Understanding the characteristics of Autism Spectrum Disorder (ASD) - including difficulties in social communication, persistent and repetitive behavioral patterns, and a narrow range of interests - within the context of specific life challenges is invaluable for comprehending the individual struggles of patients. This understanding also guides caregivers in adopting a more proactive, positive, and targeted approach. This article aims to summarize the key traits of ASD in adults, provides concrete examples of difficulties that may arise in outpatient settings, and offers guidelines for appropriate responses. Examples of the specific challenges encountered in outpatient settings were provided to help readers predict the difficulties patients may experience, and identify individuals who may have undiagnosed ASD. Effective interventions were summarized into three domains: a) clear and explicit communication, b) predictable and consistent routines, and c) understanding and addressing sensory characteristics. Applied Behavior Analysis (ABA) is also used to explore and implement strategies in these areas. The goal of fine-tuning our approach through such techniques is to provide quality healthcare services. This comprehensive understanding and tailored approach may relieve the distress of patients and empower caregivers to provide more precise and practical support.

In this paper, we introduced the executive dysfunction hypothesis and the triple pathway model for attention-deficit/hyperactivity disorder (ADHD) in adulthood, along with the basics of understanding and coping with its symptoms. We also show that international treatment guidelines recommend psychoeducation and cognitive-behavioral therapy for the acquisition of behavioral skills to deal with dysfunction. Among the cognitive-behavioral therapies, I introduced a technique that is characteristic of ADHD. Evidence for cognitive-behavioral therapy for ADHD is accumulating, but the problem is that there is little data on long-term effects, and there is a high dropout rate with app interventions.

Motivational interviewing (MI) is a collaborative communication style that aims at motivating people for change. MI has been successfully applied to various areas where therapeutic relationship is challenging. MI is considered an excellent approach for learning supportive psychotherapy due to its established training methods. Thus, we conducted group training sessions on MI at both a university and general hospital, along with supervisions in clinical settings. We analyzed attributes and feedback of the workshop participants. Professionals from various disciplines participated in these sessions, engaging in experiential exercises. Feedback from participants confirmed the notion that MI is well-suited for acquiring skills in establishing and maintaining therapeutic relationships. Individual supervisions as well as group exercises are required to master MI. Future implementation of MI training could involve collaboration among attending psychiatrists at teaching hospitals and external experts.

[Introduction] In general hospitals, insomnia with confusion in patients with physical illness adversely affects their treatment and the lives of other patients and medical staff. Lemborexant is an orexin antagonist, which is effective in treating symptoms of insomnia and delirium for cancer patients. We retrospectively investigated the efficacy of lemborexant for insomnia with confusion with physical illness within a psychiatric liaison setting. [Methods] We observed eighty patients with insomnia and confusion who consulted the psychiatry liaison team of the Hakodate Goryoukaku Hospital. [Results] There were 32 patients diagnosed with delirium without dementia (D), 37 with delirium with dementia (DB), and 11 with behavior and psychological symptoms with dementia without delirium (B). The total effective rate was 70.0% (78.1%, 64.9%, 63.6%; respectively). Six patients suffered oversedation; one was 103 years old, one had kidney failure plus hyponatremia, two patients’ C-reactive protein levels were over 10 mg/dL, and two patients had old cerebral infarction. [Discussion] One cause of delirium is the presence of inflammatory cytokines; the orexin system is hyperactivated in the background of hyperactive inflammatory cytokines. We hypothesized that lemborexant improves insomnia with confusion by inhibiting orexin in the background of hyperactive inflammatory cytokines. [Conclusion] Lemborexant may be effective for insomnia with confusion with physical illness within a psychiatric liaison setting via inhibition of orexin, particularly for patients with delirium without dementia.

Wernicke’s encephalopathy (WE) is a medical emergency, that, if left untreated for a prolonged period, can lead to severe neurological sequelae and possible mortality. On the other hand, diagnosing WE can be challenging due to the occasional absence of typical clinical and laboratory findings. Therefore, it is recommended that the treatment should be commenced promptly in individuals suspected of having WE. We report a patient strongly suspected of having WE despite an ambiguous MRI finding and a normal blood thiamine level, along with relevant literature considerations. The patient was a woman in her early 60s. She was admitted to our hospital presenting with unstable gait, dysarthria, and cognitive impairment. Despite her unremarkable MRI finding, the patient was started on an IV thiamine, resulting in a good response for about two weeks. A few days after starting the treatment, we received the pre-treatment blood test result, which showed a normal thiamine level.

We report a case of a man in his 50s who started drinking when he was 17 years old. He was fined several times for hitting an acquaintance in his 20s and was arrested in X－2 after breaking into his sister’s house with a dagger while intoxicated. In X－2 years, he was arrested for drunkenness and barging into his sister’s house with a dagger. The day after admission, he became upset with the staff and demanded to be discharged. On August 19, X, he was hospitalized for medical care the next day due to his problematic behavior after drinking. Psychological tests conducted during hospitalization suggested mild intellectual disability, ADHD, and ASD. After starting valproic acid and guanfacine, he was discharged from the hospital and has been living without relapse or problematic behavior. The presence of neurodevelopmental disorders may be a factor in alcohol use disorder, which when combined with disinhibition due to alcohol intake may lead to social problematic behavior. In reporting this case, we took into consideration the protection of personal information and anonymity, and obtained the patient’s consent.

We encountered a case in which psychiatric symptoms improved with clozapine; however, the CPMS yellow standard (white blood cell count of 3000/mm³ or more and less than 4000/mm³) persisted even after the stabilization period of one year following the initiation of treatment. The patient, a man in his 40s, opted for discontinuation due to the burden of undergoing blood tests more than once a week. This individual began experiencing hallucinations and delusions in his late 20s, leading to multiple hospitalizations. By his late 30s, he received a diagnosis of treatment-resistant schizophrenia. At the age of 38, clozapine was introduced, leading to an improvement in his symptoms. As a result, he was able to live independently while on a 75 mg dosage. However, he continued to experience yellow symptoms and requested clozapine discontinuation two years post-introduction. During an attempt to switch to an alternative primary drug, his symptoms worsened, prompting a return to clozapine at a 75 mg dosage. The ongoing requirement for blood testing more than once a week, even after the improvement of mental symptoms, imposes a significant burden on patients, their families, and medical staff. It was suggested that the monitoring system needs reconsideration, taking into account the appropriateness of Japan’s unique standard of a white blood cell count of 4000/mm³. This consideration should involve weighing the burden of monitoring, treatment continuity, and the risks and benefits associated with altering standard settings. The patient provided written consent for the case to be reported.