key: cord-0016569-tbib97zb authors: Omar, Yasmin; Paxton, Jennifer; Hui, Rebecca; Jenkins, Emma title: Medical students’ perspective on common stressors experienced at medical school and how to address them date: 2020-10-09 journal: Braz J Psychiatry DOI: 10.1590/1516-4446-2020-1371 sha: 8e6d59f100d15ec5bf0f515bc7b5c822593eb02b doc_id: 16569 cord_uid: tbib97zb nan Tourette syndrome (TS) is a neuropsychiatric disorder characterized by the presence of movement disorders, complex motor and vocal tics, psychiatric changes (such as obsessive-compulsive disorder, anxiety disorder, attention deficit/hyperactivity), and coprophenomena. 1 Here, we described a phenomenon observed in two patients, but which is likely much more frequent in clinical practice. Patient one was a 13-year-old boy who presented for his first consultation with complaints of vocal and motor tics, coprolalia, coprophagia, anxiety disorder, and signs of obsessive-compulsive disorder. His mother noted that the patient had been called to the office at school for having sent explicit sex videos to a teacher via a mobile messaging app. Interestingly, this behavior reoccurred from time to time, when he would also send similar content to family members. Patient two was a 16-year-old male who already had a diagnosis of TS and was being followed as an outpatient. When inquired as to the patient's phone usage habits, his parents reported that, in times of stress, the patient would send pornography, pictures of bizarre deaths, or grotesque scenes to family groups on a popular messaging app. Initially, they believed it was the patient's way of lashing out when he was angry at his parents, but soon realized he exhibited this behavior during periods of emotional stress in general. Both patients reported regretting their behavior, but claimed to have no knowledge of the number of people who had received the messages nor any recollection of the content itself. They both stated that the symptoms are usually preceded by an urge, and that they do not understand the reason for their actions. Curiously, this urge or feeling of ''need'' to perform the act occurred precisely when they were already using their phones or the messaging app for another purpose, and after each act, both patients usually put their phones aside and moved on to another task -which suggests a temporary feeling of relief. Both patients repeated these actions occasionally, even though neither showed any sign of hypersexuality in other aspects of life. The phenomenon was closely related with emotional stress or anxiety episodes, and improved with treatment optimization. Other coprophenomena common in TS include coprolalia (involuntary swearing or utterance of obscene or socially inappropriate words); copropraxia, defined as involuntary actions such as performing obscene or forbidden gestures; and coprographia, characterized by obscene writings or drawings. 2, 3 In recent years, with the advent of new technologies, these acts surely must have become more frequent, especially among younger people with a diagnosis of TS. The term ''copromessaging'' might be applicable to this novel coprophenomenon of involuntarily sending obscenities or inappropriate images to another person by phone or video message. Future studies are needed to confirm whether this phenomenon is part of the spectrum of TS manifestations. Medical students' perspective on common stressors experienced at medical school and how to address them We read with great interest the study titled ''Identifying the major sources of stress in Brazilian medical students,'' as it proved an informative read on an extremely important issue that resonates with us. 1 As a group of graduate medical students from Warwick Medical School (WMS) in the United Kingdom, we are no strangers to experiencing stress throughout our degree. We were very intrigued by your Medical Student Stress Factor (MSSF) instrument, and its potential to be implemented across medical schools globally. During this unprecedented time of coronavirus disease 2019 (COVID-19) , there has been a significant increase in mental health concerns and stress factors, particularly among medical students. After reading the results of your study, we thought it would be pertinent to discuss how medical schools worldwide could create a better understanding of their student populations and adapt to their common stressors. We would like to share our experiences of the coping mechanisms and strategies implemented by WMS to combat some of the consistent ''stressors'' identified. 1. Extensive content -Similar to other graduate programs, much of our theoretical content is condensed into the first year. At WMS, we have in place excellent facilities to tackle this stressor, namely through ''peer support'' groups. These groups are a student-led initiative which aim to help students meet their learning objectives through optional evening/weekend student seminars taught by students in older-year groups. From our own experience of attending such sessions and ultimately teaching in them, peer support has provided stress relief through offering a chance to enhance our knowledge on difficult topics in a more supportive, lower-pressure environment. Studies have also shown that peer teaching benefits both the teachers and the students, allowing the educators to consolidate their learning as they teach others. 2 2. Lack of time to study and lack of leisure time -Research continues to show that conflicts in work-life balance are correlated with a decline in mental health. 3 WMS recently introduced a ''4-day'' week for year 1 students, giving them an additional working day to enjoy extracurricular activities, personal leisure, and/or study time. Moreover, in later years of the degree, studentdirected learning is the centre of the program, encouraging students to organize their time and acknowledge their limitations -a key skill as a doctor. 3. Sleep deprivation -A recent meta-analysis described sleep deprivation among medical students as a pandemic, with results showing that sleep deprivation is significantly associated with decreased academic performance, creating a vicious cycle with the aforementioned stressors. 4 At WMS, mindfulness practice is incorporated regularly into the program -empowering students to adopt their own stress-relief techniques ranging from sleep hygiene to talking therapy, meditation, yoga and more. With an alarming increase in mental health concerns among medical students, it is of utmost importance for medical schools to adopt a tool like the MSSF to identify current stressors within their different cohorts of students, address these ''self-pressures'' that students face, and avoid further negative impact on mental health. As a result of war and economic/political instability in different parts of the world, forcibly displaced populations have increased to unprecedented numbers. The most recent update from the United Nations High Commissioner for Refugees estimated that at the end of 2019, 79.5 million people were forced to move from their countries due to persecution, conflict, violence or human rights violations. This is a record-high number, and an increase of 8.5 million from 2018. 1 Although Brazil has not traditionally been a destination for refugees from areas Gilles de la Tourette syndrome Tourette syndrome. Coprolalia and other coprophenomena Coprophenomena in Tourette syndrome The root of the problem: identifying major sources of stress in Brazilian medical students and developing the Medical Student Stress Factor Scale When learners become teachers: a review of peer teaching in medical student education Work-family life conflict and mental well-being Sleep disruption in medicine students and its relationship with impaired academic performance: a systematic review and metaanalysis The authors report no conflicts of interest.