognition and mood, and hyper-arousal symptoms (including disturb sleep, hyper vigilance, and an exaggerated startle response). The disorder can be seen at any age and it is associated with substantial comorbidity, such as depression, anxiety, and substance misuse. Australian guidelines recommend SSRIs, and WHO recommends TCAs and MAO-Is. All recommend against the use of antiepileptics, antipsychotics, and benzodiazepines. The revised British Association for Psychopharmacology guideline (BAP) is the most current guideline. It provides an update on key steps in acute treatment, long-term treatment, combination treatment, and further approaches for patients who have not responded to first-line interventions. BAP experts recommend, after major trauma, providing there are no contraindications, consider preventive treatment with propranolol or sertraline or traumafocused psychotherapy. In acute treatment of post-traumatic stress disorder considering an SSRI for first-line pharmacological treatment, especially paroxetine, sertraline, and venlafaxine, is recommended. Continuing drug treatment for at least 12 months in patients who have responded to treatment is also recommended. Routinely combining drug and psychological treatment approaches is not recommended for the initial treatment in the absence of consistent evidence for enhanced efficacy over each treatment when given alone.

References
There are some evidence about paroxetine may enhance the effectiveness of exposure therapy. When initial treatments fail considering augmentation of antidepressant with olanzapine, risperidone, and prazosin can be another choice. Psychological interventions administered early for traumatic symptoms consist of stress management techniques and psychological approaches. Historically, psychological debriefing was offered to survivors of traumatic events. However, meta-analyses of studies have shown that debriefing might have harmful effects on the survivors, and also that it is not protective against PTSD. Therefore, psychological debriefing is no longer recommended. Currently, problem-based, supportive techniques are considered to be beneficial in reducing the severity of PTSD symptoms, and they might also help identify the individuals who are in need of a more structured cognitive behavioural therapy (CBT) intervention. Studies have demonstrated that CBT delivered early might be effective in preventing PTSD. For survivors of trauma with protracted symptoms of PTSD, trauma-focused CBT is the best supported psychotherapy approach. CBT essentially focuses on reevaluating the traumatic event, the avoidance patterns, and cognitive distortions of the individual. There are a number of different CBT protocols for PTSD, and these protocols either have a component that involves exposure or not. In CBT protocols which include exposure techniques (e.g. prolonged exposure), the individual is asked to progressively revisit the avoided memories of the traumatic event until the event itself no longer causes the individual to feel distressed, or the need to escape or avoid the triggers of traumatic memories is diminished. This exposure-based approach is undertaken by creating a safe environment, which may be accomplished by relaxation and breathing exercises. Some other techniques used in the CBT protocols (e.g. Cognitive Processing Therapy) involve the restructuring and challenging of trauma-related dysfunctional cognitions. Addressing these kind of beliefs (e.g. the world is dangerous, the future is unpredictable and uncontrollable, the individual is helpless, and guilty because of the traumatic event) is essential, and the revised diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition also emphasize these types of cognitions in PTSD. Although exposure-based therapies are the mainstay of treatment for PTSD, some other therapeutic interventions (e.g. Interpersonal Therapy) might also be administered to alleviate traumatic distress symptoms. Current treatment guidelines still conclude that CBT is more efficacious than non-exposure therapies. Yet, recent reviews have also shown that non-exposure therapies might be as effective as exposure therapies. Authors have suggested that the similar effects might be explained by the shared components (e.g. psychoeducation, emotional regulation strategies, cognitive processing of the traumatic incident, searching for a meaning in life after the trauma) between exposure and non-exposure therapies. Some specific components of non-exposure therapies include mindfulness, focusing on conflicts in interpersonal relationship, and role transitions. Non-exposure therapies have also been used in specific symptoms of PTSD (e.g. insomnia, substance use) as an alternative to psychopharmacological options. Additional experimental and/or innovative therapeutic interventions include neurofeedback, augmentation of CBT with D-cycloserine, and metacognitive therapy. Neurofeedback is used to train the survivor to regulate the brain dysfunction via changing brain wave activities, which are shown simultaneously on electroencephalographic displays. D-Cycloserine, a partial agonist of the Nmethyl-D-aspartate receptors, has been investigated for its role in enhancing extinction learning. However, studies have shown conflicting results. Metacognitive therapy, which focuses on intrusive memories, threat monitoring, avoidance behaviours, and dysfunctional metacognitive beliefs, has also been suggested as an alternative treatment approach for PTSD. Some studies reporting a poor response to CBT have documented that memory deficits, disrupted neural network connectivity, val66met polymorphism in brain-derived neurotrophic factor, the short allele of the serotonin transporter gene, and lower activity in emotional regulation associated neural circuitry might be predictors for treatment efficacy. Identifying individuals who will respond to specific treatment approaches will also lead to personalized interventions, and clues like these predictors are therefore crucial for treatment providers. It is also of utmost importance to clarify and to take into account the survivor's priorities and goals for treatment while conceptualizing a treatment plan, and ensuring that the individual is actively participating in decisions about treatment strategies. Clinicians should also make sure that evidence-based treatment options are given priority while discussing the available options with the patient. The treatment protocol should incorporate the most distressing symptoms of the patient, and psychopharmacological treatment should be offered whenever it is deemed KEYWORDS Cognitive-behavioural therapy; D-cycloserine; exposure; post-traumatic stress disorder; psychotherapy necessary or when treatment with psychological interventions have failed to improve the in animal models. The HPA axis is important for the adaptation response to stress. Depression is associated with an over-activation of the HPA axis and antidepressant therapy is often associated with a normalization of the HPA axis [2]. In rats, systemic administration of leptin can reverse depression-like behaviours [7]. Not only the level of leptin decreases in stressed animals, there is also a reduction of the leptin-receptor mRNA in the hypothalamus inversely related to concentrations of corticosterone in the serum of these animals [3]. Specific limbic brain areas, particularly the hippocampus, might be the target site for circulating leptin to exert its mood-promoting actions [8]. Deletion of the leptin-receptors in the adult hippocampus has been demonstrated to induce depressionlike behaviour in mice [4]. Additionally, injection of leptin into the hippocampus promotes antidepressant-like behaviours [7]. The association of low leptin levels and developing depression has been proposed in humans (Miller et al., 2003). Although there are inconsistent results regarding leptin measurement in major depression [8,9], there seem to be sex differences in plasma leptin measures between patients and controls [9]. In women, low leptin levels are associated with increased symptoms of depression and there is an inverse relationship between leptin levels and anxiety symptoms independent of body weight [6]. Obese people, who commonly show high levels of leptin, are at increased risk of depression compared to non-obese people [8]. The elevated leptin levels caused by central leptin resistance support the idea of leptin insensitivity contributing to depressive disorders described in obesity [1,5]. The pathophysiology of developing a depressive disorder in the context of leptin and regulation of weight still needs to larger studies. Consequently, leptin is suggested as an indirect biomarker for developing depression [10] and could furthermore be considered as prognostic tool for determination of patients for therapy resistance risk. Approach to the children of addicted parents: from neurobiology to clinical practice

Burcu Oğuzdoğan
Moodist Hospital, Istanbul, Turkey E-mail address: burcu.oguzdogan@gmail.com ABSTRACT In the literature, it has been shown by twin and adoption studies to have a hereditary component. Findings from genetic studies showed that one of three people who develops alcohol dependency have alcohol-dependent parents. Children of alcohol dependents also have 4-5 times higher risk for alcohol dependency [2]. In twin studies, it was found that KEYWORDS Children of alcohol dependents; hereditary; multifactorial; multigenetic aetiology; genetic studies monozygotic concordance is 60% and dizygotic concordance is 39% for alcohol dependency. Additionally, monozygotic concordance is 78% and dizygotic concordance is 64% for substance dependency [1]. Schuckit et al. [3] stated that hereditary factors have a more significant influence on developing alcohol dependency than environmental factors. In adoption studies, it was found that adopted children of alcohol dependents have increased risk for dependency even if there is no history of alcohol dependency in their adoptive families [1]. Dependencies have multifactorial and multigenetic aetiology. However, there is not enough information about genetic factors in the development of abuse and dependency with substances other than alcohol. Substance use is at a high rate in adolescents. It is therefore important to identify the increased risks associated with substance use. One of the common problems of many adolescents who are addicted to the substance and trying to get rid of it is related to sleep. Sleep disorders related to substance use are included in the DSM-5 classification system. Sleep disturbances can occur as a symptom or disorder. For this reason, it is recommended that routine substance screening should be carried out in people who have trouble sleeping. In adolescents with substance abuse, sleep patterns must be investigated. Abusive substances disturb the neurotransmitter systems and affect the sleep-wake cycle. Although substance abuse is harmful to sleep at all ages, studies conducted especially on cannabis adolescents show that sleep disturbances are more common in these age groups. Stimulants shorten the total sleep duration and suppress REM sleep. Cannabis use makes sleeping easier, but at night it often wakes up and sleep quality falls. Opioids facilitate drowsiness but shorten the total duration of sleep. Research has shown that sleep disturbances in early life are effective in improving addiction. There is a bi-directional relationship between substance use and sleep disorders. In a study conducted on young people, sleeping characteristics showed that smoking, alcohol, and cannabis use were determined 2 years later. This two-way relationship leads to changes that affect emotional regulation in adolescents, self-control, and risk-taking behaviour. Studies in young samples have shown that people who use cannabis have a high level of insomnia at a significantly higher rate than those who do not. Future work is needed to understand these bidirectional relationships and the factors that alleviate this relationship. In young people with substance use disorders, the rate of treatment for sleep disorder is still limited. The impact of mother-child interaction on child's brain

Zehra Topal
Hakkari State Hospital, Hakkari, Turkey E-mail address: zehratopal86@gmail.com ABSTRACT The nervous system is immature at birth and postnatal period is characterized by rapid brain development. Specifically, the first two years of life is the period of greatest brain volume growth and a time of rapid cognitive, linguistic, social, emotional, and motor development.
Brain plasticity during this period makes the infant brain particularly sensitive to environmental influence, especially the social-affective environment (Schore 2001). Given the fact that mother-child interaction is the most important social and affective environment for a baby, it is reasonable to say that mothers can shape their baby's brain. As examples of these claims, animal experiences show that dendritic growth in rat pups is dependent on particular forms of tactile and emotional stimulation during nursing (Greenough and Black 1992). In human infants, interpersonal encounters involving mutual gaze are associated with dramatic metabolic changes in the primary visual cortex and infant's visual experiences modify synaptic connections in the occipital cortex (Katz 1999). Also, it is suggested that the amount of verbal parent-child interaction affects infant's superior temporal gyrus, which may be associated with verbal skills (Takeuchi 2015). On the other hand, early brain developments can be distorted when expected experiences do not occur, as in an emotionally deficient caregiving environment and as might occur in maltreatment. Prior reports also suggest that early childhood maltreatment is associated with later fronto-limbic abnormalities ( . Consequently, the emotional and social qualities of early experiences between child and mother are crucial. They have permanent effects on the child's brain. and inhaler) and bupropion. These medications are all equally effective and first-line agents in reducing withdrawal symptoms and smoking. Using a combination of these first-line treatments may also improve outcome. (B) Alcohol use disorders:

Mother-infant interaction
1. Management of intoxication and withdrawal: The acutely intoxicated patient should be monitored in a safe environment. Symptoms of alcohol withdrawal typically begin within 4-12 hours after reduction or cessation of alcohol use, peak in intensity after 24-48 hours of abstinence, and generally resolve within 4 days. The treatment of patients in moderate to severe withdrawal generally requires the use of i.v. fluids and thiamin, benzodiazepines, and, in some cases, anticonvulsants, clonidine, or antipsychotic agents. 2. Maintenance treatments:For maintenance treatment, there are three main options; naltrexone, acamprosate, and disulfiram. Naltrexone may alleviate the reinforcing effects of alcohol. Acamprosate, a γ-aminobutyric acid (GABA) analog that decreases alcohol craving in abstinent individuals, is also an effective adjunctive medication. Disulfiram is an effective adjunct to a comprehensive treatment programme for reliable, motivated patients whose drinking may be triggered by events that suddenly increase alcohol craving. Disulfiram produces physical reactions (e.g. flushing) if alcohol is taken within 24 hours of the medication use and is not generally used as a first-line treatment. Topiramate and gabapentin are also suggested as medications for patients with moderate to severe alcohol use disorder, but typically after trying naltrexone and acamprosate first. 1. Management of intoxication and withdrawal: Severe opioid overdose may be fatal and requires treatment in an emergency department. Naloxone will reverse all manifestations of opioid overdose. The treatment of opioid withdrawal is directed at safely alleviating acute symptoms and facilitating the patient's entry into a long-term treatment programme. Strategies found to be effective include substitution of methadone or buprenorphine for the opioid followed by gradual tapering; abrupt discontinuation of opioids, with the use of clonidine to suppress withdrawal symptoms; and clonidine-naltrexone detoxification. Maintenance treatment with methadone or buprenorphine is appropriate for patients with a prolonged history (>1 year) of opioid dependence. The goals of treatment are to achieve a stable maintenance dose of opioid agonist and facilitate engagement in a comprehensive programme of rehabilitation. Schizophrenia is rare in childhood but the incidence of this disease increases in adolescence [1]. Although early-onset schizophrenia has poorer functionality and treatment response than adult-onset schizophrenia, treatment can affect clinical course and consequences of this disease. The most efficacious treatments for schizophrenia are the antipsychotic medications. But the literature regarding the role of antipsychotics in children and adolescents with schizophrenia is already limited. It has been reported that typical antipsychotics are the gold standard of pharmacotherapy of schizophrenia in adults [2]. However, there are few studies that examined the efficacy of antipsychotics in children and adolescents with schizophrenia. Typical antipsychotics are rarely used in clinical practice because of their side effects. Extrapyramidal side effects and sedation have restricted the utility of, and compliance to, these agents. Atypical antipsychotics are the most preferred agents in childhood due to their fewer side effects and effectiveness on both positive and negative symptoms of schizophrenia [3]. On the other hand, atypical antipsychotics have been associated with increased weight gain and glucose intolerance particularly in the young [4]. However, they have not been studied much in preschool-age children. CFF-CBT has been studied and showed it to be effective in children with BD as young as 5 years old. FFT has been studied only in children over 9 years old. MF-PEP is provided groups that meet for eight sessions. This therapy has not yet been studied in preschool-aged children [1]. Also, there is limited empirical evidence addressing the treatment of DD in preschool-age children. Psychosocial treatments have the most evidence supporting their use in young children. But, there is no inclusion of randomized controlled trials, with most studies being open-label trials or case series. Treatments in addition to medication are often necessary to assist children with mood disorders and their families. These interventions may involve: . Educating the family about the nature of paediatric BD and paediatric DD, and involving the family in the treatment process. . Ensuring that children receive the special educational services necessary to prevent them from falling behind academically. . Appropriate classroom accommodations to help them function effectively in the academic environment. . Family and individual approaches to therapy should be provided as necessary. If psychosocial interventions are not beneficial in rehabilitating symptoms with BD, and if symptoms are evaluated severe, then pharmacotherapy may need to be considered. The most commonly prescribed medications for children and adolescents suffering from bipolar disorders are lithium, antiepileptic medications, and atypical antipsychotic medications. Few studies that address the efficacy of these medications in preschool children with BD exist. Specifically, studies investigating atypical antipsychotic showed positive results [2]. The most commonly used group of antidepressant medications prescribed for children suffering from depression are the selective serotonin reuptake inhibitors (SSRIs). Falling short of a few case reports, no data are available on the safety or efficacy of such antidepressant medication in any form of preschool psychopathology [3]. If medication is essential due to symptom severity and functional impairment, fluoxetine would be the initial treatment recommendation in this age group [1]. Literature on the treatment of early childhood mood disorders are lacking and few in number, and future studies with larger samples are needed to better understand the treatment of mood disorders in preschool-age children.

Ömer Faruk Demirel
Department of Psychiatry, Cerrahpaşa Medical Faculty, Istanbul University, Istanbul, Turkey E-mail address: ofdmed@yahoo.com ABSTRACT Bipolar disorder is a recurrent, pleomorphic, and often chronic illness usually causing a lifelong burden for affected individuals. Whether or not the illness is progressive and evolves in stages remains uncertain. Antidepressant-associated mania or other forms of mood swings have been noticed since the late 1950s when imipramine was first used. It is still unclear how the affective disorder is related to the antidepressant. The onset of bipolar disorder is seen with the depressive episode for about half of the cases of bipolar disorder. Some of these cases are diagnosed as bipolar disorder only after the use of antidepressants. Mood elevation associated with antidepressant treatment may reveal the efficacy of the treatment, the pharmacologic side effect, bipolar disorder that was misdiagnosed before, or switch from major depression to bipolar disorder. It is also known that antidepressants can cause abnormal mood elevation in susceptible individuals independently of the clinical diagnosis. In this presentation, it is aimed to discuss the aetiology, clinical presentation, and long-term course of manic shifts due to antidepressants according to literature data. Psychodynamic psychotherapy is based on the idea that childhood experiences and unresolved past conflicts can significantly affect an individual's current state of life. For this reason, it is understood that adulthood relationships may be a consequence of childhood unconscious patterns. Psychodynamic psychotherapy reveals the unconscious patterns of object relations, conflicts, and desires that cause depression. Psychodynamic psychotherapy can be used without medication to treat patients with mild to moderate depression. The appropriateness of psychodynamic therapy should be based on the personality, motivation, social, and occupational functioning of the patient. Clinicians should evaluate patients to determine whether psychodynamic psychotherapy is appropriate or not. The clinician should examine the past and ongoing stress factors and their defence mechanisms, what they mean to the patient, and the behavioural patterns of the patient's relationships to reduce the patient's anxiety and unconscious conflict. General treatment guidelines for psychodynamic psychotherapy can be summarized as follows: (1) To ask about stress factors and what they mean to the patient, (2) To observe how the patient is related to the clinician and how the clinician has been unconsciously resisting the efforts of the clinician, (3) To help the patient to become aware of unconscious feelings, thoughts, and behaviours that cause depression and relationship problems, (4) To change the personality traits that make the patient susceptible to depression.
The therapeutic relationship between the patient and the clinician is more important than any technique in producing a positive result. A strong therapeutic alliance is defined by the following: the patient is connected to the clinician, feels that the therapist is aided and cooperates with him. Treatment requires the use of the following interventions: interpretation, observation, confrontation, explanation, encouraging refinement, empathic verification, psychoeducation, suggestion and appreciation. Psychodynamic psychotherapy treats mild-moderate depression effectively. Controlled trials have shown that psychodynamic KEYWORDS Psychodynamic psychotherapy; depression; current; treatment therapy is superior to control conditions (waiting list or routine treatment) and is comparable to other types of psychotherapy (cognitive behavioural therapy or interpersonal therapy). This presentation evaluates psychodynamic psychotherapy in the treatment of mild to moderate depression in adults in the context of current developments. The diagnosis of depression, prognosis, initial treatment, resistant depression, and treatment of depression in advanced age will be discussed. In this presentation, the results of a completed work carried out at the Istanbul Medeniyet University's Department of Psychiatry Clinic will be presented. Attention-deficit/hyperactivity disorder (ADHD) affects 5-10% of all school-aged children and the heterogeneity in clinical presentation, treatment response, and outcome requires valid biomarkers that can assist diagnosis, predict developmental outcomes, and monitor treatment response. Neurophysiological measures have been a major focus of research in ADHD. Brain electrical activity can be recorded via electroencephalography (EEG) during rest or while performing a cognitive task. EEG offers a different way of neural assessment from blood flow-dependent measures and it measures neuronal postsynaptic electrical fields. In the ADHD literature, excess theta activity, increased theta/beta ratio (TBR), and reduced amounts of alpha activity are often reported findings and have been interpreted as signs of immature brain activity or hypoarousal, but are insufficient as a diagnostic biomarker. On the other hand, high TBR and excess theta activity are thought to be possible positive prognostic markers and excess beta activity or beta spindles negative prognostic markers for stimulant treatment response. Only a handful of studies investigated the behavioural correlates of proposed EEG markers in ADHD. Positive relation between theta activity and inattention symptoms in adults and children, negative relation between theta activity and hyperactivity/ impulsivity symptoms in children and decreased frontal theta and increased frontal beta activity in parent improved ratings of parent reported ADHD symptoms in children using psychostimulants have been reported. Additionally spindling excessive beta activity is specifically associated with impulse control problems. Frontal alpha asymmetry, the difference in alpha-band activity over right vs. left frontal hemispheres, is also proposed to be associated with reduced reward responsiveness, aggression, and difficulties with inhibition. There appears to be increased slow-wave and decreased fast-wave activity in ADHD and other forms of externalizing behaviour. It can be hypothesized that slow waves are associated with subcortical motivational systems and fast waves with cortical cognitive systems. In our current study, 80 right-handed, psychotropic medication naïve, 6-10 years old boys with a total IQ score of 75 or more, newly diagnosed with ADHD according to DSM-5 criteria were recruited. Detailed psychiatric evaluation, clinician-and parent-rated scales, along with WISC-IV and Bruininks-Oseretsky Test of Motor Proficiency, was administered and eyes open and closed resting state Electroencephalography (EEG) recordings were taken. As expected theta activity and TBR were negatively correlated with age but could only reach statistical significance at the temporal lobe. Theta and beta activity were not correlated with parent reported psychiatric symptoms nor cognitive measures but children with ADHD Inattentive Type had significantly higher theta activity at frontal and parietal electrodes. Additionally, left TBR was negatively correlated with clinician rated inattention symptom severity. As for original findings, bilateral coordination and upper limb coordination scores were significantly negatively correlated with theta activity and overall TBR was significantly negatively correlated with total motor proficiency, more significant at the left hemisphere. Fine motor integration, manual dexterity, bilateral coordination, balance and upper limb coordination were significantly negatively correlated with left hemisphere TBR. To the best of our knowledge, this is the first study to demonstrate the association of TBR with motor skills in ADHD. Quantitative EEG findings in the psychopharmacological treatment of ADHD

Abdül Baki Artık
Department of Child and Adolescent Psychiatry, Hacettepe University School of Medicine, Ankara, Turkey E-mail address: bakiartik@gmail.com ABSTRACT Abdülbaki Artık, MD Atomexetine effects on QEEG characteristics in 6-10 years old children with attention-deficit/ hyperactivity disorder Atomoxetine is a selective noradrenergic reuptake inhibitor and a selective inhibitor of the presynaptic norepinephrine transporter. Administration of atomoxetine selectively activate the prefrontal catecholamine systems in rats that is responsible for influencing to difficulties in attention and impulse control that are central to the attention-deficit/hyperactivity disorder (ADHD). Treatment-responsive QEEG subtypes have been described in several psychiatric disorders. Previous studies detected that atomoxetine normalizes beta and theta activity in ADHD patients. There are a few studies which have shown that QEEG differs between ADHD responders (R) and non-responders (NR) to stimulant medication with a sensitivity of 68.7-81%. In a research they detected that at baseline responders showed increased frontal/ anterior temporal alpha and elevated frontal/anterior temporal delta and theta in comparison to the normal population. Afterwards, treatment with atomoxetine reduced the frontal QEEG abnormality present in the responders and had no effect upon the QEEG of the non-responders. Atomexetine decreases absolute theta, and this reduction appears greater in the midline than the hemisphere. Atomoxetine also increases absolute beta (particularly noncentrally, and especially in right and midline anterior regions). In our current study, 80 righthanded, psychotropic medication naïve, 6-10 years old boys with a total IQ score of 75 or more and newly diagnosed with ADHD according to DSM-5 criteria were recruited. After treatment with atomoxetine for 16-20 weeks, we recorded EEG from participants. We detected that the theta/beta ratio decreases especially in the left temporal region. This reduction causes increased beta.

Adnan Özçetin
Department of Psychiatry, Duzce University School of Medicine, Duzce, Turkey E-mail address: adozcetin@gmail.com ABSTRACT Bipolar disorder is a psychotic disorder which causes permanent destruction of the ability and is one of the top 10 diseases that cause the destruction of ability in young adults. The prevalence of lifetime prevalence is over 2%. The disease usually starts in the period of adolescence or early adulthood. It is seen with episodes of disease mania, hypomania, depression, and mixed features. Between attacks, some of the patients can gain normal functionality and can resume their lives without major problems. However, it includes similar symptoms that frequently recurrent, major episodes with significant loss of functionality despite being under treatment and major and minor morbid conditions involving rare euthymic periods in the long-term outcome of bipolar disorder. Subsipromal states in bipolar type I and bipolar type II are more common than in syndromal states. Depressive symptoms are more common than manic/hypomanic symptoms; this rate is 3:1 in bipolar type I and 39:1 in bipolar type II. The question of whether a patient has major depressive disorder or bipolar disorder appears to be an important problem in clinical practice. Various studies have shown that bipolar disorder can be confused not only with personality disorders, substance use, and schizophrenia but also with anxiety and depressive disorders. Certain features are predictors of bipolar disorder. These features are early onset, psychotic disorder starting before the age of 25, recurrent depression, postpartum depression, bipolar family history, psychomotor retardation, hyperthymic temperament, hypomania due to antidepressants, and recurrent loss of antidepressant activity. It should be suspected that bipolar disorder may be present in such clinical situations which are agitation may be associated with depression, periodic KEYWORDS Bipolar depression; challenges; hypomania; pharmacotherapy; treatment depression, periodic sleep disorder or combination of these, refractory depression (no benefit from three different antidepressants), depression of someone who is outward-looking profession, intermittent impulsivity (such as gambling, sexual abuse, and travel passion), or intermittent irritability, suicide crises, or both, as well as depression, bipolarity, which may be associated with inconsistent personality disorders. Even if they are not criteria for the bipolar disorder alone, it should be suspected that bipolar disorder may be present in their clinic. Significant problems and treatment resistance are experienced in the treatment of bipolar depression episodes. Drugs that are preferred in bipolar depression treatment; lamotrigine, quetiapine, olanzapine/fluoxetine combination, lurasidone, lithium, carbamazepine, valproate, and in obligatory cases antidepressants. In appropriate cases, ECT should be kept in mind as an effective treatment option. The patient is experiencing problems with the one hand there is the need for effective monotherapy, on the one hand the necessity of drug combinations, on the other hand side effects of the drug/drugs used and the use of uncontrolled antidepressants for do not repeat their depression. Apart from pharmacotherapy, psychosocial therapies, vagal nerve stimulation, transcranial magnetic stimulation, sleep deprivation, and phototherapy can be applied as additional treatment modalities. In our course, general information about bipolar depression disorder will be reviewed first and then the problems and solutions seen during follow-up and treatment of this patient group will be studied interactively. Some of the major problems experienced in the bipolar depression patient group are; . Diagnosis and treatment initiation in patients, . Which medication should be chosen in which patient, what should be the treatment process (???), . The importance of treatment compliance follow-up, . The desire be hypomania of the bipolar patient group and uncontrolled attempts to do so, . Others.

[Abstract:0722][Addiction]
Up-to-date psychosomatic approaches in substance use disorder treatment

Ilker Özdemir
Giresun University Prof. Dr. A. İlhan Özdemir Research and Training Hospital, Giresun, Turkey E-mail address: ilkerozdemir249@yahoo.com ABSTRACT The most common treatments for substance use disorders (SUDs) are 1. Detoxification treatment, 2. Agonist maintenance (buprenorphine) and antagonist (naloxone) treatment, 3. Therapies: (a) Substance-free treatment in outpatients: It is an appropriate treatment method for individuals who are currently employed or have significant social support. (b) Short-term residential treatment: It is a compact but short treatment model based on a 12step approach. This model includes participation in extended outpatient therapy and self-help groups such as AA. (c) Long-term residential treatment: Treatment communities that lead 6-12 months, focus on re-socializing the individual. SUDs are increasing rapidly throughout the world. Treatment rates for these disorders are very low. For this reason, current and new treatment approaches are needed in SUDs. The only drug licensed in our country for SUDs is buprenorphine and naloxone. The other main drugs used in the treatment of SUDs in the world are: methadone (opioid agonist), naltrexone (partial opioid antagonist), LAAM (levacetylmethadol) (opioid agonist), gabapentin (calcium channel blocker), and pregabaline (calcium channel blocker). Other possible agents: Aprepitant: a neurokinin-1 receptor antagonist. It may be used for the treatment of craving and relapse in cocaine use disorders in the future. N-acetylcysteine: It is being investigated for its use in the prevention of relapse of cocaine use disorder with the assumption that it may increase the level of extracellular glutamate. Immunotherapies: These are vaccines (active immunization) and monoclonal antibodies (passive immunization). They combine with substance to form large molecules so that they cannot cross the blood-brain barrier. Thus, the effect of the substance on the central nervous system is prevented. Genetic therapies: Studies on genetic therapies are continuing in substance use disorders as well as in all areas of medicine. Epigenetics and nanotechnology are emphasized in studies. It is thought that transcription factors, especially CREB and delta fosB, are effective in behavioural responses to the substance.

KEYWORDS
Substance use disorders; deep transcranial magnetic stimulation; craving; treatment; therapy; psychopharmacology Deep TMS: The hypothalamic pituitary adrenal axis and dopamine have a key role in SUDs. The medial prefrontal cortex was shown to modulate dopaminergic activity and cortisol releasing factor (CRF) release in hypothalamic and extra-hypothalamic systems. The recent advancement in non-invasive neurostimulation technologies has enabled stimulation of deeper brain regions using H-coil transcranial magnetic stimulation (TMS) in humans. Deep TMS is predominantly used in depression and obsessive-compulsive disorders in the world. In recent years, several studies have been done to investigate the effectiveness of deep TMS in SUDs. Recent studies have shown that the treatment of deep TMS reduces craving urges in SUDs. There is also evidence that impulsive behaviours that cause substance use are reduced in the people. SUDs are one of the most important public health problems of our time. The lack of adequate therapeutic agent in this area is a serious problem. For this reason, many studies on substance dependence, drug researches and genetic studies are performed. In current conditions, pharmacotherapy in SUDs is rarely sufficient. Treatment results indicate that the dose-response effect depends on the provided psychosocial treatment services. The diagnosis of psychiatric disorders is based on self-reports and the doctor's observations, and because they are not supported by biological objective evidence, they can be diagnosed as incomplete or incorrect and the treatment process can be adversely affected. For this reason, researchers are working on biomarkers that can objectively diagnose and monitor the treatment process. In 2001, Biomarkers Definitions Working Group defined biomarker "as a property that can be objectively measured and evaluated, which can be a marker of normal biological processes, pathological processes, or pharmacological responses to a therapeutic treatment." Development of neuropsychiatric biomarkers is difficult due to the main pathophysiological and biological processes in neuropsychiatric diseases are still unclear, complexity of the central nervous system physiology and pathophysiology, difficulty of direct examination and sampling of the target organ, difficulty of obtaining cerebrospinal fluid according to other body fluids, and restricted entry of neuroimaging ligands for research purposes. Biomarker research is technology dependent and with the development of technology, new areas will be explored. Yet, exploratory biomarkers in major mood disorder research have emerged, examples being found in clinical and demographic factors, genetics, cellular and molecular biology, neurophysiology, and neuroimaging. Potential neuropsychiatric biomarkers can be divided into classes such as risk (a measurable feature that allows identification of individuals at risk for developing a neuropsychiatric disorder), diagnostic/trait (ideally a measurable one that reflects the presence of a disease state without causing overlap or confusion among disorders, a measurable feature that reflects the current severity of the disease episode and the severity of the disease process), stage (a measurable characteristic that reflects the disease stage, a measurable characteristic that reflects the current classification of the stage), treatment response (individual therapeutic responses to the patient, the evaluation of the likelihood of a response to treatment given to assist clinicians in selecting a known feature), and prognostic biomarkers (a measurable characteristic that can predict the course of a disease and its outcome). Biomarkers for mood disorders are being investigated, especially in major depression and bipolar disorder. For biomarker researches, many researches have been done on oxidative stress, inflammation, and neurotrophic factors in mood disorders. However, by the using of high-efficiency "multi-omics" (genomic, epigenetic, proteomic, transcriptomic, metabolomic and lipidomic, telomeric); mood disorders can be understood more pathophysiologically and thus valid biomarkers can be determined. So, the need for psychiatric biomarkers to identify is very wide. In this presentation; various biomarkers in mood disorders, validity and reliability studies, new biomarkers, their effects on treatment development processes and their use in therapy monitoring will be discussed in the context of current literature. EEG provides information about the electrical activity of the brain. The scalp-recorded signal provides a diffuse picture of that underlying activity and that record can provide valuable information on the brain, with high temporal but poor spatial resolution. Recently, a number of studies have examined qEEG differences in children, adolescents, and adults with and without ADHD and a number of researchers have investigated the utility of EEG measures as a biomarker for ADHD. Briefly, a biomarker is an objectively measured index of pharmacological response or biological process that is quantifiable, precise, and reproducible. This biomarker may be used to diagnose or stage a disease process or predict a clinical response to treatment. Preliminary findings of our recently completed research, which was conducted collaboratively at Hacettepe University Child and Adolescent Psychiatry and Biophysics Departments, entitled "Quantitative EEG findings in the psychopharmacological treatment of ADHD: Possible markers and the relations between these markers and motor competence, cognitive skills and treatment response" will be presented along with a literature review within the scope of variables related to psychopharmacological treatment of ADHD. Our research protocol for review is outlined below: Eighty right-handed, psychotropic medication naïve, 6-10 years old children with a total IQ score of 75 or more on Wechsler Intelligence Scale for Children IV (WISC-IV), diagnosed with ADHD according to DSM-5 criteria without comorbid clinical learning disorders, conduct disorder, developmental coordination disorder, tic disorders, autism spectrum disorder, psychotic or affective disorders, anxiety disorders, obsessive-compulsive disorder, head trauma and chronic neurological disorders were enrolled. The control group consisted of 20 right-handed, psychotropic medication naïve, 6-10 years old children with a total IQ score of 75 and above on WISC-IV, who had no psychiatric disorders and neurological or long-term chronic diseases, and no history of head trauma, who were admitted to the General Paediatrics outpatient clinic of Hacettepe University Department of Pediatrics. All the children and their families gave informed consent to participate in the study. The study group was assessed immediately before the onset of psychopharmacological treatment and the control group after the acute complaints had been rectified and their physical health had been achieved. They were evaluated with a semi-structured diagnostic interview and different scales filled by the parents. Additionally, Bruininks-Oseretsky Test of Motor Proficiency (BOT) was administered and eyes open and closed resting state Electroencephalography (EEG) recordings were taken. Children in the study group were put on methylphenidate/atomoxetine treatment and the treatment response was evaluated along with all the other clinical and parent reported scales and eyes open and closed resting state EEG recordings were repeated in the 8-12th weeks of treatment. Patients who did not meet the widely accepted dosing and treatment algorithm of methylphenidate or atomoxetine (AACAP 2007), who did not have treatment compliance, and who did not tolerate treatment due to side effects, switching to/augmented with another psychopharmacological agent were excluded from the study. As a result, approximately 63 patients completed the study. Attention-deficit/hyperactivity disorder (ADHD) diagnosis: DIVA and other diagnostic tools

Arif Çipil
Health Sciences University, Haydarpaşa Numune Research and Training Hospital, Istanbul, Turkey E-mail address: arifcipill@gmail.com ABSTRACT Adult attention-deficit/hyperactivity disorder (ADHD) is a relatively common, often unrecognized disorder. It affects 4.4% of adults in United States, but most adults with ADHD live with the symptoms and suffer the devastating effects of ADHD in their lives without identifying the source of their struggles. Instead, their difficulties are attributed to their own shortcomings. Many adults who suffer from untreated ADHD avoid diagnosis or treatment due to the negative stigmatitzaion associated with ADHD. Mental health workers sometimes dismiss ADHD and define it as little more than laziness which is targeted as a marketing opportunity by pharmaceutical companies. However, many years of scientific research confirms adult ADHD does indeed exist, and that ADHD diminishes adults' quality of life. DIVA semi-structured interview allows a thorough evaluation of the diagnostic criteria of DSM-IV-TR for ADHD in adulthood, as well as in childhood. It is divided into two domains, each applicable for childhood (before age 12) and for adulthood: the DSM-IV criteria for inattention, and for hyperactivity/impulsivity. Adult ADHD Self-Report Scale-V1.1 Screener (ASRS-V1.1): The 6-item ASRS-V1.1 designed as a tool to help screen for ADHD in adults (aged 18 years and older). The 6 questions are consistent with the DSM-IV criteria and address the manifestation of ADHD in adults. The paper version requires 1-2 min to complete. Respondents are required to use a 5-item Likert scale to indicate the frequency of occurrence of symptoms (0 = never; 1 = rarely; 2 = sometimes; 3 = often; 5 = very often). According to the convention, if the respondent has 4 or more responses marked in the darkshaded boxes of the copyrighted paper-version of the Screener (or in Part-A of the ASRS Symptom Checklist), then the current symptom profile of the individual is considered to be highly consistent with ADHD diagnosis in adults. Accurately diagnosing ADHD is critically important, as highlighted by the findings of Barkley and colleagues and Biederman and colleagues. These studies demonstrate that missed diagnosis and the absence of treatment were associated with educational, occupational, and social impairments in adaptive functioning, as well as an increased risk of substance use disorder. Because of the high prevalence rate of ADHD relative to other Axis I psychiatric disorders, clinicians should be aware of the symptoms and adult manifestations of ADHD and include screening in every adult psychiatric evaluation. Rating scales can be helpful in complementing the clinical interview, quantifying target symptoms, and measuring treatment response. Woman's brain versus man's brain: how similar, how different?

Esra Yazıcı
Department of Psychiatry, Sakarya University School of Medicine, Sakarya, Turkey E-mail address: dresrayazici@yahoo.com ABSTRACT It is hard to say for men and women brain that there is no difference but it is hard to say there is a difference too. Brain behaves independently from its gender and clinical conditions, at least we accept it in such condition but is it truth? Current morphometric studies showed the brain in a mosaic pattern that has female intensive patterns and male intensive patterns and in unisex patterns. While gross differences in total brain volume are well-established, regional sex-related differences in neuroanatomy have not been well understood and require detailed studies and confirmation. It is that observed males have significantly greater than female variance for several key brain structures, including cerebral white matter and cortex, hippocampus, pallidum, putamen, and cerebellar cortex volumes. Functionality is very important as well as the morphology of brain and FMRI studies provide data about male and female differences in different conditions. Also, there have been differences in the receptor level in various areas of the brain which is related to different hormones, mainly testosterone and progesterone. Hormonal fluctuations were found to be correlated with changes in white matter microstructure. Aging is another parameter related to morphology and functionality of the brain and that may differ according to sex too. Females and males occur into the same uterus but they have been exposed to different hormonal regulation from the initiation and so on. Then environmental and cultural aspects are adding a continuum of interaction with the brain. Evolutional and genetical heritage interact these environmental, cultural and hormonal effects. Can we say the brain is a stable organ and do not differ or is it plastic? Neuroplasticity is described and being investigated for a while but the relationship between gender and neoplasticity is still not clear. Probably, the most important interference to be a women brain is becoming a mother. Adolescence, menopause, menstruation are other parameters that interact with the brain. KEYWORDS Brain; gender; hormones; morphology; neuroscience; sex Also, neurocognitive functions differ according to the sex of the brain, emotion recognition, colour perception, visuospatial construction, and others. Another question is effects and interaction of various psychiatric diseases (autism, demans, schizophrenia, depression, etc.) on male and female brain. In this presentation, the similar and different aspects of female and male brain will be discussed in the light of current literature.

Rukiye Ay
Malatya Research and Training Hospital, Malatya, Turkey E-mail address: rukiyeayy@gmail.com ABSTRACT Stigmatization is to discredit, to look down on an individual in a way that would detach him/her from the others. It is, in a general sense, the defamation of an individual. Stigmatization comprises three components: cognitive problems (stereotype), attitude problems (prejudice), and behaviour problems (discrimination). There are three levels of stigmatizationstructural, social, and internalized. Structural stigmatization occurs on a systemic level, social stigmatization occurs on a group level, and internalized stigmatization occurs on an individual level. Internalized stigmatization is the individual's acceptance of the negative stereotypes in the society for him/herself and as a result, withdrawal from the society due to negative emotions such as unworthiness and shame. In these patients, shame, feelings of unworthiness, increase in automatic negative thoughts, avoidance from social relationships, and decreased self-worth are observed. Bipolar mood disorder is a disease frequently observed in the society and has high mortality and morbidity. In 20-46% of the studies on bipolar disorder, internalized stigmatization was detected. Patients with internalized stigmatization have lower functional scores, shorter periods of well-being, and more depressive episodes. Internalized stigmatization is more frequent among seasonal and rapidcycling patients in the rural areas, who are unemployed, have low socio-economic status, and low educational level. Psychosocial problems frequently observed in these patients are social isolation, problems of social adaptation, decrease in self-esteem, drop in school performance, difficulties in finding a job, deterioration of sociability and marital life. The society's views on bipolar disorder should be challenged and the patients should be treated. In addition to informing the society about the disease, the individuals' stories of recovery should also be shared. Starting from the training in medical faculty, emphasis should be placed on the training of the health personnel. Results: ADHD and the control group did not differ in age (mean age: 10.4 ± 2.4 vs. 10.7 ± 2.4) and sex distribution (56 vs. 42 boys). Being female and parental separation is related to lower HRQoL in the ADHD group (p < 0.05 for both). Children with ADHD had worse psychosocial and physical HRQoL than healthy controls (p < 0.05). No relationship was found between academic achievement and physical or psychosocial scores of CHQ-PF50. Psychosocial QoL scores were found significantly higher in children with ADHD-hyperactive type (p < 0.05). Children with ADHD reported lower self-concept than controls (p < 0.01) and the decreasing tendency of self-concept scores in older ages was not observed, which was seen in healthy controls. Positive judgement on Happiness/satisfaction and Behavioural adjustment subscales of PHSCS appeared to affect the HRQoL positively (p < 0.01). In contrast, adverse life events had a negative impact on HRQoL measures (p < 0.05) in the ADHD group. Conclusions: Low self-esteem in the presence of worser HRQOoL measures may create difficulties in the adjustment processes of ADHD children. Families with ADHD children may be more prone to perceive HRQoL much worser when there is a history of adverse life event.
Positive self-concept of children with ADHD may affect parents' perception of HRQoL. Obsessive-compulsive disorder (OCD) is a chronic neuropsychiatric disorder that typically manifests during childhood or adolescence and is resistant to therapeutic intervention. OCD is characterised by the occurrence of either obsessions, compulsive rituals or, most commonly, both. Obsessions are recurrent and persistent thoughts, impulses or images that are experienced in an intrusive and inappropriate way, cause marked anxiety and distress, and persist despite all attempts to try to ignore or suppress them. Compulsions are repetitive behaviours or mental acts that a subject feels driven to perform in response to obsessions and are aimed at preventing or reducing anxiety. The prevalence of OCD is 1-3% [1]. The current Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition classifies OCD under the "obsessive-compulsive and related disorders." If OCD is not treated properly, chronic illness can occur causing considerable functional impairment and predisposition to various psychiatric comorbidities. Cognitive behavioural therapy (CBT) is recommended as a first line of treatment in children and adolescents with mild to moderate cases of OCD. Numerous studies have consistently shown CBT's acceptability and efficacy. Moderate and severe OCD treatment requires psychopharmacological treatment options in addition to CBT. Regarding psychopharmacological therapy, serotonergic agents, especially selective serotonin re-uptake inhibitors (SSRI), are used as a first-line treatment in children and adolescents. But, between 40% and 60% of OCD patients fail to respond to SSRI treatment and require augmentation therapy. "Treatment resistant OCD" indicates persistent and substantial OCD symptomatology despite adequate treatment, which is known to be effective in childhood OCD. American Academy of Child and Adolescent Psychiatry (AACAP) has identified criteria for "Treatment resistant OCD": (a) failure of adequate trials of at least two SSRIs or one SSRI and a clomipramine trial, (b) failure of adequately delivered CBT, (c) minimum 10 weeks of therapy of each SSRI or clomipramine at maximum recommended or maximum tolerated doses, KEYWORDS Adolescents; augmentation; children; psychopharmacology; Treatment-resistant obsessive-compulsive disorder (d) no dosage change in the last 3 weeks. In treatment-resistant cases, SSRI therapy may be reinforced usually with clomipramine, benzodiazepine (Clonazepam) and typical/atypical antipsychotic agents. In clinical practice, the most common drug augmentation strategy is atypical antipsychotic agents. Despite all these measures, some cases fail to respond and may require alternate treatment options [2]. In recent years, stimulants, gabapentin, lamotrigine, topiramate, duloxetine, venlafaxine, agomelatine, sumatriptan, ondansetron, pindolol, inositol, opiates, donepezil, St. John's wort, and glutamatergic agents (such as N-acetyl cysteine, memantine, riluzole, etc.) have been used in the treatment of OCD. But the studies were usually conducted in adult age group and the data regarding the use of these drugs in treatmentrefractory OCD is limited. For now, these drugs are not recommended for routine use [2,3]. In this symposium, novel pharmacological options in treatment-resistant OCD will be discussed. Family, business and interpersonal relations, budget management, health management, childrearing, driving, educational, legal, and social issues are the most affected areas. Undiagnosed or untreated ADHD is a serious public health problem. ADHD could cause damage to relationships. It is reported that spouses who married to persons diagnosed ADHD experience some serious problems regarding marital adjustment, marital functionality, communication, affectivity, spouse roles, and problem-solving. Spouses with ADHD report occupational and marital problems, spouses report low marital satisfaction. Both spouse try to cope with disappointment, low self-esteem and exhaustion. Medication partially improves occupational, marital and social functioning but mostly the problems turn back after medication is being quitted. Unless a multimodel treatment plan been organised, traditional family therapy techniques could be inadequate to help couples. Course content and plan: This course will be held in two sessions. In the first session, the problematic areas experienced by the couples suffering from ADHD will be described and the solutions for them will be discussed. Following this, the management of the difficulties of couple therapy sessions will be discussed.

References
In the second session, assessment of the couple, Cognitive Behavioural Therapy (CBT) techniques of ADHD, psychoeducation of the couple, and management of the grief reaction will be addressed. Following this, the steps of CBT sessions of ADHD for couples will be introduced. Cognitive assessment and restructuring, detecting reciprocal triggering schemas and behavioural vicious circles, finding dysfunctional coping strategies and changing them with functional ones, enhancing problem-solving strategies, improving communication strategies, and stimulating positive interactions between the couple will be explained via case examples. At the end of the course interactive, questions and answers part will be held. Novel approaches in neurobiology of obsessive-compulsive disorder: Where is glutamate in the OCD brain?
İpek Perçinel Yazıcı Department of Child and Adolescent Psychiatry, Firat University School of Medicine, Elazig, Turkey E-mail address: ipek.pr@hotmail.com ABSTRACT Obsessive-compulsive disorder (OCD) is a common, chronic, and treatment-resistant neuropsychiatric disorder that frequently begins during childhood and adolescence. OCD is characterized by obsessions and/or compulsions. Obsessions are recurrent, intrusive, persistent thoughts, impulses, and/or images that often cause anxiety or distress.
Compulsions are ritualized and stereotypic behaviours or mental acts that are often performed to relieve anxiety or distress associated with obsessions. In Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), OCD is classified in the group of "Obsessive Compulsive and Related Disorders," which also includes trichotillomania, skin picking disorder, body dysmorphic disorder, and hoarding disorder. The aetiology of paediatric OCD has not been fully known, despite considerable research to date. The standard neurobiological model of OCD is especially focused on the cortico-striato-thalamiccortical pathway, and neuroimaging studies have implicated this pathway in the pathophysiology of the disorder. It is thought that the imbalances in neuronal metabolite and neurotransmitter within cortico-striato-thalamic-cortical pathway have been shown as the leading reasons for the OCD onset. The most of the OCD-related research has been related to the serotonergic and dopaminergic systems. However, evidence-based pharmacological studies have indicated that serotonergic and dopaminergic agents are not always efficacious in OCD. In recent years, the glutamatergic system has been implicated in the aetiology of obsessive-compulsive spectrum disorders. Several clinical research methods support the role of the glutamatergic system in OCD, and the glutamatergic agents have been increasingly used in the treatment of OCD and disorders within the OCD spectrum [1]. Glutamate is a major excitatory neurotransmitter in the central nervous system. It includes several cognitive functions such as learning, memory, and perception. It is known that glutamate signalling is critical in early brain development through the facilitation of neuronal proliferation, migration, and differentiation. Its dysregulation could lead to psychopathology in youth. A growing body of literature has investigated the role of glutamate in the pathophysiology of psychiatric disorders such as OCD, and increasing evidence has shown that the neurotransmission of glutamate within the cortico-striato-thalamic-cortical pathway may be disrupted in OCD [2,3]. The aim of this seminar is to discuss the existing literature on current evidence with glutamatergic dysfunction in patients with obsessive-compulsive disorder. It was estimated that 60-80% of the energy is consumed during the resting state activity of the CNS. The additional energy burden related to tasks was expected to be as little as 0.5-1%. It can be seen that the resting state does not mean "inactive" state, in fact it is the dynamic substrate of the "present," momentary state of the brain, and determines the fate of incoming information. By examining ongoing activity on the basis of dynamical changes and network structures which is called as quantitative EEG analysis, it is possible to get more comprehensive information about the activity of CNS and the shifts from resting state to response and also understanding changes related to different diseases and/or disorders. In recent years, on the basis of the results of quantitative EEG analysis, it was shown that the increases in theta band activity and in theta/beta power (θ/β) ratio are two of the most reliable EEG findings in ADHD to date. The increase in theta band activity is concluded as the signatures of underarousal and maturational delay. It was also shown that children with ADHD having higher theta band activity power are more likely to show a positive response to medication. Results related to θ/β ratio indicated that it was related to faster reaction times and increased omission errors and concluded by increased impulsivity, i.e. an increase in the speed with a decrease in the performance. As a result, examination of resting state rhythmical activity of CNS provides tools for getting more comprehensive information about CNS activity and finding signatures to identify different diseases/disorders. In the case ADHD, in addition to defining disorder-specific frequency bands, it is important to define topographical and dynamical shifts/changes during resting state. Most studies have shown that comorbidity of anxiety disorders are associated with unfavourable outcomes in people with bipolar disorder, such as a greater number of recurrences, worse treatment response, and higher risk of attempting suicide. With recent progress in psychiatric genetics, it has been shown that there is a substantial degree of aetiological overlap among the major psychiatric phenotypes, in this prospect genetic analyses may provide new insights about the comorbidity of the mood and anxiety disorders in the near future. Generally, it is first recommended to achieve adequate mood stabilization before using antidepressants for the treatment of comorbid anxiety disorders. There is a need for further research to help find relevant treatments for comorbid anxiety syndromes. In this presentation, the impact of anxiety on the presentation, course, and treatment response of patients with bipolar disorder will be discussed.  In many studies, the connection between epilepsy and depression and anxiety has been demonstrated. Depression is the most common psychiatric disorder comorbid with epilepsy. In a study using population-based data sources, the prevalence of mood disorders with epilepsy was 24-74%, depression 30%, anxiety disorders 10-25% [1]. Drug-refractory epilepsy was also associated with a higher prevalence of depression. The lifetime prevalence of anxiety was also found to be 2.4 times higher in people with epilepsy than in people without epilepsy [2]. Structural abnormalities, monoamine pathways, cerebral glucose metabolism, the hypothalamic-pituitary-adrenal axis, and interleukin-1b play a role in the common pathogenesis of these conditions. The stress of living with a chronic condition can also worsen feelings of depression and anxiety. Epilepsy may be more difficult to manage as depression is sometimes known to make seizures more frequent and can decrease the motivation to manage epilepsy effectively. Recent studies have identified depression and anxiety as risk factors for drug-refractory epilepsy in newly diagnosed epileptic patients. These risk factors have also been associated with worse outcomes of epileptic surgery. In addition, depression and anxiety have been associated with increased adverse events in response to antiepileptic drugs, a greater frequency of perceived stigma, a higher risk of suicidality and decreased the quality of life [3]. Therefore, clinicians should be aware of the importance of early detection and management of depression and anxiety comorbid with epilepsy.

KEYWORDS
Anxiety; comorbidity; depression; epilepsy; prevalence Impulsivity during pregnancy and the postpartum period

Gamze Ergil Altın
Istinye University Hospital, Psychiatry Clinic, Istanbul, Turkey E-mail address: gamzeergil@yahoo.com ABSTRACT Impulsivity is defined as a predisposition towards rapid, unplanned reactions to internal or external stimuli without regard to the negative consequences of these reactions to the impulsive individual or to others. Some researchers separate impulsivity into three components: (1) acting on the spur of the moment (motor activation), (2) not focusing on the task at hand (attention), and (3) not planning and thinking carefully (lack of planning). Impulsivity is an important aspect of several psychiatric disorders such as affective disorders, personality disorders, substance use disorders, eating disorders, attention-deficit hyperactivity disorder, and impulse control disorders. Impulsivity and impulse control disorders may cause high-risk behaviours, problems in interpersonal relationships, social and economic difficulties in pregnancy and postpartum. Impulsivity has been shown to be an important risk factor for unplanned pregnancies. In qualitative interviews, women commonly report increased impulsivity and onset or worsening of explosive anger during the period of pregnancy and the post-partum. Impulsiveness and aggressiveness can be the symptoms of perinatal stress that are overlooked or unrecognized by the patient's family and/or health-care providers.

KEYWORDS
Impulsivity; impulse control disorders; pregnancy; postpartum; perinatal Besides the functional impairment experienced by the mother, anger outbursts during pregnancy also affect the health of the foetus. Data show that impulsive, uncontrollable outbursts of temper increase the risk for later cardio-vascular disease for the newborn. There is also a link between anxiety and impulsivity. Given the fact that in the perinatal period women are more vulnerable for mood and anxiety disorders, impulsivity might be a good indicator of a need for an intervention for the well-being of the mother and the baby. , and the studies about ToM skills in the diagnosis of neurodevelopmental disorders are becoming more and more interesting. In addition to impulsive control, attention, and other neurocognitive problems in the Attention-deficit/ hyperactivity disorder (ADHD), children have emotional problems and interpersonal problems with parents, siblings, peers, and teachers. Social dysfunction is considered one of the most debilitating aspects of ADHD. It was found that 22% of children with ADHD had deficits in social functioning and this was significantly higher than the control group. Social dysfunction is very important for short-and long-term prognosis of children with ADHD. The relationship between ADHD and social cognitive deficits including emotional face recognition and prosodic perception has been clearly demonstrated. It is unclear whether impairment of emotion recognition and ToM deficits in ADHD are comparable to ASD in terms of severity. It is important to investigate whether social cognitive disorders in ADHD are independent abnormalities or secondary to neurocognitive skill abnormalities affecting social cognitive tasks of neuropsychiatric patients. We will present our study of social cognition in children presenting with ADHD, Specific Learning Disorder, and ASD diagnoses.

KEYWORDS
Theory of mind; neurodevelopmental disorders; psychopathology; tasks; ADHD; ASD experiences related to traumatic event, have been the main component of psychotherapy for post-traumatic stress disorder (PTSD).Third wave cognitive-behaviour therapies and especially Acceptance and Commitment Therapy(ACT) use mindfulness exercises for observing negative private experiences without judgement and aim to orient commitment action through valued life direction instead of trying to reduce symptoms, can be effective in the improvement of the treatment of PTSD. In ACT Psychopathological processes are conceptualized as a misapplied control strategies for internal unwanted experiences (Thoughts, emotions and memories …) and ACT offers acceptance to the unwanted emotions and defusion to the cognitive components of problems. Misapplied control as the solution to healing from trauma may, in fact, be part of the problem. Moreover and paradoxically, efforts to control these internal events by avoidance can actually amplify the experience of the event. If we examine the impact of the verbal behaviour (to speak, form thoughts, use our minds) of humans as a whole, we will see how it can come to a ect a trauma survivor's life more globally.
Our human ability to be verbal can play a critical role in moderating the damage caused directly by a traumatic event. For instance, given the nature of human language, the description and evaluation of the trauma itself can become aversive. Simply telling the story of a trauma can evoke negative emotions and experiences; the actual trauma does not have to be present. ACT tries to alter the functions of those thoughts and internal fenomeneologies. At a fundamental level, rather than changing a person's internal experience, ACT loosens the grip such phenomena can have over the person's life, freeing them to live intentionally rather than reactively. epilepsy, multiple sclerosis, stroke), or traumatic brain injury. Mania due to the general medical conditions is presence of a prominent and persistent period of abnormally elevated, expansive, or irritable mood and abnormally increased activity or energy predominating in the clinical picture that is attributable to another medical condition. In most cases, the manic states appear during the initial presentation of the general medical conditions. The manic states due to the general medical conditions differ from typical mania, and are often difficult to treat because of underlying aetiologic factors. In addition to the treatment of the underlying general medical condition, anti-manic or antipsychotic agents may also be used for the treatment of mania due to the general medical conditions. neuropeptide studies implicating abnormalities in noradrenergic, benzodiazepine, corticotrophin-releasing hormone, and other neurotransmitter and neuropeptide systems across different diagnostic conditions. Biomarkers are defined as anatomical, biochemical or physiological traits that are specific to certain disorders or syndromes. Identifying biomarkers that co-occur with anxiety, as well as those that precede the onset of anxiety, may enhance our understanding of the etiopathogenesis of clinical anxiety and may provide novel targets of treatment for cognitive, behavioural, or pharmacological approaches. Besides, biomarkers can also be used in the treatment response assessment as a biological predictor. Biological predictors of treatment response, which are also defined as "treatment biomarkers" would contribute to the personalized medicine approach, in which biomarkers would guide decision making and help to select the most suitable medication for individual patients [1]. Although, none of the putative biomarkers is sufficient and specific as a "diagnostic tool" or "treatment biomarkers", researches that improve our understanding of the neurobiological causes of anxiety disorders are on the rise. The objective of this presentation is to summarise the current knowledge of potential biomarkers for anxiety disorders in neurochemistry (neurotransmitters such as serotonin, norepinephrine, dopamine or GABA, neuropeptides such as cholecystokinin, neurokinins, atrial natriuretic peptide, or oxytocin, the HPA axis, neurotrophic factors such as NGF and BDNF, immunology), neurophysiology (EEG, heart rate variability), neurocognition, neuroimaging, including structural brain morphology, functional magnetic resonance imaging and techniques for measuring metabolic changes, and clinical and molecular genetic findings of family, twin, linkage, association and genome-wide association studies [2,3].

[Abstract:0745][Psychotherapies]
Cognitive behavioural therapy approaches in substance use disorder treatment

Erkan Kuru
Özel Boylam Psychiatry Hospital, Ankara, Turkey E-mail address: erkankuru83@gmail.com ABSTRACT Substance use disorders (SUD) can be defined as "a cluster of cognitive, behavioral and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems" (APA, 2013). It can emerge from a dysfunctional pattern of behaviours and emotions related to the consumption of psychoactive substances, such as alcohol, cannabis, cocaine, and opioids (Morin et al., 2017). According to an epidemiological study, about 17-19% of the population suffers from substance misuse (Kessler et al., 1996), which makes it the second most prevalent class of disorders within the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5; APA, 2013). In a recent report, the World Health Organization (WHO) stated that problematic substance use was on the rise, afflicting more than 5% of the world population, and representing about 3.3 million deaths worldwide (WHO, 2014). The cognitive approach helps individuals to come to grips with the problems leading to emotional distress to gain a broader perspective on their reliance on drugs for pleasure and relief from discomfort. In addition, specific cognitive strategies help to reduce urges and at the same time, establish a stronger system of internal controls. Moreover, cognitive therapy can help patients to combat their depression or anxiety which frequently fuels addictive behaviours. A major trust of cognitive therapy of substance abuse is to help the patient in two ways: (1) to reduce the intensity and frequency of the urges by undermining the underlying beliefs and (2) to teach the client specific techniques for controlling or managing their urges (Beck et al., 1993). This presentation focuses on two main topics. First, cognitive-behavioural therapy (CBT) models of intervention for SUDs. The relapse prevention model is the most commonly described CBT intervention KEYWORDS Substance use disorder; treatment; psychotherapy; cognitive-behavioural therapy; relapse prevention for SUDs and was developed to assist clients who had achieved abstinence through detoxification in order to maintain abstinence over the long term (Marlatt & Donovan, 2005). Other interventions were guided self-change, behavioural couples therapy, and community reinforcement approach. Also, personality-targeted CBT intervention represents a more personalized version of the CBT model to address heterogeneity and comorbidity within SUDs by targeting common personality risk factors for behavioural and mental health problems that co-occur with SUDs (Morin et al., 2017). These cognitive behavioural interventions for SUD are presented in more detail. The second topic is researches. The articles on the treatment of SUD with CBT that were published in the last 10 years have been screened in national and international databases. As the importance of normal person relationships and psychiatric status is understood, research on the neural bases in the brain of ToM skills is increasing. The first step is the discovery of mirror neurons and the idea that these neurons can form neural networks. Although these neurons were first described in primates, they were also found to be present in the human brain in functional imaging studies. It is defined that mirror neurons are involved in defining the motion of others. In general, studies have shown that the frontal, temporal, parietal cortex in ToM gives the foreground results. İt has been shown that the right hemisphere is active and plays an important role in understanding and meaningfully empathizing imitative and facial expressions.

KEYWORDS
Autism; child; neurobiology; social cognition; theory of mind How can we overcome treatment resistance in schizophrenia? Is clozapine fear justifiable or exaggerated? Principles of clozapine treatment in stages and psychosocial approaches in overcoming treatment resistance schizophrenia and schizoaffective disorder. There are also studies showing that chronic use of clozapine improves interpersonal cohesion, social and occupational functioning in some of the patients, which also contributes to their continuing education and training, reducing hospitalization frequency and duration of hospitalization. It is thought that 1 / 3-1 / 5 of patients with schizophrenia are treatment-resistant There are serious side effects such as agranulocytosis, myocarditis / cardiomyopathy and epileptic seizures, daytime sedation may cause side effects such as urinary incontinence, hypersalivation, weight gain, metabolic syndrome and constipation at night. Clozapine at least 10-15 times less than expected in the world and in Turkey and is often used in 2-10%. In a recent study conducted with outpatients, it showed that clozapine use was less than 8%. This leads to the fact that the most prominent leading clinicians do not have enough consciousness and experience to manage serious side effects, and the need to have a blood count every week for 18 weeks leads physicians to be reluctant to use clozapine. These side effects and difficulties can in fact be overcome with conscious approaches and the advantages brought about by the widespread use of TRSMs which allow close and frequent follow-up of patients with schizophrenia While starting clozapine The effect of clozapine has been proven in patients with treatment-resistant schizophrenia. However, prescription of clozapine is limited due to need the gradual increase in dose in the initiation protocol, the long and costly follow-up protocol, the interaction with many drugs, the presence of life-threatening side effects, the gradual cessation of treatment within 1-2 weeks, and the high cost of treatment. Therefore, these conditions motivate clinicians to identify patients with adequate response. In addition, when compared with other antipsychotics, it is reported that clozapine needs a longer duration of treatment and the clinical response may appear to be relatively late. In this regard, drug plasma concentration, brain imaging, clinical parameters, genetic studies, quantitative electroencephalography (QEEG) studies were used to predict clozapine response. Data obtained from current studies will prevent clinicians from wasting time in patients who are unlikely to respond to clozapine by not using a drug that does not have a positive effect on the treatment process, while at the same time preventing patients from being exposed to the sideeffect profile of clozapine. However, progress in this area will significantly contribute to the prevention of improper use of health care facilities, the reduction of financial costs associated with the use of unresponsive drugs, the reduction of the use of additional medication and health units due to clozapine side effects In clinical studies there is a strong relationship between gastrointestinal symptoms and mental disorders. As a well-known reality, there are direct and indirect interactions between our gastrointestinal system and our brain like between our whole body and our brain. These interactions have some physiological consequences which are necessities for a healthy and well performing gastrointestinal system in normal daily life of a human being. What is going on in our gastrointestinal system when something went wrong with our mental status? There are many gastrointestinal signs and symptoms when we feel any mental stress. We can directly feel that we are under stress, even just observing our gastrointestinal motility and changes in our daily gastrointestinal habits. Psychological stressors, can even modulate the intestinal immune system. Indeed, although acute stress accelerates the resolution of an infection by increasing both cellular and humoral immunity, prolonged periods of stress have the opposite effect and dampen immune responses to invasive pathogens, thereby increasing the vulnerability to infections. Finally, psychological comorbidities may lead to altered brain processing of incoming sensory signals, thereby contributing to functional gastrointestinal system symptom development. Psychological stressors contribute to the initiation and course of functional gastrointestinal system symptoms, potentially via mechanisms involving immune modulation and altered brain processing of incoming nociceptive signals. The stress-induced release of the mast cell mediators, histamine, tryptase and serotonin, trigger sensitization of afferent nociceptive neurons, thereby leading to aberrant visceral pain perception. Theory of mind ability assessment tools and theory of mind-based therapies

Saliha Baykal
Department of Child and Adolescent Psychiatry, Namık Kemal University School of Medicine, Tekirdağ, Turkey E-mail address: salihabaykal35@hotmail.com ABSTRACT Theory of mind (ToM) is defined as the capacity to interpret, deduce, and explain the mental states underlying the behaviours of others. It includes the abilities to understand false beliefs, clues, intents, humour, deception, metaphor, and irony. ToM is associated with various areas, such as joint attention, pretend play, language development, social behaviour, and executive functions. Tager-Flusberg and Sullivan described two aspects of ToM, social-cognitive and social-perceptual, and reported that these can be measured with different tests. The aspect known as social-cognitive ToM refers to the interpretation of mental states by looking at the behaviours of others, and false belief tests are used for evaluation. The aspect known as social-perceptual ToM is associated with the affective system and is defined as the ability to perceive the mental state of others based on directly visible information. The Reading the Mind in the Eyes test (Eyes Test) is most commonly used for evaluation. Both ToM components work together for understanding the mental states of other people. Various tests concerned with ToM have been developed. Efforts toward evaluation with different components have been made based on the idea that it is difficult to maintain that the concept of ToM represents a single ability. These components consist of understanding first-order false belief, second-order false belief, metaphor and irony, and faux pas. First-order false belief tests: These assess first-order false belief ability. This is the ability to understand what the subject himself knows and what the other person does not know. Firstorder false belief tests include the Sally-Anne test and Bonibon test (Smarties test). Second-order false belief tests: The second-order false belief task is the ability to predict the thoughts of a second person concerning a third individual. According to Perner and Wimmer, this ability is "belief about belief." Second-order false belief tests include the Chocolate bar task and the Ice-cream truck task.

KEYWORDS
Theory of mind; therapies; belief; tests In the inner world of our patients, there is a path that extends from past to present and is almost always the same way if not intervened. Psychotherapies are like navigation guides that will make this journey more smooth and peaceful. One of our most basic tasks as psychiatry professionals is to understand the inner world of our patients. Thus, we can understand the elements that cause problems in the external world. Some of these elements may exhibit repetitive patterns. At the basis of this pattern may be the nature of their relationship established with early childhood objects. The nature of this relationship in the past can manifest itself in the relationships they have established today. Similarly, the way our patients relate to their therapists gives clues about their relations in the outside world. Psychodynamic psychotherapy promises us a very useful method of understanding the inner world of our patients. Psychodynamic psychotherapy is based on the idea that childhood experiences and unresolved past conflicts can significantly affect an individual's current state of life. For this reason, it is understood that adulthood relationships may be a consequence of childhood unconscious patterns. Psychodynamic psychotherapy reveals the unconscious patterns of object relations, conflicts, and desires that might cause problems. Psychodynamic psychotherapy emphasizes an understanding of unconscious conflict in the clinician-patient relationship as well as in the patient's life outside of therapy, through transference, countertransference, defence mechanisms, and resistance. The clinician interprets and recognizes the patient's repetitive patterns and unconscious conflicts. The therapeutic relationship between the patient and the clinician is more important than any technique in producing a positive result. A strong therapeutic alliance is defined by the following: the patient is connected to the clinician, feels that the therapist is aided, and cooperates with him. The therapeutic strategy followed to help patients to deal with their problems based on determining the patient's desires, expectations, and dreams about other people; the way the patient perceives the reactions of other people to these desires, expectations, and fantasies, should be evaluated against the imaginary reaction of the other. The therapist defines these thoughts and emotions from the stories of the patient's childhood and adulthood experiences and observes how they emerge in a therapeutic relationship. Methylphenidate effects on EEG characteristics in school age children with attention-deficit/ hyperactivity disorder

Yusuf Karaer
Department of Child and Adolescent Psychiatry, Hacettepe University School of Medicine, Ankara, Turkey E-mail address: dryusufkaraer@gmail.com ABSTRACT Attention-Deficit/ Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterized by inattentiveness and / or hyperactivity-impulsivity that disturbs the functioning or development of the individual. It is known that ADHD is accompanied by a number of electroencephalography (EEG) changes. Typically, ADHD children have increased theta activity which occurs primarily in the frontal regions, increased posterior delta and decreased alpha and beta activity, also most apparent in the posterior regions, compared to children without ADHD. Calculations of ratios of EEG activity between frequency bands have also been used to assess differences between clinical groups, with ADHD children having an increase in the theta/alpha and theta/beta ratios compared to normal children. These results have been shown as indicating that ADHD children have a maturational lag in central nervous system development or are cortically hypoaroused. In addition, the effects of drugs used in the treatment of ADHD on EEG have been investigated for a long time. Psychostimulants are the first choice drugs in the treatment of ADHD for many years. Psychostimulants have been shown to improve, but not normalize, many ADHD-associated abnormal EEG activities. methylphenidate (MPH) has a tendency to decrease the theta band and increase the beta band power, particularly when associated with medication-related improvements in cognition. Studies have shown that regular use of MPH in ADHD increases beta power on EEG. Several researchers have reported that EEG measures discriminate well between children with and without ADHD and others have asserted that the EEG works well in determining medication responders from non-responders. In this study, we tried to evaluate the effects of methylphenidate on EEG in children with ADHD during school age. In our current study 80 right handed, psychotropic medication naïve, 6-10 years old boys with a total IQ score of 75 or more and newly diagnosed with ADHD according to DSM-5 criteria were recruited. Detailed psychiatric evaluation, clinician and parent rated scales, along with WISC-IV and Bruininks-Oseretsky Test of Motor Proficiency was administered and eyes open and closed resting state Electroencephalography (EEG) recordings were taken. In this study, it was observed that there was a decrease in theta/beta ratios in the frontal and parietal areas with MPH. This is dominant on the left but not statistically significant. In the human intestinal tract up to 10 14 microorganisms are living. The diversity and number of bacteria differentiate according to anatomical areas. Bacteroidetes, Firmicutes, Actinobacteria, and Proteobacteria are among the most common bacterial phyla identified in the human intestine. The common functions of intestinal microbes are defined as nutrient metabolism, opportunistic pathogens defence, immune system development, and intestinal barrier function regulation. The intestinal microbiota alterations have been demonstrated in many neuropsychiatric conditions including Parkinson's disease, multiple sclerosis, autism, chronic fatigue syndrome, depression, and anxiety symptoms. Faecal microbiota transplantation (FMT) is a technique of transplanting faeces from a healthy donor to receiver's gut to treat the impaired intestinal microbiota. FMT was studied in preclinical studies in neuropsychiatric disorders. Thus, the aim of this presentation is to evaluate the associations between microbiota, gut, and brain axis and the possible effect mechanism of FMT in neuropsychiatric disorders.

KEYWORDS
Microbiota; brain gut axis; psychiatry; immune system; depression The clinical interview is one of most common methods for assessing childhood anxiety. Numerous interview schedules are designed to be used to both children and parents have been developed and empirically tested. Although most of these interviews are designed to elicit general diagnoses in children, not all have been found to be reliable and valid for diagnosing anxiety. The reliability of children reports tends to increase by their age, and conversely reliability of parents reports tends to decrease. The assessment of anxiety in children requires a multimethod approach, getting information from clinical interviews, selfreport, parent and teacher ratings, behavioural observations, as well as family history and patterns of interaction. Developmentally sensitive synthesis of behavioural and cognitive treatment approaches would lead to therapeutic gain for the anxious child. It has been well documented that there is a relationship between the nature of parent and child anxiety and the role of parental behaviour in maintaining the child's anxiety. In the literature, it is noted that parents of anxious children are more likely to engage in behaviours that communicate a sense of continued threat and danger to their child. Other research suggests that parents of anxious children tend to be more overly controlling, protective and critical, and this results in the child having fewer opportunities to develop successful coping skills. These findings would suggest that children of anxious parents become sensitive to the threatening features of their environment. If parents are educated in, and able to support, the treatment rationale, they are able to send consistent messages to the child about the importance and value of the skills they are learning. The transferring the skills from clinical to real-life situations can be encouraged. The extent of parental involvement will vary depending upon the nature of the problem and the age of the child. In terms of age, it is noted that parental involvement is more important for younger children. On the other hand, with older adolescents the parents may have a less direct role in therapy sessions, although they will still need access to psychoeducational resources and information that will allow them to support the intervention outside of the clinic setting. Parents have been involved in child-focused CBT in various roles. If parents are involved, their role needs to be defined, the focus of the parental sessions needs to be clarified, and the process by which parents facilitate change in their child needs to be defined. In this presentation, CBT approaches to an anxious child and adolescent and involving the family will be described.

KEYWORDS
Anxiety; children; family; behaviour; CBT; therapy produce metabolites, such as short-chain fatty acids, that have neuroactive properties. Moreover, the gut microbiota and the brain are linked through additional pathways, such as the vagus pathway, enteroendocrine signalling and through the modulation of key dietary amino acids, such as tryptophan.
Understanding the role of gut bacteria in the regulation of the brain functions will contribute to the development of new therapeutic strategies for neuropsychiatric disorders.

Challenging behaviour (CB) is a social construct and has been defined by Emmerson as:
Culturally abnormal behaviour(s) of such intensity, frequency, or duration that the physical safety of the person or others is likely to be put in jeopardy, or behaviour which is likely to limit the use of, or result in the person being denied access to ordinary community facilities [1]. In order to include a developmental perspective, some have added "or impair a child's growth, development or family life." Challenging behaviour in individuals with intellectual disability (ID) is a complex but common problem that can present diagnostic and management challenges for healthcare professionals. All behaviour serves a purpose, has an origin and a meaning, and is therefore produced by an interaction between an individual and their environment. Challenging behaviour can include a range of behaviours and usually categorized as physical aggression towards people or objects, self-injury, sexually inappropriate behaviour, and offending behaviour. Epidemiology: The prevalence figures of challenging behaviour in adults vary from 82% to 6.1% depending on the definition used for ascertainment, study methodology, and settings and population. In a study with adults with ID (N:151) carried out in Turkey, it was found out that 34% of adults displayed CB [2]. In the literature, aggressive behaviour was found to be associated with male gender; self-injury was more likely in those with severe or profound ID and those with communication difficulties. Diagnosis of autism was associated with selfinjury, aggression and disruption to the environment. Aetiology: Challenging behaviour is not a diagnosis and often reflects some underlying physical or psychological problems. Communication difficulties and atypical presentation of mental disorders can pose significant problems for clinicians to identify the exact cause of the CB. Management: Understanding the physical and mental health needs along with the social context is important. A thorough process of assessment will usually require multiple interviews of the index patient, their family and carers and professionals in their network. Physical assessment with investigations often reveals useful information. A systematic approach to CB has the potential to improve the care and the quality of life for the people involved. There is very little support for the use of pharmacological treatment for people with CB and ID in the absence of co-existing mental illness. However, medication can be required in the presence of high arousal and severe aggressive behaviour. There is growing interest in behavioural interventions for reducing CB.

KEYWORDS
Intellectual disability; challenging behaviour; adults; management; interventions ACC are reported in both disorders. On the other hand, there is a systems level convergence of emotion and cognition interplay, which may explain AD vulnerability in BD. However, studies that compare BD patients with or without an AD diagnosis for the neurobiological differences are scarce. It is important to understand the neurobiology of this comorbidity, since it may guide neurobiology based treatment approaches. Current literature suggests a burden in the treatment of AD in BD. Antidepressant treatments, frequently used for the treatment of AD, are not found suitable for long-term treatment of AD in BD. Mood stabilizers which are known to have more anxiolytic effects or atypical antipsychotics or short-term benzodiazepine use have been studied with limited evidence. Among the various psychotherapy methods that have been investigated, cognitive behavioural therapy was shown to produce the highest benefit. In this presentation, current evidence of neurobiology and treatment of comorbid anxiety disorders in bipolar disorder will be summarized.

Sevda Bag
Bakirkoy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul, Turkey.
E-mail address: sevdabag@yahoo.com ABSTRACT Breast cancer is the second most prevalent type of cancer and is equally common in developing as well as developed countries (American Cancer Society, 2013). Despite favourable survival in developed countries, the most frequent cause of cancer deaths in women is still breast cancer, in developed as well as in developing countries. Cancer is a serious health problem that mostly leads to death in the absence of early diagnosis and treatment. In addition to causing death in millions of people, it brings a considerably high probability of the occurrence of psychiatric disorders. Accompanying psychiatric disorders have a significant impact on a patient's quality of life, self-care, adaptability to treatment, and over the course of time, the severity and prognosis of cancer as well as response to treatment. Patients with breast cancer may suffer from significant psychological problems due to several reasons including uncertainty about treatment, physical symptoms, fear of recurrence and death, change in female identity, body image and sexuality, difficulties in daily life activities, family-related problems, and lack of emotional support. Cancer involves a high probability of the occurrence of psychiatric disorders, notably depression, anxiety, and adjustment disorders. The frequency of depression among patients with cancer ranges from an extremely low rate of 1% to considerably high rates such as 50%, partly due to the differences in cut-off scores suggested by varied diagnoses and scales. On the other hand, the frequency of suicide among patients with cancer is relatively higher with a relative risk of two times more than the general population. Most patients with breast cancer are well-adjusted, single patients with advanced-stage breast cancer who have poor socio-economic conditions have been found to have a higher suicide risk. Breast cancer involves a certain degree of malignancy, which leads to sexual dysfunction more than other cancer types because mastectomy is a common procedure. Other major factors that reduced sexual appetite of patients with breast cancer were reported as loss in breast tissue, hair loss, pain, body image, childbirth capacity, and changes in perception of medical status. One of the most common symptoms seen in patients with cancer is insomnia. Patients with breast cancer report higher prevalence of insomnia compared with patients with other types of cancer from 38% to 61%. Also steroids and medications used in symptomatic treatment such as metoclopramide, an antiemetic drug, can lead to anxiety. Drugs that cause encephalopathy and delirium may simultaneously give rise to anxiety. Also diagnosis and treatment of breast cancer may induce psychological challenges such as anxiety, depression, anger, uncertainty about the future, hopelessness, desperateness, fear of recurrence of cancer, fear of separation from relatives, fear of pain, KEYWORDS Breast cancer; depression; suicide; psychiatric symptoms; fear decrease in self-esteem, impairment of body image, fear of losing sexual capabilities, anxiety of assistant during his presidential period. It was implemented by Kenan Tunahan Dr. According to Vasil Yagcioglu, the first application was made in the Greek Greek Hospital. The purpose of ECT today is to treat by generating electrical stimulation of generic seizures. For many years, it has been practised without ECT anaesthesia for many years. In addition to observing the seizure with advanced ECT devices, recording of the seizure with EEG, qualitative and contingent evaluation of the seizure is performed and the healing of the patient is ensured. In addition to EEG, modern instruments used in EMG and ECG recordings are used.  (Shapiro, 1991). Shapiro (1995Shapiro ( , 2001 hypothesizes that EMDR therapy facilitates the accessing of the traumatic memory network, so that information processing is enhanced, with new associations forged between the traumatic memory and more adaptive memories or information. These new associations are thought to result in complete information processing, new learning, elimination of emotional distress, and development of cognitive insights. EMDR therapy uses a three pronged protocol: (1) the past events that have laid the groundwork for dysfunction are processed, forging new associative links with adaptive information; (2) the current circumstances that elicit distress are targeted, and internal and external triggers are desensitized; and (3) imaginal templates of future events are incorporated, to assist the client in acquiring the skills needed for adaptive functioning.

Murat Altın
Istinye University Hospital, Psychiatry Clinic, Istanbul, Turkey E-mail address: drmurat7602@gmail.com ABSTRACT Impulsivity is an imbalance between behavioural activation and is prominent in psychiatric disorders. Several definitions have been proposed for impulsivity from different perspectives. From bio-psycho-social perspective, impulsivity is characterized by decreased sensitivity to long-and short-term negative consequences of risky behaviours and failure in inhibiting impulsive immediate and unplanned actions. From a cognitive perspective, impulse control as an important component of executive functions and impulsivity is the inability to inhibit behavioural impulses and thoughts. According to DSM-5, impulsivity is defined in terms of an aspect of disinhibition, and considered as an immediate reaction to stimuli, unplanned reaction on the spur of the moment or with no regard for its consequences, problem in programming or adhering to programmes, sense of urgency, and self-harming behaviour in the time of emotional turmoil. While DSM conceptualization only includes negative and pathological aspects of impulse control disorders, this definition is not including the role of dysfunctional impulsivity in other psychiatric disorders. Impulsivity symptoms are present in several psychiatric disorders, such as attention-deficit/ hyperactivity disorder (ADHD), depression, manic episodes of bipolar disorder, impulsive aggressive disorders of personality (borderline, antisocial, histrionic and narcissistic), neurological disorders with behavioural disinhibition, eating disorders, dementia, and substance/alcohol abuse. There are several studies revealing the role of impulsivity in mental disorders and results in the literature have shown a correlation between impulsivity and severe behavioural complications such as committing suicide, criminal conviction in patients with bipolar disorder, antisocial personality disorder, and substance-use disorders. In this manner, defining impulsivity as a concept and symptom and understanding neurobiological mechanisms to discuss its relation to mental disorders can produce advances in development of specific treatments.

KEYWORDS
Impulsivity; psychiatric disorders; symptom; behaviour; neurobiological ABSTRACT Phytotherapy provides an alternative in the treatment of several medical conditions, including psychiatric disorders such as depression. Previous research suggests that patients may turn to herbal medicine because of a reluctance to take prescription medications that are anticipated to cause side effects or a dissatisfaction with the results. They consider phytotherapy to be a safer or more natural treatment alternative, which may be associated with improved compliance. In this presentation, current alternatives for the phytotherapy of depression, ranging from St. John's Wort to saffron, will be discussed. Interview tools and imaging modalities in adult ADHD

Murat Altın
Istinye University Hospital, Psychiatry Clinic, Istanbul, Turkey E-mail address: drmurat7602@gmail.com ABSTRACT Current literature findings suggest that the symptoms of childhood attention-deficit/ hyperactivity disorder (ADHD) persist into adulthood. Patients experience devastating effects of ADHD on their careers, relationships and personal safety which cause a great morbidity across lifespan. Thus, diagnosis of ADHD is of great importance. Despite the significant negative impact on the quality of life, many patients ignore ADHD because of lack of knowledge. On the other hand, evidence of survey studies with physicians shows that physicians even psychiatrists avoid diagnosis or treatment due to the negative stigma associated with ADHD. The first step of ADHD diagnosis is patient self-awareness about the ADHD and motivation to seek for solution. In this regard, The World Health Organization and the Workgroup on Adult ADHD have developed The Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist. This screening test was prepared as a self-screening questionnaire for patients to determine if they might have adult ADHD. The clinical diagnostic process is accomplished when the patient meets DSM-5 criteria for an ADHD disorder. The main requirements for the diagnosis for the ADHD are the onset of and the persistence of the ADHD symptoms. When evaluating for ADHD, clinicians will use a variety of clinical practice tools to gather information, including standardized clinical rating and self-report checklists, behaviour questionnaires, and/or rating scales. Interview tools are a helpful component of a comprehensive evaluation for ADHD and provide information needed to screen, diagnose, and develop a treatment plan. During treatment, they can be used to track symptoms and monitor treatment progress. Although neuroimaging research has provide unprecedented windows on the neurobiology of ADHD and the neural effects of medications used to treat the disorder (as yet), none of these methods has been found to be sensitive and specific enough to serve as a standard diagnostic test.

KEYWORDS
Attention-deficit/ hyperactivity disorder; interview; diagnostic tools; neuroimaging Depression and anxiety disorders are well known to be common in patients with epilepsy. They should be screened and treated properly because they are associated with many adverse outcomes. Many physicians may be reluctant to treat epileptic patients because they may be afraid of side effects of drugs in such a vulnerable population of patients. In terms of pharmacological management, selective serotonin-reuptake inhibitors and serotonin and norepinephrine-reuptake inhibitors (SNRIs) are considered as the first-line therapy for depression in epileptic patients because they are unlikely to provoke seizures and have favourable adverse-effects profiles. To prevent adverse effects, antidepressants should be started at low doses, and titrated upwards in small increments until the desired clinical response is achieved. Clinicians should be aware that SSRIs may inhibit hepatic enzymes and consequently increase the serum levels of antiepileptic drugs. So, prior to initiating antidepressants, plasma levels of antiepileptic drugs should be checked. Both groups of antidepressants have been shown to be effective against both depression and anxiety in epileptic patients. Choice of antidepressant will depend upon a number of factors including whether one with sedating, arousing, or anxiolytic properties is required; familiarity with common side effects of antidepressants is also essential since the patients need to be warned about these. Educational interventions were found to be beneficial in improving the knowledge and understanding of epilepsy, coping with epilepsy, compliance to medication, and social competencies. Cognitive-behavioural therapy (CBT) can alleviate symptoms of both depression and anxiety and a combination of psychotherapy and medication has been shown to be more effective.

KEYWORDS
Epilepsy; anxiety; depression; treatment; therapy Substance use disorders are known as one of the most prevalent, deadly, and costly of health problems. Comorbid substance use disorder and other psychiatric disorders are very common in both clinical and epidemiological samples. Research has consistently found that the presence of other psychiatric disorders among those with substance-related disorders is substantial. Twothird of the substance use disorder patients were accompanied by additional psychiatric disorders. The most common axis-1 diagnosis in substance use disorders are anxiety disorders, mood disorders, psychotic disorders, and attention deficit and hyperactivity disorders. When substance use disorders and comorbid psychiatric disorders are seen together, course of these disorders and treatment response are worse and this condition has a negative effect on patients' quality of life. Treatment of comorbid substance use disorder and psychiatric disorders has special difficulty. One of the difficulties in this comorbid situation is that drugs used in these disorders have addiction potential. The other potential difficulty is that these patients have high suicidality risk. İn the treatment of this population, safety and stabilization of the patient must be ensured. After that in the long period, both pharmacologic and psychosocial treatment strategies must be used collaterally. The most effective treatment approach in patients with comorbid substance use disorder and severe psychiatric disease is to apply the treatment methods of each disease by the same clinician who is good in two areas in the same therapeautic setting. When treatment of this disease is made effective, success of therapy of both substance use disorder and comorbid disease increases and the course of these diseases is better. For 30 years, bright light therapy (BLT) has been considered as an effective, fast-acting, and welltolerated treatment option for seasonal affective disorder (SAD) and although still questionable in non-seasonal types of depression [1]. A comprehensive review that evaluated 20 placebocontrolled studies reported BLT to be superior to placebo in non-seasonal depression. This review emphasizes that there are more significant differences in the effectiveness of BLT in high-quality studies [2]. A meta-analysis, based on randomized, controlled trials with stringent inclusion criteria suggests that BLT is efficacious for SAD and non-SAD with effect sizes equal to the most antidepressant pharmacotherapy trials [3]. A recent meta-analysis, which included 458 patients, revealed that BLT is an effective treatment as an augmentation therapy compared to antidepressant usage alone. In addition, the effect size of BLT was found to be similar to that of other common augmentation strategies [4]. According to the American Psychiatric Association Practice Guideline for the treatment of patients with major depressive disorder, BLT might be used to treat non-seasonal affective disorder as well as seasonal depression. Other studies have shown that BLT is well tolerated compared to other pharmacological agents and that drop-out rates due to side effects are much less [5]. In addition, a recent meta-analysis investigating the efficacy of BLT for bipolar depression revealed BLT to be an effective and safe treatment option as an adjunctive therapy, as our study [6,7]. Consequently, a treatment option that is fast-acting like BLT may facilitate recovery in the acute phase of depression and may help to form better adherence and higher remission rates. There is a need for large sample sized, double-blind controlled studies for establishing the efficacy and safety of BLT for the treatment of depression in future.

KEYWORDS
Antidepressant; bright light therapy; depression; seasonal affective disorder; treatment multiple drugs, etc. Studies that used general symptom scales have reported a long list of side effects or adverse reactions in individuals using drugs with probable or possible side effects. In general, other than the nervous system, symptoms can occur in the alimentary tract and intestines, haematopoietic organs, genito-urinary system, reproductive organs, musculo-skeletal system, respiratory system, and sensory organs [8]. The list of side effects, however, is much longer and includes, dry mouth, sore throat, dry skin, reduced sweating, constipation, functional ileus, fever, photosensitivity, blurred vision, tachycardia, hypertension, urinary hesitation, nocturnal incontinence, impaired coordination, confusion, memory problems, incoherence, reduced ability to concentrate, hallucinations, and dementia. More general symptoms such as drowsiness that may be missed by the patient, caregiver, or the physician may also be experienced. Up to one-third of older adults use anticholinergic drugs which are significantly associated with an increased number of anticholinergic symptoms, and dry mouth and constipation can be seen in almost half of the individuals [9]. Notably, tricyclic antidepressants and agents used for treating urinary incontinence come forward with their more frequent anticholinergic side effects. On the other hand, not all drugs are susceptible for anticholinergic side effects and the severity of adverse reactions can differ by the drug classes [10]. Different drugs with a similar clinical indication and efficacy may show different levels of anticholinergic side effects, limiting the choices of some generics from the same family among older adults. In conclusion, efforts should be made to increase physician awareness about anticholinergic side effects, especially among older adults. These side effects should be realized as the "risk" of any treatment with a specific indication and, on an individual basis, such risks should never overweigh the benefits.
has been definitive in decision making of absolute benefits and harms. In this context, any drug that has been widely used for years may now be regarded unsafe [1]. Nevertheless, deprescription or withdrawal of medications has never been a trending topic in chronic conditions. Beers Criteria from the United States [2] and STOPP/START from Europe [3] point to a need for improvement for the prescription of drugs with anticholinergic effects in older adults.
Researches have also shown that these two are compatible for most parts and applicable in different populations [4]. Beers criteria recommend avoidance of first-generation antihistamines; antiparkinsonian agents benztropine and trihexyphenidyl; disopyramide; a long list of antidepressants; and some skeletal muscle relaxants in people aged 65 years or older. Concerns and limitations were also mentioned about antimuscarinics used to treat urinary incontinence among Beers criteria, but loratidine was removed from the list of drugs to be avoided in the update version [2]. The START/STOPP criteria showed a 31% increase in its version 2 update after seven years and include recommendations against the use of diphenoxylate, loperamide, or codeine phosphate for the treatment of severe gastroenteritis, selective alpha-blockers in males with frequent urinary incontinence, first-generation antihistamines and long-term opioids in patients with falls, and long-term opioids in those with dementia unless indicated for palliative care or management of moderate/severe chronic pain syndrome [3]. Moreover, both publications address use of scales [5][6][7][8] to rank anticholinergic activity before decision making of continuing or withdrawal of a medication but Beers criteria acknowledge a list of drugs with strong anticholinergic properties. However, although elements of the deprescribing process have been defined by several authors [9], there is no specific guideline outlining how to perform evidence-based deprescription in the care of older adults.
Ongoing research are expected to identify the problems and introduce successful interventions to reduce the prescription of anticholinergic and sedative medicines [10,11]. Yet, advanced clinical skills and experience may help reduce the burden of anticholinergic drug exposure, but a broader use of an anticholinergic risk scale by physicians seems critical [12]. In addition, involvement of patients in the process of deprescribing should not be ignored, and understanding of prescriber barriers needs to be determined to reduce iatrogenic harm [13].

ABSTRACT
Depression is a serious and debilitating mental health problem that is estimated to affect 350 million people worldwide [1]. It is well known that it causes a significant occupational and social impairment with a recurrent or chronic course. However, SSRIs and cognitive behavioural therapies are accepted as current effective treatment strategies, and there is a considerable failure of available treatment approaches. Furthermore, depression creates a great socioeconomic burden in societies. In line with these issues, new therapeutic approaches are highly needed for not only treating depression but also preventing the development of depressive symptoms. There is a bidirectional relationship between physical activity and depression. In literature there is data that individuals with depression tend to show lower physical activity and lower physical activity seems to be related with higher levels of depressive symptoms particularly with somatic complaints and lower self-efficacy [2]. Both for preventing and reducing the severity of depression, physical exercise has been suggested in medical settings. According to the recent studies, there is robust evidence suggesting that exercise provides protection against future depression. Also, studies found that exercise was moderately effective in reducing depressive symptoms in individuals with depression. However, the optimal intensity of exercise and possible underlying neural effects of exercise are less known. In this section we will present the current literature regarding the effects of physical exercise in both preventing and managing depression. The beneficial and/or harmful effects of different exercise subtypes will be reviewed. Possible neuromolecular and neurochemical mechanisms of the exercise's antidepressant effect will be discussed. Finally, we will discuss how we should place physical exercise recommendations in treating our patients with depression in our daily practice. Adult attention-deficient/hyperactivity disorder and classical cyst applications

Gülay Oğuz
Samsun, Turkey E-mail address: gozdemir24@hotmail.com ABSTRACT ADHD is a problem diagnosed in childhood and continues in adulthood. In follow-up studies, 80% of children with ADHD have been shown to be adolescent and 50-70% continue in adulthood.
Adult ADHD in our country has become more and more recognized in recent years, and ADHD findings were seen in childhood with a majority of patients diagnosed with Anxiety Disorder, SAB, or BAB in these developments. Despite the use of medication in the treatment of ADHD, especially during childhood, medication is used in some special cases (academic exams or family crises) in adults and these medicines are not paid for in adults over 25 years of age. Cognitive Behavioural Therapy (CBT) is the most commonly applied treatment for children and adolescents besides taking medication. Children with this diagnosis met with better results when they were receiving skills training with the CBT as well as drug therapy. In adults, academic performance and self-esteem are negatively influenced by reasons such as not being able to finish work and dependency tendencies. Due to the fact that executive functions are impaired, these patients are negatively affected by their care and organizational and planning skills, and their work and family lives are negatively affected. For this reason, the panel will focus on the importance of using ADHD and individual BDT and the techniques used. BDT treatment protocol steps: (1) Psychoeducation: Disease and CBT education (2) Identification of problem areas: Problems such as not focusing attention, deferring, being unable to organize, taking responsibility, impulse control problems are common. (3) Skill development; Organization and planning skills, attention training, problem-solving skills development, the ability to control the prosperity is studied. (4) Cognitive configuration: It allows patients to develop new ability to cope and to create new experiences in life-threatening areas that are difficult to manage up to now. With these new experiences, it can be ensured that the belief system is rearranged, the impulse control, the longer thinking action and the motor action are performed properly.

Mindfulness in adults with attention-deficit/hyperactivity disorder (ADHD) therapy
Gülçin Şenyuva NP Istanbul Brain Hospital, Istanbul, Turkey E-mail address: gulcinsenyuva82@gmail.com ABSTRACT Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental condition that is manifested in childhood with attention deficit, hyperactivity, and impulsivity. In the emergence of ADHD according to the results of the research, biological, genetic, psychosocial, and familial factors play a role. The prevalence of ADHD in the community is reported to be approximately 8% in childhood, 6% in adolescence, and 4% in adulthood. The inability to start a job in adult ADHD, the inefficiency and bad time management at work, the start of a large number of jobs, but not a majority, a meeting during a meeting, an inability to cope with stress and anger control problems, a tendency to tell the first thing that comes to mind and to fulfil marriage and responsibilities intensive problems often arise. Awareness is based on being able to pay attention to the present "moment" in a nonjudgmental way, and accepting whatever it is experiencing. In this approach awareness and consciousness, acceptance, judgment, self-observation, and focus are the main components. Certain regions of our brain have the ability to control self, the ability to manage emotions, and to make healthy decisions. The aim of the awareness therapy in ADHD individuals is to teach them to be aware of their mind and body, to be able to control their own behaviours, to increase their attention skills, self-confidence level, anger control skills, to adapt to social environments, and to make inter-person relations more healthy.

KEYWORDS
ADHD; neurodevelopmental condition; therapy; awareness; brain ABSTRACT Obesity is a chronic and progressive disease which is considered as one of the 10 most risky diseases by the World Health Organization (WHO), and which negatively affects the quality of life of the individual, and in which patients live usually for less than 60 years. Along with 2-3 times increased risk of obesity in individuals with mental illnesses, the rate of mental illness in obesity is 30-70% (3). Recently, cognitive behavioural therapy approaches have also started to make an important role in the treatment of obesity in addition to other treatments. Behavioural treatment of obesity aims to replace eating behaviours leading to obesity and unwanted behaviours about physical activity; with desired behaviours or decrease those unwanted behaviours, as well as to reinforce desired behaviours to become a "lifestyle." Cognitive Behavioural Therapy in Obesity:

KEYWORDS
Consultation liaison psychiatry; obesity; cognitive behavioural therapy; selfmonitoring; unwanted behaviours (1) Self-monitoring: Self-monitoring is the core of the treatment and serves the target of defining to be controlled behaviour. (2) Stimulus control: Stimulus control is established through reinforcement due to the desired behaviour in provision or the presence of target stimulus. (3) Control of eating behaviour: Aim is to decrease the speed and frequency of eating behaviour. (4) Reinforcement: Reinforcement by learning principles is based on the effects of results of behaviour on its frequency and intensity. (5) Cognitive restructuring: Cognitive behavioural therapy of obesity relies on evaluating the cognitions maintaining the problematic situation and replacing these conditions with functional alternative cognitions. (6) Proper nutrition education: Patients need to perceive nutritional education as a method to learn an eating behaviour that will last lifelong. (7) Increasing physical activity: After observing physical activity, behavioural techniques are developed in order to increase observed physical activity level. (8) Behavioural contracting: Contracting is applied in order to match reinforcement methods and stimulus control. (9) Methods to maintain ideal weight Risky circumstances that may lead to relapse are determined during the active treatment period and strategies are developed in order to cope with these circumstances. In treatment of obesity, combining lifestyle changes such as diet and physical activity together with cognitive behavioural interventions increase treatment efficacy and enable maintaining the attained weight (4).

[Abstract:0786][Other]
Off label use of atypical antipsychotic drugs in paediatric population: a doubleedged sword

Çiğdem Yektaş
Duzce University School of Medicine, Department of Child and Adolescent Psychiatry, Duzce, Turkey E-mail address: drcigdemyektas@hotmail.com ABSTRACT Use of atypical antipsychotic agents (AAPs) in management of various psychopathologies in Child and Adolescent Psychiatric practice is gradually increasing. According to the Texas-Medicaid Study, total use of antipsychotics in children and adolescents has increased from 7.7% to 20.0% from 1996 to 2000. Possible reasons for the rising trend in antipsychotic use are listed as: (1) greater acceptability of psychotropic medication use in children; (2) increased knowledge and awareness; (3) limited access to non-pharmacologic treatments; (4) demand for quick and affordable treatments; (5) inadequate provider time and reimbursement for managing behavioural problems and (6) limited treatment options for vulnerable populations. FDA has approved risperidone for the treatment of irritability and aggression in autistic children aged 5-16 years and risperidone and aripiprazole for the treatment of schizophrenia in children aged 13-17 years. More recently, four other atypical antipsychotic medications were approved for the treatment of bipolar I disorder and schizophrenia: quetiapine, olanzapine, ziprasidone, and aripiprazole (for bipolar disorder only), paliperidone (for schizophrenia only). It is important to note that although the FDA has approved second-generation antipsychoti medications for these conditions, most paediatric use is off label, that is, prescribed for conditions not approved by the FDA. AAPs are more frequently used in paediatric samples for the management of Attention-Deficit/Hyperactivity Disorder (ADHD), Conduct Disorder (CD), and mood disorders rather than psychotic KEYWORDS Atypical antipsychotics; offlabel use; child and adolescent; safety; efficacy; adverse effects disorders. Among adult patients with Major Depressive Disorder (MDD), AAPs' agents are frequently used in the management as augmentative agents along with anti-depressants. It was also suggested that AAPs may be used in adolescent patients with MDD and irritability/ self-harming behaviours. A recent study from the US reported that AAPs' agents were more frequently used in the treatment of MDD in the late adolescence-early adulthood. They also reported that off-label use of antipsychotics for the management of depression and anxiety disorders was more common in female patients. Off-label use of APs is also common among patients with Intellectual Disability (ID) especially for non-compliance and behaviour problems. Clinicians show a tendency to use atypical antipsychotics rather than typical antipsychotics because of their decreased risk to cause extrapyramidal symptoms and tardive dyskinesia. In line with the literature, AAPs have been shown to reduce aggression, and practice guidelines support the appropriate use of atypical antipsychotics in youth. Even though the growing body of evidence supports the safety and efficacy of atypical antipsychotics, especially risperidone, for the treatment of aggression; off-label use of AAPs in youth and temporal trends for increasing use have also raised concerns about adverse effects of AAP use. Most commonly reported adverse effects in youth using AAPs were reported to be weight gain, obesity, hyperglycaemia, diabetes and insulin resistance (i.e. metabolic syndrome), cardiac problems, sedation, extra pyramidal symptoms (EPS), and hyperprolactinaemia. Also twofold to fivefold increase in the use of antipsychotic medications in children younger than 6 years has been reported, despite little information on their long-term effects on child health and the developing brain. Use of optic coherence tomography in psychiatric diagnosis and follow-up

Mehmet Hamdi Örüm
Department of Psychiatry, Adiyaman University School of Medicine, Adiyaman, Turkey E-mail address: mhorum@hotmail.com ABSTRACT Optic coherence tomography (OCT) is a novel imaging method that can capture biological tissue layers by acquiring high-resolution sections. This technique measures the delay time and intensity of infra-red light, which is transmitted to and reflected from different tissue layers. It gives cross-sectional images of tissues similar to, but with much a higher resolution than ultrasonography. Its use increased rapidly because it is a non-invasive and rapid method that can assess the macula thickness (MT), volume (MV), and retinal layers. Because OCT technology significantly enhances the imaging resolution, the segmentation of retinal layers, such as the ganglion cell layer (GCL), inner plexiform layer (IPL), and retinal nerve fibre layer (RNFL), is now possible. The RNFL involves axons of ganglion cells, the ganglion cell layer (GCL) involves bodies of ganglion cells, and the IPL involves dendrites of ganglion cells (Parver, 1991). Another parameter that can be measured with OCT is choroidal thickness. More recently, its use was expanded to neurodegenerative diseases because the retina is an anatomical extension of the brain, and retinal changes may occur in parallel with inflammation and CNS degeneration. OCT has shown retinal changes in neurodegenerative diseases, such as multiple sclerosis, Alzheimer's disease, Parkinson's disease, and restless leg syndrome which correlated with the severity of clinical disease. More recently, OCT was used to detect neuronal degeneration in psychiatric disorders. Our group demonstrated reduced GCL and IPL volumes in schizophrenia patients compared with controls using spectral OCT. We also detected significant negative correlations between disease severity parameters and GCL and IPL volumes. In our another study, it is suggested that the neurodegeneration that occur during the course of bipolar disorder may be demonstrated by decreased GCL at early stages, and as the disease progresses, involvement of other retinal layers, such as the RNFL KEYWORDS Optic coherence tomography; ganglion cell layer; inner plexiform layer; retinal nerve fibre layer; macula; choroidal thickness and IPL, may be observed. Again, our research team demonstrated that the OCT finding of decreased GCL and IPL volumes supports previous research suggesting degeneration in major depressive disorder. In another our study in patients with obsessive-compulsive disorder (OCD), we suggested that OCT can be used to detect neurodegeneration in OCD and that the GCL and IPL volumes can also be used to monitor the progression of neurodegeneration. Again, we have demonstrated that in a study comparing OCT results of conversion disorder (CD) patients with healthy controls, the GCL and IPL findings suggest that neurodegeneration occurs during the course of CD especially in subtype involving motor component. The choroid may be used to determine the active stage of the disease and to monitor inflammatory process like other inflammation markers used in systemic inflammatory diseases. In sum, there are significant results about OCT use in psychiatry. The analysis of GCL and IPL volumes with more sophisticated OCT devices provides better structure-function correlation and may be used to monitor the progression of neurodegeneration. I would like to thank Dr Aysun Kalenderoğlu, my assistant professor for the help in writing, and from whom I benefited from his knowledge on OCT.

[Abstract:0788][Psychotherapies]
What is the situation of psychotherapy in Turkey?

Erol Göka
SBÜ Ankara Numune Eğitim ve Araştırma Hastanesi E-mail address: erolgoka@hotmail.com ABSTRACT Although psychotherapies and psychological treatment services are irreplaceable for modern psychiatry and psychological initiatives, there is a serious chaos in the area. The reason for the confusion is that there is no certainty concerning the concept, definition, and practice, as well as that there is uncertainty about the professional boundaries because they deal with many professions. The case in point all over the world is in a chaotic situation when it comes to Turkey. In the current legal situation, almost every attempt can be made named as "psychotherapy" except psychopharmacological and somatic therapies applied by the psychiatrists, whereas the treatment attempts made by the people outside psychiatry are almost criminal. There are many reasons for the chaos in the field of psychotherapy and psychological treatment services in Turkey, and it is necessary to find a solution as soon as possible. So, in this speech, we will try to create a panoramic image for the psychotherapy field in Turkey as well in the meantime we will try to focus on the practical implementation challenges. The effect of clozapine has been proven in patients with treatment-resistant schizophrenia. However, the prescription of clozapine is limited due to need for the gradual increase in dose in the initiation protocol, the long and costly follow-up protocol, the interaction with many drugs, the presence of life-threatening side effects, the gradual cessation of treatment within 1-2 weeks, and the high cost of treatment. Therefore, these conditions motivate clinicians to identify patients with adequate response. In addition, when compared with other antipsychotics, it is reported that clozapine needs a longer duration of treatment and KEYWORDS Clozapine; clozapine response; treatment resistant; schiophrenia; psychosocial approaches the clinical response may appear to be relatively late. In this regard, drug plasma concentration, brain imaging, clinical parameters, genetic studies, and quantitative electroencephalography (QEEG) studies were used to predict clozapine response. Data obtained from current studies will prevent clinicians from wasting time in patients who are unlikely to respond to clozapine by not using a drug that does not have a positive effect on the treatment process, while at the same time preventing patients from being exposed to the side-effect profile of clozapine. However, progress in this area will significantly contribute to the prevention of improper use of health-care facilities, the reduction of financial costs associated with the use of unresponsive drugs, and the reduction of the use of additional medication and health units due to clozapine side effects Chronic migraine is a public health concern, causing serious amounts of disability, excessive drug usage, and frequent hospital admissions. Chronic migraine, described as headache occurring on 15 or more days per month for more than three months, which, on at least 8 days per month has symptoms of migraine headache according to The International Classification of Headache Disorders (ICHD-III beta version), negatively affects patients' quality of lives. Patients who have received appropriate prophylactic treatments for their pain management such as anticonvulsant, beta blockers, calcium channel blockers, and tricyclic anti-depressants but whose quality of life is negatively affected even though they are administered with adequate doses and period of time can be evaluated as treatmentresistant. The American Headache Society (AHS) has proposed in 2008 to name chronic migraine patients who have modified triggers, lifestyle factors, and those who have taken adequate amounts of acute and prophylactic drug combinations but still have not gained any significant change in their quality of life as "Refractory Chronic Migraine Patients." It has been reported that psychiatric conditions are important in the chronicity of migraine-type headache, which are known to be associated with temperament traits such as perfectionism, neuroticism, and suppressed aggression. Cognitive Behavioural Therapy (CBT) for pain management is a form of therapy which aims to modify thoughts and behaviour in a realistic and balanced way and change in behaviours during headache attacks. In CBT for migraine rationale for behavioural pain management, headache diaries, relaxation, pleasant imagery, and pleasant activities techniques might be used. Psychopharmacological treatment of attention deficit hyperactivity disorder comorbidity in ASD Gülser Şenses Dinç Department of Child and Adolescent Psychiatry, Ankara Children's Hematology Oncology Research and Training Hospital, Ankara Turkey E-mail address: gulserdinc@yahoo.com ABSTRACT Autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) are neurodevelopmental disorders. ASD is characterized by impairments in communication and social reciprocity and stereotypic and/or repetitive behaviours. ADHD, the most common psychiatric disorder diagnosed in childhood, is characterized by symptoms of inattention, impulsivity, and/or hyperactivity beyond what would be expected for the developmental level. Despite these main symptom differences, between 30% and 50% of individuals diagnosed with ASD also exhibit elevated levels of ADHD symptoms. These behaviours may be related to comorbid attention-deficit/hyperactivity disorder (ADHD) or to other factors KEYWORDS Autism spectrum disorder; attention-deficit/ hyperactivity disorder; ADHD; psychopharmacology; treatment that affect function in children with ASD (e.g. overarousal, anxiety). If the behaviours do not improve with environmental or behavioural interventions, they may respond to pharmacotherapy [1]. Psychostimulant medications: Methylphenidate appears to improve symptoms of hyperactivity and inattention in children with ASD, but the response to methylphenidate is lower in children with ASD than it is in children with isolated ADHD. In the largest crossover trial, approximately 50% of children with ASD responded to methylphenidate; the effect size ranged from 0.20 to 0.54, depending upon dose and rater, with greater improvement at higher doses [1,2]. Studies of amphetamines in the treatment of attentional symptoms in children with ASD are lacking. It is not clear that the results from trials of methylphenidate can be generalized to amphetamines [2]. Non-psychostimulant medications: Studies of atomoxetine for symptoms of hyperactivity and inattention in children with ASD are limited. Randomized crossover trials suggested some improvement in hyperactivity-impulsivity symptoms compared with placebo. However, as with methylphenidate, the overall effect size for atomoxetine in children with ASD and symptoms of ADHD is smaller than for children with ADHD without ASD [2,3]. Studies of alpha-2-adrenergic agonists are limited, and sample sizes are small. Some studies show that guanfacine and clonidine are effective in reducing hyperactivity, inattention, and irritability symptoms [1,2]. Other drugs that may be beneficial for symptoms of hyperactivity and inattention in children with ASD include risperidone and antiseizure drugs. The use of risperidone for symptoms of hyperactivity in children with ASD is supported by open-label and randomized controlled trials. The evidence for antiseizure agents is limited to small, open-label, or observational studies [2]. In conclusion, researches generally support the use of psychopharmacological treatments for reducing impairing ADHD symptoms in individuals with ASD. But further studies are needed to increase understanding of the effectiveness and about clinical practice. obesity and insulin resistance. With LDL cholesterol usually at normal levels, there is an increase in the atherogenic and small dense LDL subgroups. Hypertriglyceridaemia and low HDL lead to an increased risk of cardiovascular disease. A single genetic, infectious, environmental factor that may explain the aetiopathogenesis of all components of MS has not yet been identified. However, insulin resistance is the basic pathology of this syndrome. According to many tests measuring insulin resistance, HOMA and QUICKY are reliable methods. In turns out that insulin resistance is very important as it is thought to be related to obesity, hypertension, and hyperlipidaemia. Metabolic syndrome and hyperlipidaemia in psychiatry: treatment option

Erdal Erşan
Sivas Numune Hospital, Community Mental Health Center, Sivas, Turkey E-mail address: eerdalersan@hotmail.com ABSTRACT Life standards of schizophrenic and other psychiatric patient groups must be monitored and also kept under control. Both antipsychotics and antidepressants have various side effects and therefore each of them should be used with great attention. Some of these side effects are termed as metabolic side effects and these are the most important side effects of all. If necessary precautions are not taken serious physical problems may occur. While the treatment proceeds, the weight, blood sugar level, and blood lipid profile should be kept under control. Evaluating frequent blood tests, regular weight control, paying attention to keeping a balanced diet, and regular blood pressure control are necessary. If some of the controlled values are out of the expected boundaries, the medical treatment should be reevaluated. Briefly while the psychiatric treatments are proceeding, regular internal examinations and regular blood tests should be done. All of the systemic disorders presented by the patients who have metabolic syndrome are phenomena that trigger each other and are both causes and consequences of each other. In this regard, reducing these systemic disorders should be the first plan before medical treatments in the treatment of metabolic syndrome. Diet and nutrition: The most important phase of the treatment of the metabolic syndrome is controlled weight loss. Hypnobesity: The processes of making the patient gain a healthy and balanced diet as a habit by the use of hypnosis is called hypnobesity which is a useful treatment option for the weight control of the suitable patient groups. Physical activities: The main reasons for obesity are unhealthy diet and physical inactivity. Also in the course of the treatment of metabolic syndrome, physical activity is also as important as diet. All patients with metabolic syndrome should carry out a systemic diet and exercise programme. Patients who have lost approximately 10% of their weight due to an organized diet and exercise programme experience a decrease in nearly all the metabolic syndromes and symptoms of its components. Medical treatment: For the treatments of problems that are also the components of metabolic syndrome such as insulin resistance, high blood pressure and blood cholesterol levels, obesity, and diabetes, there are medical options that can be used proportional to the advancement of the individual problems of the patient. Surgical treatment: When the classical treatment options have failed, the most effective and the permanent treatment option is metabolic surgery. During the treatment course of the psychiatric patients, being under control and monitored by a nutrition specialist decrease the possibility of heart diseases and metabolic syndrome and increase patients' quality of life. Problematic sexual behaviours and their treatment in children and adolescents with autism spectrum disorder(ASD) and intellectual disability

Mehmet Fatih Ceylan
Department of Child and Adolescent Psychiatry, Yıldırım Beyazıt University School of Medicine, Ankara, Turkey E-mail address: fatihceylan80@yahoo.com Individuals in their teenage years try to get over from the effects of the parents and seek answers to "Who am I?" question. In this period, due to the effects of hormones and brain development not being complete, inappropriate sexual behaviours can be seen even in normal intelligence individuals. Intellectual disability is present in mentally retarded or autistic individuals; however, their hormone levels are normal. Thus, we see inappropriate sexual behaviours in these individuals more often. Sexual aggression, as well as physical aggression due to the effects of hormones, is increasing in individuals with autism and intellectual disability during adolescence. Masturbatory behaviours in the wrong places, sexual aggression to other family members are more frequent in those disabled group. Cognitive therapy is difficult to respond to these patients because of their cognitive development. Treatment strategies that include behavioural suggestions, use of psychopharmacologic or drugs that suppress sexual desire, and hormonal remedies to suppress male hormone in resistant cases will be discussed. Using antipsychotics in children with autism spectrum disorders

Selma Tural Hesapçıoğlu
Department of Child and Adolescent Psychiatry, Yıldırım Beyazıt University School of Medicine, Ankara, Turkey E-mail address: selmahesapcioglu@yahoo.com ABSTRACT Autism spectrum disorder (ASD) is a heterogeneous neurodevelopmental disorder characterized by impairment in social communication and interaction and by restricted and repetitive behaviours, interests, and activities. Besides those core symptoms, serious behavioural disturbances such as irritability, which may manifest as aggression, tantrums, and deliberate self-injury are not rare in ASD. These symptoms further impair social interaction and communication, represent a significant burden to individuals and their families, and disrupt school and family environments. No psychopharmacologic drugs targeting the core symptoms of ASD have been approved yet. However, antipsychotics are found to be effective in the treatment of paediatric patients with irritability associated with autistic disorder, including symptoms of aggression toward others, self-injuriousness; temper tantrums, and quickly changing moods. Studies showed that antipsychotic agents decrease behavioural problems and increase the adaptation of the individual with ASD to the environment. The first-generation antipsychotic use is decreased in recent years. Secondgeneration antipsychotics risperidone and aripiprazole are approved by the FDA for the treatment of irritability associated with autistic disorder. Levine et al. (2016) reported that parents could expect benefits from risperidone in terms of irritability and lethargy with moderate to severe symptoms of ASD. The improvement of social skills was also reported with risperidone (Aman et al. 2015). Lamberti et al. compared risperidone and aripiprazole in the treatment of attention deficit hyperactivity (ADHD) symptoms in children with ASD, with 37 of the children completing the 24 weeks of treatment. They suggested that both aripiprazole and risperidone are effective in ameliorating the ADHD symptoms in ASD (Lamberti et al. 2016). Moreover, Ghanizadeh and Sahraeizadah (2014) reported that the safety and efficacy of aripiprazole and risperidone were comparable in their head-to-head comparison study. A few studies compared the effectiveness and adverse effects of olanzapine in children and adolescents with ASD. In this presentation, the effectiveness, tolerability, and side effects of the antipsychotics will be discussed in the ASD patients with behavioural disturbances.

KEYWORDS
Autism spectrum disorder; antipsychotic; risperidone; aripiprazole; olanzapine Identifying the boundaries and context of the interaction between psychiatry and the law is a subject of a long-standing puzzlement for the members of both professions. Nevertheless, it is well known that there are certain paths in which both civil and criminal legal systems rely on psychiatric input. Psychiatrists have been increasingly aware of the need for expertise in legal aspects of psychiatric practice and in satisfying the legal systems' needs for psychiatric participation in adjudicating matters involving mental health. Indeed, such a necessity has led to the fact that forensic psychiatry has become one of the most acknowledged and respected psychiatric subspecialty in particular countries in recent decades. Forensic psychiatry primarily covers the field of expert witnessing; it also deals with the patients' clinical needs. Mens rea is the mental element of an offense, and psychiatric disorders have the potential to influence the competency or capacity to form any particular intention or behaviour that can lead to a crime. Therefore, psychiatrists are frequently asked to evaluate a defendant's mental state at the time of the offense to determine the required mens rea that is related to the crime. In different countries, psychiatrists are involved in various stages in law systems. For instance, assessment for insanity defence (or competency assessment for criminal responsibility) is one of the vital parts of forensic work in Mainland Europe countries, including Turkey, while very few cases of insanity come to the courts in Anglo-American law. On the other hand, in the United Kingdom, if there is a suspicion of a presented mental disorder of the offender that is thought unfair to proceed with the trial, psychiatrists are invited to assess an individual's fitness to plead (competence to stand trial in the United States). Clinicians are needed to indicate whether a defendant has sufficient understanding and cognition to comprehend the purpose of trial proceedings or to defend him/herself in front of the court. Although forensic psychiatry usually deals with the assessment and management of mentally disordered offenders and other patients with mental disorders who are, or have been potentially or actually violent, civil legislations also occasionally require psychiatric testimony. Civil law which relies heavily upon common law is the term used for the law dealing with disputes between individuals or organizations. Psychiatrists become involved in civil law on an occasional basis which usually requires a detailed clinical evaluation for judgment and decision-making abilities. Psychiatrists may be asked to comment on the mental capacity or state of mind of a patient or individual in relation to a contract or statement, to consider whether a particular act or omission committed by a defendant has caused a psychiatric disorder, or to comment a patient's requisite for authorization of a legal representation or a legal supervision in order to employ official proceedings. The civil law system used in most parts of the world is quite different. In Turkey, the Turkish Civil Code regulates the issues mentioned above that become subjects of psychiatric expert witnessing. Involuntary treatment of the mentally ill is an essential matter in the context of civil law. It is among the most controversial issues in mental health care and is the subject of ongoing debate among patients, mental health professionals, and a wider public due to its both ethical and legal amorphous characteristics. In Europe and other developed countries, independent mental health laws are in force and regulate involuntary commitment of psychiatric patients that mainly possess a danger to him/herself or the public due to their mental disorder. Mental health laws authorize the psychiatrists to determine a patient's need for involuntary treatment and hospitalization; however, for instance, clinicians' decisions would be challenged and frequently need to be backed by a second opinion or an independent tribunal according to the Mental Health Act in the United Kingdom. In some countries including Turkey, responsible psychiatrists should apply to the civil court for involuntary psychiatric treatment for non-criminal psychiatric patients. In Turkey, enactment of the Mental Health Law is in progress and is expected to come into force in the near future. The template of the Mental Health Law is inspired from the mental health legislation and clinical implications of mainland Europe countries and it is strongly asserted that Mental Health Law would disambiguate the controversies regarding evaluation and treatment processes that psychiatrists encounter in clinical settings. Prospective studies suggest that approximately 30% of trauma-exposed individuals will meet criteria for posttraumatic stress disorder (PTSD) within three months following the exposure while the remaining individuals seem to be resilient. After treatment of this affected population, some individuals continue to experience disruptions in quality of life, especially relationship difficulties, although PTSD symptoms have been reduced (1). Intervention on two trauma-related emotionguilt and shameseems to play a key role to overcome difficulties in relationships and self-compassion (SC) interventions could provide an effective way for this. Also the protective role of SC with respect to trauma-related psychopathology was indicated in many studies. Shame has two transdiagnostic behavioural dimensions; experiential avoidance and self-criticism, that are closely related to PTSD and Acceptance and Commitment Therapy (ACT)-based SC interventions could be useful for both dimensions. Neff conceptualized SC as feelings of care and kindness towards oneself through taking a non-judgemental attitude towards one's perceived inadequacies with a willingness to be open to one's own suffering without avoiding it (2). The ACT processes of defusion, acceptance, present moment, values, committed action, and self-as-context are to some degree inherently self-compassionate and so SC is implicit in the processes targeted by ACT. ACT work as SC focuses on deictic frames or perspective taking based upon Relational Frame Theory (RFT). RFT suggests that I and you are intimately interconnected, in that there cannot be an 'I/Here/Now' without a 'You/There/ Then.' From this perspective, ability to feel warmth and express warmth towards oneself, the target of SC, depends on perspective-taking frames (3). While SC can be seen as implicitly involved in all ACT work, making it explicit in in therapy, especially when working with highly self-critical and shame-prone clients as in PTSD, may improve the outcomes. Studies on self-stigma, whose main emotional component is shame, provide support for the application of ACT for self-stigma and shame (4,5). Also in a study that addresses self-stigma related to HIV status, combination of ACT and Compassion-Focused Therapy (CFT) was found to be effective in increasing psychological flexibility and reducing HIV-related stigma (6). In light of these, self-criticism and shame should be taken in consideration in ACT work when studying patients with PTSD symptoms to improve therapy outcomes.

KEYWORDS
ACT; self-compassion; shame; self-criticism unwanted experiences. Each of these can be considered as processes that persist in PTSD. Unfortunately, the literature to date suggests that the optimal ways to apply mindfulness for therapeutic change are not yet clear. This is not to suggest that mindfulness should be abandoned. By contrast, clinical wisdom suggests that mindfulness can be very meaningfully applied to support psychological change. Thus, the questions of for whom mindfulness will be most impactful, in what way it should be taught and how the experience of mindfulness may be best leveraged to support change will become paramount.

SPSS for dummies
Yüksel KIVRAK Department of Psychiatry, Kafkas University School of Medicine, Kars, Turkey E-mail address: ykivrak21@gmail.com ABSTRACT SPSS is known to be difficult. Those who don't know how to drive also think driving is difficult. A car has many parts and each has its own significance. The motor converts energy. There are gasoline, diesel and electrical motors. Gasoline motors are those that are most commonly used at the moment. Approximately 20% of the consumed fuel is directed to the wheels. Suction, compression, expansion and exhaust are the working stages of a four-cycle engine. The mechanism is slightly different in diesel and electric motors. The transfer elements are the clutch, crankshaft and the differential gear. However, it is not necessary to know all these to drive a car. Many people can use a car in their daily life after receiving the necessary training. Even those who do not transfer loads and passengers participate in car races or produce and repair cars can use a car in their daily life without knowing most of this information. Many psychiatrists need to use SPSS from time to time. It seems to be scary and too complicated for an ordinary person to use, something to stay away from as much as possible. The aim of the course is to show that SPSS is not a monster and that it can be used with various approaches. We will work with participants who have never used SPSS using free Internet resources. The data will be entered into SPSS by a voluntary participant and then will be analysed with SPSS using algorithms, through the use of these resources.

Vahdet Görmez
Bezmialem Vakif University, Department of Child and Adolescent Psychiatry, Istanbul, Turkey E-mail address: vahdetgormez@gmail.com ABSTRACT Children and adolescents often present with firmly held rigid beliefs, emotions, and behaviours representing their psychopathologies. As cognitive behavioural therapy (CBT) introduces a flexible framework for emotional changewhich, according to the cognitive therapy, can be accomplished through a rational analysis of the cognitions and adaptive modification of the related behaviours metaphors and stories may be included in this flexible framework of meaning transformation. Providing a conceptual bridge from a problematic interpretation to a constructive and problem-solving new perspective, metaphors are especially useful in boosting-up children's information processing systems and aiding them to recall the new information they gained through the process of CBT. Although they can be simple figures of speech, metaphors are often presented in the form of short stories and parables that provide a more elaborate visual description. In this presentation, the importance of metaphors in CBT is emphasized and examples of metaphors and stories are provided for therapists to augment traditional cognitive behavioural interventions and for clinicians to enhance their daily clinical practice.