Poor sleep quality may contribute to dysfunctional illness perception, physical and emotional distress in hospitalised patients: results of a national survey of the Italian Society of Consultation-Liaison Psychiatry.

Distress associated with physical illness is a well-known risk factor for adverse illness course in general hospitals. Understanding the factors contributing to it should be a priority and among them dysfunctional illness perception and poor sleep quality may contribute to it. As poor sleep quality is recognised as a major risk factor for health problems, we aimed to study its association with illness perception and levels of distress during hospitalisation. This cross-sectional study included a consecutive series of 409 individuals who were hospitalised in medical and surgical units of different hospitals located throughout the Italian national territory and required an assessment for psychopathological conditions. Sleep quality was assessed with the Pittsburgh (Sleep Quality Index), emotional and physical distress with the Edmonton Symptom Assessment System (ESAS), and illness perception with the Brief Illness Perception Questionnaire (BIPQ). Differences between groups, correlations and mediations analyses were computed. Patients with poor sleep quality were more frequently females, with psychiatric comorbidity, with higher scores in the ESAS and BIPQ. Poor sleep quality was related to dysfunctional illness perception, and to both emotional and physical distress. In particular, by affecting cognitive components of illness perception, poor sleep quality may, directly and indirectly, predict high levels of distress during hospitalisation. Poor sleep quality may affect >70% of hospitalised patients and may favour dysfunctional illness perception and emotional/physical distress.Assessing and treating sleep problems in hospitalised patients should be included in the routine of hospitalised patients.

Six things to know about the homicides of doctors: a review of 30 years from Italy.

BACKGROUND: Healthcare workers have a 16 times greater risk of suffering workplace violence than workers in other sectors and around 50% experience workplace violence in the course of their career. The objective of this study is to explore the characteristics and circumstances of work-related killings of doctors. METHODS: Work-related homicides of doctors over the period 1988-2019 were identified retrospectively through the Italian national statistical agencies. Variables such as perpetrator, motive and location of the crime were obtained through forensic psychiatric work. After classification, the absolute and percent values of the main characteristics of the homicides were calculated. RESULTS: Over the period considered, 21 doctors were killed in Italy in connection with their professional activity. In 52% (n = 11) of cases, the killer was one of the doctor's patients, in 29% (n = 6) of cases it was a patient's relative, in 19% (n = 4) an occasional patient (first consultation). The location of the homicide was a community clinic in 48% (n = 10) of cases, the street in 19% (n = 4) of cases, the doctor's home in 14% (n = 3), the hospital in 14% (n = 3) and the patient's home in 5% (n = 1). In 57% (n = 12) of cases the perpetrator was not affected by any mental disorders. The motive for the homicide was revenge in 66.7% (n = 14) of cases; in 28.6% (n = 6) the revenge was preceded by stalking. CONCLUSIONS: Doctors should be aware that the risk of being killed is not limited to hospital settings and that their patients' family members might also pose a threat to them.

Admission leukocytosis in acute cerebral ischemia: influence on early outcome.

BACKGROUND: Leukocytes are the first cells that arrive in the stroke region(s), and they increase in peripheral blood. The contribution or leukocytes in the early acute phase of cerebral ischemia has not yet been investigated. METHODS: In consecutive first-ever acute ischemic stroke patients whose symptoms had started <12 hours earlier, we aimed to establish whether admission leukocyte count affects the short-term neurologic outcome, and whether there are differences between the various clinical syndromes of stroke. The National Institutes of Health Stroke Scale (NIHSS) was assessed at admission (NIHSS(0)) and after 72 hours (NIHSS(72)). Modified Rankin scale (mRS) scores were evaluated at discharge. The Spearman rank correlation was used for the correlation between leukocytes and outcome measures. RESULTS: Eight hundred and eleven patients were included (median age 77 years [range 68-82]; 418 [53%] were male; the median NIHSS(0) score was 7 [range 4-12], the median NIHSS(72) score was 6 [range 3-12], and the median mRS score was 2 [range 2-4]). The median leukocyte count at admission was 8100/mm(3) (range 6500-10300). Higher leukocyte levels predicted a worst clinical presentation and a poor functional outcome (NIHSS(0)P < .001; NIHSS(72)P < .001; mRS P < .001). The correlation between leukocyte count and outcome measures remained significant after multivariate analysis (NIHSS(0)P < .001; NIHSS(72)P < .001; mRS P < .008). Focusing on clinical syndromes, a higher leukocyte count predicted severe NIHSS(0) and NIHSS(72) scores in patients with total anterior cerebral stroke (P = .001), partial anterior cerebral stroke (P = .004), or posterior cerebral stroke (P = .026). CONCLUSIONS: An elevated leukocyte count in the acute phase of cerebral ischemia is a significant independent predictor of poor initial stroke severity, poor clinical outcome after 72 hours, and discharge disability. The involved underlying mechanism is still to determined.

Changes of consultation-liaison psychiatry practice in Italian general hospitals: A comparative 20-year multicenter study.

Introduction: Conducted under the auspices of the Italian Society of Consultation Liaison Psychiatry (SIPC) the aim of this study was to describe the characteristics of Consultation Liaison Psychiatry (CLP) activity in Italy (SIPC-2-2018) over the past 20 years by comparing with data from the first Italian nation-wide study (SIPC-1-1998). Methods: We collected data on CLP visits of 3,943 patients from 10 Italian hospitals over a period of 1 year. Data were compared with those from the SIPC-1 1998 study (4,183 participants). Patients were assessed with the same ad hoc 60-item Patient Registration Form recording information from five different areas: Sociodemographic, hospitalization-related, consultation-related, interventions and outcome. Results: Compared with participants from the previous study, SIPC-2-2018 participants were significantly older (d = 0.54) and hospitalized for a longer duration (d = 0.20). The current study detected an increase in the proportion of referrals from surgical wards and for individuals affected by onco-hematologic diseases. Depressive disorders still represented the most frequent psychiatric diagnosis, followed by adjustment and stress disorders and delirium/dementia. Also, CLP psychiatrists prescribed more often antidepressants (Φ = 0.13), antipsychotics (Φ = 0.09), mood stabilizers (Φ = 0.24), and less often benzodiazepines (Φ = 0.07). Conclusion: CLP workload has increased considerably in the past 20 years in Italy, with changes in patient demographic and clinical characteristics. A trend toward increase in medication-based patient management was observed. These findings suggest that the psychiatric needs of patients admitted to the general hospital are more frequently addressed by referring physicians, although Italian CLP services still deserve better organization and autonomy.

[The investigation of non-verbal behavior through Nonverbal Behavior Analysis Matrix in the forensic setting]. / L'indagine del comportamento non verbale attraverso la Nonverbal Behavior Analysis Matrix in ambito forense.

The application of the neuroscience in forensic sciences has long opened up new scenarios within the legal world. While on one hand we tend to emphasize the benefits of the new research methods based on the recent neuroscience knowledge, on the other hand the use of these new tools has sparked a justified debate at the international level that touches all the areas that directly or indirectly approach forensics. Factors like lack of responsability or mitigation provided by science are part of those topics that, thanks to neurosciences, are back in the spotlight on a highly empirical basis. At the same time, these factors mentioned above influence our way to interpret reality. NBAM takes place within this debate as a new scientifically proven protocol and technologically supported, making way for an objective development of the neuroscience research.

Eating disorders and diabetes: behavioural patterns and psychopathology. Two case reports.

The relationship between eating disorders and diabetes is complex in terms of both reciprocity and comorbidity. In some cases, patients with eating disorders and diabetes develop 'purging' behaviours through the use of insulin as a bodyweight control tool, with serious physical complications that can compared to those of untreated diabetes (diabulimia). The clinical cases presented have in common the distorted use of insulin: one patient failed to take the required amounts of insulin, incurring hyperglycaemia, while the other overused it, incurring hypoglycaemia. From a psychopathological point of view, both patients were diagnosed with Borderline Personality Disorder. While these are just two case reports, it is our clinical experience that female diabetic patients with eating disorders who use insulin as a tool for weight control (purging) following binge eating should be assessed for borderline personality disorder in order to tailor a more effective therapeutic approach.

[The physician's suicide: study of an Italian sample]. / Il suicidio del medico: studio di un campione italiano.

OBJECTIVE: The main objective of the present study is to examine a number of suicides among Italian doctors. We further compared data from our sample with those of suicide in the general population and in the literature, in order to detect any differences that can provide preventive recommendations. METHODS: This is a retrospective study of 60 suicides committed by doctors from 2009 to 2019, in Italy. RESULTS: The sample was constituted mainly by men (77%, 46 cases) aged between 50 and 69 years (70%, n=42). Most of the suicides took place in Northern Italy (50%, n=30). Among known medical specialization, 26% (n=14) concerned general practitioners, the remaining 74% (n=39) were specialized doctors, with a prevalence of anesthetists (9%, n=5), haematologists (8 %, n=4), pediatricians (6%, n=3), psychiatrists (6%, n=3) and oncologists (6%, n=3). Regarding the suicide method, the most used was precipitation (30%, n=16), followed by poisoning/overdose (24%, n=13), firearm (19%, n=10), suffocation/hanging (19%, n=10) and self-induced injuries (8%, n=4)). The most frequent place of suicide is in 35 cases was at home (59%), followed by the hospital (18%; n=11), or others (23%; n=14). When possible, any reported risk factors and predisposing conditions for suicide were studied, and divided into five categories: depression/psychiatric pathology (28%, n=16); other organic disease (8%, n=5); work-related problems (stress, burn-out, mobbing, work-related judicial problems) (20%, n=12); judicial problems unrelated to the medical profession (8%, n=5); family and relationship problems (12%, n=7). CONCLUSIONS: The risk factors for suicide in our sample of doctors overlap with data from literature for doctors in western countries. Clinical recommendations and prevention strategies for suicide risk are therefore similar.

[Homophobic bullying: critical considerations, and legal-institutional interventions]. / Bullismo omofobico: considerazioni critiche e interventi giuridico-istituzionali.

Instances in the increase of homophobic bullying mean a major interest in order to develop strong bullying prevention programming which should be a major priority for adults, governments and institutions responsible to promote and ensure a responsible development of society. The complexity of the problem requires a multidisciplinary approach of a comprehensive nature. Starting from the construction of gender identities, and taking into account and understanding the biological aspects, external influences, and arising contrasts during the process, a young person faces adolescence: a transition period when sexual orientation or preference faces higher risks as the person has to come to terms with a mismatch between scales of knowledge. The outcome will result in an inter-generational conflict which becomes a prejudice. By acquiring the desired characteristics of mind and body, adolescents develop their own cognitive skills. Thus we can consider homophobic bullying in its psycho-sociological implications. The aim of this paper is to delineate an explanation of the topic in a scientific, educational and professional way, and at the same time to take into account all legal and institutional issues.

[Regulatory evolution of the crime of infanticide]. / Evoluzione normativa del delitto di infanticidio.

The objective of the present study consists of the juridic-anthropological analysis of the infanticide, a phenomenon that nowadays is highly existent within the context of crime-settings. Particular consideration has been given to the legal developments of the infanticide act, which occurred simultaneously with the mutation of the socio-cultural contexts. Because the legislative process of the infanticide act has not evolved since 1981, it was possible to underline the criticisms and the inadequacy of such norm. Indeed, the legal norm has not always been able to provide an exhaustive answer concerning cases of infanticide. The process of humanisation of the law led to the introduction of a legal system, which describes the infanticide act as a condition of material and moral abandonment. This has become uncertain and ambiguous to interpret, risking to relegate the legislative matters of infanticide only to exceptional cases. The current study aims to highlight the criticisms and hypothesised different reform perspectives.

Lithium Use During Pregnancy in a Patient With Bipolar Disorder and Multiple Sclerosis.

Although lithium is widely used as a first-line treatment for mood disorders, its mood-stabilizing effects remain not fully understood. A growing body of data are stressing that lithium seems to show broader properties, including neuroprotective effects. Lithium's ability to inhibit glycogen synthase kinase 3ß, an enzyme that participates in the phosphorylation of τ, a microtubule-associated protein, stimulated interest in its possible therapeutic role in Alzheimer disease and other neurodegenerative disorders. Preliminary data also support exploration of lithium's potential therapeutic role in multiple sclerosis, an autoimmune disorder that is associated with co-occurring mood disorders. Lithium is associated with teratogenic risks to the developing fetus; however, recently revised downward estimates of its teratogenic risk of causing fetal cardiac malformation suggest that its potential therapeutic benefit to both mothers with bipolar disorder and their offspring should be considered in at least some cases. A 43-year-old woman previously diagnosed with bipolar disorder and MS was treated with lithium and thyroid hormone supplementation as her sole medications during her pregnancy. The patient remained euthymic throughout her pregnancy and over the course of her 5-year follow-up evaluations on this medication regimen. In addition to her stable mood, there has been no symptomatic progression or relapse of her MS, and her daughter continues to develop normally.The case supports consideration of balancing lithium's mood-stabilizing benefit with its known teratogenic risk during pregnancy. The case also supports exploration of possible additional benefit in the context of MS co-occurring with bipolar disorder.

[Guidelines in psychiatry: clinical and forensic issues]. / Linee guida in psichiatria: criticità cliniche e forensi.

Treatment guidelines (GL) in psychiatry represent a useful and functional tool to be explored and enhanced in terms of the contribution of patient care and the promotion of scientific improvement. However, they show some limitations, both clinical and forensic. The objective of this paper is to examine the objectives, the clinical limitations and the applicability of the GL on professional liability (forensic aspects). From a clinical point of view, the GL have objectives that are functional to the promotion of physical and mental health, among which the constitutional observance of the right to health, the improvement of public health, the implementation of best clinical practices, the promotion of scientific research, the professional training of operators in the field of physical and mental health. However, GL cannot replace a contextualized clinical judgment. GL must be applied, in the single clinical case, in light of their multiple criticalities, including the limits of the methodology used for their formulation, the differences between the GL' recommendations, the difficulty of their application in daily clinical practice, the lack of specific treatment interventions. From a forensic psychiatric point of view, GL, as currently conceived, cannot be used in terms of professional liability without their interpretation on a legal basis with forensic psychiatric methodology, similarly to any other clinical and scientific information, with its qualifications and criticalities.

[Professional liability in psychiatry: evolution and critical issues]. / La responsabilità professionale in psichiatria: evoluzione e criticità.

The aim of the article is to present the evolution of professional liability in psychiatry from law 36 of 1904 to today. Through an examination of the doctrinal positions and of the jurisprudential expression it was possible to highlight three distinct phases in which professional responsibility has declined over the years. A custodial phase, in which the spirit that animated the law of psychiatric assistance was inspired by principles of social defense and the responsibility of the psychiatrist was recognized mainly in the lack of custody of the psychiatric patient. A phase of indulgence, in which, like other disciplines, the psychiatrist was recognized with "reduced impunity" due to an alleged "special difficulty" in exercising the medical profession. A phase of empowerment, in which the doctor in general, and the psychiatrist in particular, was confronted with empowering positions that led to convictions. An examination of the application of the guarantee position to psychiatry allows us to highlight current difficulties, sometimes a legacy of the past.

[The psychiatrization and unpredictability of interpersonal violent behavior]. / Sulla psichiatrizzazione e imprevedibilità del comportamento violento sulla persona.

The relationship between mental illness and violent behavior is a complex phenomenon. Scientific literature indicates that the presence of a mental disorder, even severe, is not sufficient, alone, to predict or motivate violent behavior, which seems to be more associated with other intermediate variables. The phenomenon of psychiatrization of violent behavior can be defined, from a psychiatric-forensic point of view, as the prejudicial and erroneous attribution to mental illness as a causal factor in relation to violent behavior. This phenomenon has consequences in psychiatric clinical practice, but also at the level of social stigmatization, management of organizational and economic resources, and the judicial system. In this paper, clinical criticalities related to the psychiatrization of violent behavior will be analyzed, including the need to differentiate clinical etiology and legal causality, predictability and avoidability, protective clinical factors and clinical risk factors, the limits of categorical psychiatric diagnosis, the need for specific victimological information, the criticalities of pharmacotherapy. Some forensic criticalities will also be analyzed, including errors in clinical and forensic methodology (psychiatrization of the symptom, prejudicial contamination, diagnostic overshadowing, legal causalization of protective and risk factors, the use of categorical diagnosis in the forensic field, the psychiatrization of non-pathological human experiences, the criminalization of the subject with mental disorder). In conclusion, it is highlighted that an individual can have a psychic disorder, even severe, but this disorder is not necessarily in a causal relationship with violent behavior. The lack of a causal relationship makes predictability of violent behavior difficult, even impossible depending on the case, both in the general population and in individuals with psychiatric disorders.

Comparison of the effects of diuretics on blood pressure and arterial stiffness in patients with stroke.

OBJECTIVES: Indapamide (IND) and bendroflumethiazide (BDZ) are both widely used in patients with stroke. We compared their effects on arterial blood pressure (BP) and arterial stiffness in a group of patients with stroke. METHODS: In a prospective, randomized, double-blinded study we investigated the effect of 28-day treatment with BDZ (2.5 mg once daily) or IND (2.5 mg once daily) on BP and arterial stiffness in a group of patients with first-ever ischemic stroke. RESULTS: All data are expressed as mean (SD). In all, 23 patients completed the protocol (age 70.0 +/- 9.55 years). Group I (IND) and group B (BDZ) comprised 13 and 10 patients, respectively. Groups were well matched for demographics and baseline characteristics. Mean arterial pressure reduction from baseline was I = 14.3 +/- 10.3 mm Hg (P < .001) versus B = 9.1 +/- 11.2 mm Hg (P = .03). Augmentation index (AI) was reduced by: I = 4.94 +/- 7.22% (P = .037) versus B = 6.17 +/- 7.85% (P = .035). Time to reflection was increased by I = 3.22 +/- 9.57 milliseconds (P = .268) versus B = 4.71 +/- 5.30 milliseconds (P = .020). There was no significant difference between the two drugs with regard to change in BP or arterial stiffness. Pooled data showed a reduction in mean arterial pressure by 12.1 +/- 10.77 mm Hg (P < .0001) and in AI by 5.5 +/- 7.36% (P = .002), and a small increase in time to reflection by 3.9 +/- 7.79 milliseconds (P = .029). The change in BP explained up to 28% of the change in AI. CONCLUSION: Both diuretics altered hemodynamic parameters to a similar extent. The results are consistent with a direct effect of diuretic therapy on vascular function. The influence of both diuretics on arterial stiffness was similar.

Determinants of outcome in patients eligible for thrombolysis for ischemic stroke.

OBJECTIVES: Eligibility criteria for thrombolysis in ischemic stroke have been clearly defined. However, not all eligible patients benefit from this treatment. This study aimed to assess the determinants for clinical outcome in consecutive, eligible patients with ischemic stroke treated with thrombolysis in a single-center study. METHODS: Consecutive patients with ischemic stroke were treated with tissue plasminogen activator (t-PA) following the established eligibility National Institute of Neurological Disorders and Stroke (NINDS) and European Stroke Initiative (EUSI) criteria. Risk factors including blood pressure and pre-treatment glycemia were properly managed. Death and disability at 3 months were the study outcomes. Disability was evaluated by the Rankin-scale. Favorable outcome was defined as 0-2 and adverse outcome as 3-6 including death. RESULTS: Seventy-eight patients were included in the study in a single stroke unit. The mean age was 70.9 +/- 13.2 years (range 36-94). Follow-up at 3 months was completed in 73 patients. A favorable outcome was observed in 37 patients (50%) and adverse outcome in 36 (36%). Nine patients (12.3%) died within 3 months. The presence of an occluded carotid artery was a strong predictor for adverse outcome (p < 0.0001). A low NIH Stroke Scale-Score (NIHSS) at admission was a associated with a favorable outcome, while history of diabetes mellitus led to an unfavorable outcome. CONCLUSION: Among patients eligible for thrombolysis, many do not benefit from this treatment. These include patients with carotid occlusion and diabetes.

[Trazodone prolonged release in bipolar disorder II-obsessive-compulsive disorder comorbidity: a case report]. / Trazodone a rilascio prolungato nella comorbilità disturbo bipolare II-disturbo ossessivo-compulsivo: un caso clinico.

Approximately 21% of patients with bipolar disorder (BD) also have an additional diagnosis of obsessive-compulsive disorder (OCD). This condition is associated with a more severe prognosis and complicates the treatment of BD. In our case report we provide documentary evidence of our experience with trazodone prolonged release in the treatment of depressive phase in a patient with BD II-OCD comorbidity. Rationality in the choise of treatment was based on the need to manage depressive and obsessive symptoms without facilitating hypomania switches.

[Clinical interview in psychiatric difficult situations]. / Il colloquio in situazioni psichiatriche di crisi.

There are here described a number of basic principles underlying an effective clinical interview in psychiatric difficult situations (violent or suicidal patients, victims of serious physical and psychological damages, authors of inadequate or anti-social requests to the therapist). The aim of the present study is to provide the psychiatric operator with useful skills for the optimal management of the interview in difficult situations both at diagnostically and therapeutically level. The methodology was based on examination of the literature and personal experience of the authors. The authors highlighted 18 working hypothesis that may represent beneficial instruments in situations of difficult psychiatric interview. Further studies will deepen under the clinical, actuarial and statistical validity the principles covered in various clinical and crisis situations with difficulty to the interview, in relation also to specific types of patients for a more updated training of the operators in the field of mental health.

[Charges and convictions of psychiatrists for the violent behavior of the patient: psychiatric-forensic remarks]. / Osservazioni psichiatrico-forensi sulle imputazioni e condanne agli psichiatri per il comportamento violento del paziente.

Purpose of the present study is to point-out a number of psychiatric-forensic remarks about the management of violent behavior against the person (VBP) amongst psychiatric patients. The study is the authors' personal contribution based on clinical and forensic experience as experts in the management of psychiatric patients with VBP. Twelve psychiatric-forensic remarks have been highlighted in the present study: 1) VBP is a multifactorial event; 2) the risk of VBP against the person may change rapidly over time in quantity and quality; 3) there are no methods for reliable prediction of VBP in a single clinical-case; 4) there are no medications with an indication of "heal" the VBP; 5) there are no therapeutic measures that neutralize always, quickly and without recurrences VBP; 6) there exist clinical hypotheses to assess VBP; 7) there exist principles of victimology to assess VBP; 8) there are emotional reactions that can affect the evaluation and clinical and forensic management of VBP; 9) the responsibility of the psychiatrist has to be evaluated at the moment of the events; 10) the responsibility of the psychiatrist must be contextualized in the single clinical-case; 11) there is the need to clarify the individual professional responsibility of psychiatrists who treated a patient; 12) there is the need to clarify the criteria for the definition of the guarantee role. The above-mentioned twelve psychiatric-forensic remarks have implications in the assessment and management of psychiatric patients with violent behavior. They may constitute a basis for further discussion aiming to obtain consensus amongst psychiatrists about good clinical practice and forensic implication in the management of psychiatric patients with VBP and to avoid charges and convictions.

[Murder of the doctor]. / L'omicidio del medico.

AIM: To examine possible risk factors for the doctor to be killed by the patient in the clinical practice by examining a series of murders that involved physicians. METHODS: This aim has been achieved through a retrospective review on clinical cases of doctors killed by patients within the period between 1988 and 2013, in Italy. RESULTS: In this period 18 Italian doctors have been killed in the workplace, with a rate of 0.3/100,000. In 7 cases, the murder resulted in the context of doctor-dissatisfaction; in 7 cases the murder was committed by a psychiatric patient; 1 case in the context of a stalking; 3 cases occurred in a workplace which was not safe enough. Four categories of at-risk contexts have been identified. One category includes a murder in the context of a doctor-dissatisfaction, perceived by patient. The second category concerns murders committed by patients suffering from mental illness. A third category includes homicides in a workplace which is not safe. The last category comprises the murder in the context of stalking. CONCLUSIONS: These categories identify specific dangerous situations for physicians, in which are highlighted elements that have played a crucial role in the murder and for which special precautions are suggested preventive.