[Effects of Group Psychoeducation on stress reactivity neuroendocrine profile in stabilized bipolar patients. A controlled study]. / Effetti della psicoeducazione di gruppo sul profilo neuroendocrino di reattività allo stress in pazienti bipolari stabilizzati. Uno studio controllato.

INTRODUCTION: Patients with bipolar disorder show a high relapse rate generally related to their poor adherence to the prescribed medications and to their high stress vulnerability, linked to genetic, neuroendocrine and cognitive factors. AIMS: The first aim of this study was to verify if for a group of pharmacologically stabilized bipolar patients, the attendance to a Group Psychoeducation program according to the Barcelona model would result in an improvement of their stress resilience, as measurable by evaluating their morning cortisol secretory profile. The second aim of the study has been to verify if these effects would maintain stable over time, organizing follow-up evaluations, after one year and after two years form the end of the group psychoeducation program. MATERIALS AND METHODS: 96 patients who had been euthymic for at least 6 months and were under stabilized pharmacologic maintenance treatment, were randomized in two groups: pharmacological treatment as usual (TAU) or pharmacological treatment plus group Psychoeducation (PE). Patients in both groups underwent a psychological assessment (HAMD, YMRS e ARMS), and to a functional assessment of the HPA axis activity, obtained evaluating cortisol levels from salivary samples collected in 5 different moments of the day: at baseline, at the end of the group psychoeducation program, and after 1 year and 2 years from the end of the last PE session. RESULTS: At the end of the study, both groups (PE and TAU) did not show any significant intergroup difference with regard to all the clinical variables and the patients' adherence to the prescribed medications. On the contrary, significative intergroup differences were observed with regard to morning cortisol secretory profile, that was found normalized at the endpoint only among patients of the PE group, but not among those of the TAU group. This normalization of the morning cortisol secretory profile observed among patients of the PE group, proved to maintain stably overtime, since it was observed also in the two follow-up assessments, organized after 1 year and after 2 year from the end the treatment. DISCUSSION: Data collected in this study may indicate that the efficacy of the psychoeducation programs for bipolar patients may activate an improvement of the functional activation of the HPA axis, and so obtaining a reduction of their stress vulnerability.

[Disturbo dissociativo d'identità, auto-ipnosi e sintomi simil-psicotici: da un caso clinico a un problema di diagnosi differenziale].

We report a case of a forty-nine-year-old patient suffering from his first psychiatric episode, who required hospitalization in a psychiatric unit. The presence of mood alterations with Schneiderian first-rank symptoms could have suggested an initial diagnosis of bipolar disorder (BD) with psychotic symptoms, directing the patient towards a definite therapeutic process. However, we hypothesized that the presence of a clear dissociative state similar to the hypnotic trance preceded by an uncontrolled self-hypnosis process, the presence of 'inner voices' and a high vulnerability to dissociation, were all elements that may reasonably lead to a diagnosis of Dissociative Identity Disorder (DID). Several authors have reported the presence of psychotic-like symptoms in patients with DID. However, in clinical practice there is a tendency not to acknowledge the possibility of dissociative disorders diagnoses, in favor of others more frequent psychiatric disorders. This paper aims to highlight some etiopathogenetic and psychopathological features that might help clinicians in identifying a DID.

Bipolar Spectrum Disorders in Patients With Cerebellar Lesions: A Comparison With Parkinson's Disease.

Nonmotor functions of the cerebellum are well known. Within this frame, the aim of this study was to compare psychiatric morbidity rates among patients affected by cerebellar diseases or Parkinson's disease (PD). Forty-seven patients (27 cerebellar and 20 PD) underwent a comprehensive psychiatric evaluation (psychopathological rating scales and the Structured Clinical Interview for DSM-IV-TR Axis I Disorders). Psychiatric disorders were slightly more frequent among cerebellar than among PD patients (89% vs. 75%; p = 0.21). Mood disorders were more frequent in the cerebellar than in the PD group (90% vs. 55%; p < 0.01). Among those subjects with no psychiatric history prior to the onset of neurological disease, bipolar spectrum disorders were more frequent within the cerebellar group (p < 0.01). These results confirm high rates of psychiatric disorders among cerebellar patients. The higher frequency of bipolar spectrum presentations found in the cerebellar group may suggest a specific involvement of cortico-cerebellar circuits in the pathophysiology of mood dysregulation.

[Predictive factors for further suicide attempts in individuals presenting to an emergency service for an attempted suicide. A one-year longitudinal study]. / Fattori predittivi di nuovi tentativi di suicidio in soggetti che accedono in pronto soccorso per un tentativo di suicidio. Uno studio longitudinale a un anno.

UNLABELLED: Suicide attempts (SA) have been recognized among the most important predictors of suicide. AIM: The aim of this study was to assess suicidal ideation, socio-demographic and clinical characteristics in patients admitted to the emergency room for a SA and to identify factors associated with clinical outcome. Admission to a Psychiatric Intensive Care Unit and further SA within one year were considered. MATERIALS AND METHODS: Patients that agreed to participate in the study were evaluated in the emergency room with a clinical interview and they were administered the Intent Score Scale. Patients were then contacted and interviewed by telephone 1, 6, and 12 months after the SA. Clinical outcomes and the occurrence of new SA were investigated. RESULTS: Seventy-four patients were enrolled and 49, 24, and 20 patients were reassessed at the 1, 6, and 12 month follow-up respectively. Eight patients reported at least one new SA within one year. Six SA occurred within the first month. Unemployment and underemployment were significantly associated with further SA. The time interval before a new SA was longer for patients admitted at the Psychiatric Intensive Care Unit and shorter for those with high suicidal intent at the first SA. CONCLUSIONS: Although with limitations, our study might suggest that future research should focus on the role of hospitalization in the management of SA.

Seizure threshold variations in ECT-treated chronic patients with schizophrenia: a brief report.

Seizure threshold (ST) is a parameter that differs in each person and can be modified both spontaneously and because of drug intake and/or other exogenous factors. A rise in ST during a course of electroconvulsive therapy (ECT) has been demonstrated in patients with depression and mania, but little information has been available as to whether the same result occurs in schizophrenia (SCZ). 11 male patients underwent estimation of the seizure threshold over a bilateral ECT course. Mean ST changed not significantly. No correlations were found between baseline ST and Positive and Negative Syndrome Scale (PANSS) scores. A significant positive correlation emerged between baseline ST and the variation of Hamilton Depression Rating Scale (HDRS) total and cognitive scores. The results suggest that ST in SCZ patients is not related to baseline psychopathological features, it is not related to clinical improvements of negative or positive SCZ symptoms and it does not change during the ECT course but it appears predictive of the improvement of affective and cognitive symptmos.

[Hikikomori (ひきこもり): a culture-bound syndrome in the web 2.0 era]. / Hikikomori (ひきこもり): una culture-bound syndrome nell'era del web 2.0.

In 1998 the Japanese psychiatrist Tamaki Sait¯o invented the term hikikomori, referring to a condition characterised by a state of social withdrawal and avoidance (education, work, friendships) combined with a persistent isolation and confinement in the own home for at least 6 months, due to various factors. Initially it undoubtedly regarded a disorder related to a specific socio-cultural context, however in the last couple of years some cases of hikikomori behaviour have also been observed in other countries far from Japan, both geographically and culturally. By way of hypothesis this diffusion can probably be attributed to the cultural revolution represented by mass communication in the internet era; in particular, it seems to be closely related to the immediateness and diffusion of web 2.0, i.e. of social networks. Therefore, we report a case of hikikomori behaviour, who was referred to our ward. M. is a 28-year-old man, who has lived the last 10 years in a state of almost complete isolation. He has maintained contacts with the outside world almost exclusively via internet. He started several therapies with psychiatrists and psychologists, without achieving significant results. The case of M. represents, to our knowledge, the first case of hikikomori described in Italy.

Anti-purkinje cell and natural autoantibodies in a group of psychiatric patients. Evidences for a correlation with the psychopathological status.

Phenomena of autoimmunity are frequent among psychiatric patients, but we don't know yet if they should be considered primary and linked to the pathophisiology of the disorder, or aspecific and associated to a general immune system activation. Paraneoplastic Cerebellar Degeneration (PCD) represents a well known model of specific autoimmunity. In order to better understand the abovementioned issues, we used this condition to compare a set of immune dysfunctions found in a group of psychiatric patients. For this reason we tested sera from 48 psychiatric patients (24 schizophrenics, 17 bipolars and 7 obsessive-compulsive), 22 PCD patients and 52 healthy controls for the presence of anti-Purkinje autoantibodies and of some natural autoantibodies (ANAs, AMAs, APCAs, ASMAs). Psychopatological status of the psychiatric patients was assessed with BPRS, SANS, SAPS, HAM-D, CGI-S. In the psychiatric group anti-Purkinje autoantibodies were identified in 11/48 (22,9%) patients, while they were present in 22/22 (100%) PCD patients and in 0/52 (0%) healthy controls. Among all anti-Purkinje autoantibody positive patients (in the PCD and psychiatric samples), only those belonging to the psychiatric sample, but not those with PCD, were frequently found positive also for natural autoantibodies, that are considered good markers of aspecific immune activation. In these patients, both anti-Purkinje and natural autoantibodies were found associated with acute/positive psychopathological symptoms. These results seem to point out that some phenomena of auto-immunity described in psychiatric patients could be aspecific, unrelated to the pathophysiology of the concomitant mental disorders and could be more frequent during phases of acute/positive symptoms.

[Clinician' emotional resonance as investigation tool: development and preliminary validation of a questionnaire]. / Il sentire del clinico come strumento di conoscenza: sviluppo e validazione preliminare di una scala di valutazione.

AIMS: A robust psychopathological and psychotherapeutic tradition underscores the importance of the clinician's feelings in the assessment and therapeutic process. Our aim is to develop an instrument to evaluate psychiatrist' experience induced by each patient. This paper describes the development and preliminary validation of this instrument. METHODS: Based on the relevant literature and our clinical experience, we developed a self-completed questionnaire consisting of 65 items covering various aspects of the clinician' emotional resonance. Ten psychiatrists completed our questionnaire immediately after first clinical interviews involving a total of 125 patients with various psychiatric diagnoses. Also, they completed the Profile of Mood State (POMS) immediately before and after these interviews. The factor structure and convergent validity of the questionnaire was examined. RESULTS: We identified a six-factor structure. The factors showed acceptable internal consistency and were interpretable as different aspects of the clinician-patient interaction as experienced by the clinician. There was a consistent pattern of correlations between factor scores and changes in POMS scale scores during the clinical interviews. DISCUSSION: The study results, though preliminary, suggest that clinicians' subjective reactions during their interactions with patients can be validly and reliably measured. Quantitative measurement of clinician's subjectivity is potentially useful in both clinical and research settings.

Symptomatic subsyndromal depression in hospitalized hypertensive patients.

BACKGROUND: Clinicians generally agree on the association between depression and hypertension. Less clear is if the nature of the link is direct or indirect and if this should be considered confined only to syndromal forms or if it concerns also subsyndromal affective presentations. This study investigated the nature of the association between hypertension and subsyndromal depression in hospitalized hypertensive patients. METHODS: 196 hypertensive and 96 non hypertensive inpatients underwent a SCID interview, to exclude patients positive for any Axis I or Axis II diagnosis. Symptomatic Subsyndromal Depression (SSD) was identified according to criteria proposed by Judd. Psychopathological assessment was performed with Anxiety Sensitivity Index (ASI) and Hopkins Symptom Checklist-90 (SCL-90). Clinical assessments included blood pressure measurement, evaluation of general health conditions and screening cardiovascular risk factors (smoke, alcohol, body weight, sedentary life style). RESULTS: Hypertensives met more frequently criteria for SSD. They also scored higher on ASI and SCL-90. However, those with more severe physical conditions, if compared with more healthy patients, did not show increased psychopathological severity. Similarly, psychopathological symptom severity did not differ among hypertensives positive for other cardiovascular risk factors, commonly more frequent among depressed subjects. LIMITATIONS: Further analyses are needed to explore the potential advantage obtained on blood pressure control by treating SSD. CONCLUSIONS: Hospitalized hypertensives, more frequently satisfied criteria for Symptomatic Subsyndromal Depression. These milder affective forms are probably directly linked to the presence of hypertension, rather than being indirectly associated to physical impairment or to higher prevalence of other cardiovascular risk factors.

[Stress and night eating syndrome: a comparison study between a sample of psychiatric outpatients and healthy subjects]. / Stress e Night Eating Syndrome: uno studio di confronto tra un campione di pazienti psichiatrici ambulatoriali e soggetti sani.

The Night Eating Syndrome (NES) is a disorder characterized by the clinical features of morning anorexia, evening hyperphagia, and insomnia with awakenings followed by nocturnal food ingestion. The core clinical feature appears to be a delay in the circadian timing of food intake. The diagnosis and early treatment of NES may represent an important means of prevention for obesity. Aims. The aim of the present study was to determine the vulnerability to develop NES between a clinical sample of patients with psychiatric disorders and a non clinical sample. We investigated a possible relation between stress and a dysfunctional eating behaviors as NES. Methods. The Night Eating Questionnaire (NEQ) has been administered to 147 psychiatric outpatients and to 531 subjects attending the University of L'Aquila. The NEQ is a questionnaire used to evaluate the prevalence of NES. The sample has been also evaluated through the Stress-related Vulnerability Scale (SVS) to measure both perceived stress and social support. Results. The 8.2% of patients scored above the diagnostic cut-off of the NEQ, compared to the 2.1% in the sample of healthy subjects. The majority of patients who had shown NEQ>25 had a diagnosis of major depressive disorder (MDD). The total scores on the NEQ were strongly associated with the SVS total score and especially with the "lack of social support" subscale. Conclusions. This study shows the increased vulnerability of NES in the sample of psychiatric patients compared to the sample of healthy subjects. The study further confirms the strong association between perceived stress, social support, altered eating behaviors and obesity.

Aripiprazole augmentation in patients with resistant obsessive compulsive disorder: a pilot study.

BACKGROUND: Antipsychotic augmentation is an effective treatment intervention for Obsessive Compulsive Disorder (OCD) patients resistant to Selective Serotonin Reuptake Inhibitors (SSRI) agents. This pilot study was conducted to evaluate the effectiveness and tolerability of Aripiprazole for the augmentation of standard treatments in patients with resistant OCD. METHODS: Twenty patients diagnosed with OCD according to DSM-IV TR criteria and having a history of resistance to standard pharmacological treatment were included in the study. Aripiprazole was added to ongoing SSRI or clomipramine treatment with a starting dose of 5 mg/day and titrated up to a maximum of 20 mg/day (mean dose 12.62 mg ± 4.25). Efficacy was assessed with the Yale-Brown obsessive compulsive scale (Y-BOCS) and the Clinical Global Improvement-severity scale (CGI-S) at baseline and at week 12 of Aripiprazole augmentation. Side effects were monitored by the Udvalg for Kliniske Undersogelser (UKU) side effect rating scale. RESULTS: All 20 subjects enrolled in our study completed the full 12-week course of treatment. A significant improvement over the 12-week study period was observed (paired t-test for mean Y-BOCS total score at week 12 as compared with baseline - all patients: t = 13.146, d.f. = 19, p= 0.0001). Aripiprazole was generally well tolerated and no changes were observed in vital signs. The most commonly observed side effects after the introduction of the augmenting agent included: akathysia, nausea/vomiting, hyperkinesia, tension/inner unrest, tremors, asthenia/lassitude/increased fatiguability. CONCLUSIONS: Although results of this pilot study are preliminary and require confirmation in randomized controlled trials, our experience suggested that Aripiprazole is effective and well-tolerated as an augmenting agent in patients with treatment resistant OCD.

Immediate serum growth hormone decrease as a potential index of dopamine-related response to electroconvulsive therapy in schizophrenic patients.

OBJECTIVES: : The objective of this study was to investigate the immediate response of the dopamine-regulated growth hormone (GH) to electroconvulsive therapy (ECT) in schizophrenic patients and the changes in the serum GH levels throughout the consecutive sessions of the therapeutic ECT course. METHODS: : Serum GH levels were measured in a sample of 11 men with schizophrenia according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, who were administered a course of 8 bilateral ECT treatments. Measurements were performed 5 minutes before ECT, during ECT, 15 minutes after an ECT session, and 30 minutes after an ECT session during the first, fourth, and eighth ECT sessions. RESULTS: : At both the fourth and the eighth ECT sessions, a significant decrease in GH levels 15 and 30 minutes after ECT was observed compared with the baseline values. No change in baseline serum GH levels was observed either during or at the end of the treatment. Clinical improvement was indicated by a significant reduction in the total score, negative subscale score, and positive subscale score of the Positive and Negative Syndrome Scale. CONCLUSIONS: : The results are consistent with the potential role of immediate serum GH changes as an index of potential dopamine-mediated response to ECT. It can be assumed that GH reduction may be partially related to an antidopaminergic action of ECT, but further research is still needed to better evaluate the correlation of the dopamine system instability during the course of the illness with the previously mentioned immediate treatment response. Also, the role of other neurotransmitters in the regulation of GH production and ECT response must be taken into account for the purpose of an overall evaluation of the results and of their potential clinical implications.

[Stress vulnerability and night eating syndrome in the general population]. / Vulnerabilità allo stress e night eating syndrome nella popolazione generale.

AIM: Night Eating Syndrome (NES) is an eating disorder characterized by the clinical features of morning anorexia, evening hyperphagia, and insomnia with awakenings followed by nocturnal food ingestion. The core clinical feature appears to be a delay in the circadian timing of food intake. Energy intake is reduced in the first half of the day and greatly increased in the second half. In particular, NES is clinically relevant because of its association with obesity. The aim of the present study was to determine the vulnerability to develop NES in the general population and to investigate the hypothesized role of acute and chronic stress in the pathogenesis of dysfunctional eating behaviors. METHODS: The Night Eating Questionnaire (NEQ) and the Stress Vulnerability Scale (SVS) have been administered to 531 adults attending the Department of Science of Health at the University of L'Aquila. Socio-demographic and anthropometric features were collected through a specific questionnaire. RESULTS: 9.3% of patients reported evening hyperphagia, while 2.7% reported nocturnal food ingestion. A negative relationship was instead found between NEQ scores and SVS "lack of social support" subscale. CONCLUSIONS: The study confirms the strong association between perceived stress, altered eating behaviors and obesity.