Psychosis, symbol, affectivity 2: another perspective on the treatment of psychotic disorder.

This is the second of two papers concerning our study into an integrated approach to psychotic disorders conducted at the University Psychiatry Unit of Palermo's Polyclinic over approximately 15 years; this paper concentrates on the clinical phenomena. The study aimed to find the best possible treatment and to improve the prognosis of this patient group. We have explored the efficacy of a range of psycho-therapeutic (cognitive-behavioural, systemic-relational, psychodynamic, group and others), psycho-pharmaceutical, psychiatric rehabilitative and psycho-educational treatments, with a hermeneutic approach instead of a systematic one. The study's conclusions, described in the paper, are that all psychotic functions start with a nuclear psychic issue connected to emotional development. We describe how the most significant symptoms of acute psychotic manifestations (delusions and misperceptions) make use of an encrypted psychological meaning that can be decoded through the patient's symbolic language. This language is a key element in diagnosis and in the choice of treatment. The paper describes how we revised our understanding of psychosis from being a brain disease to being a process aimed at the rearrangement of psychic functioning. Our significant results are described.

Ceci est le deuxième d'une série de deux articles consacré à notre étude d'une approche intégrée des troubles psychotiques, conduite sur une quinzaine d'années à l'Université de Palerme, dans le service de Polyclinique en Psychiatrie. Cet article se concentre sur les phénomènes cliniques. L'étude visait à trouver le meilleur traitement possible et à améliorer le pronostic pour ce groupe de patients. Nous avons exploré l'efficacité d'un éventail de traitements: psychothérapeutiques (cognitif-behaviouriste, systémique-relationnel, psychodynamique, de groupe, etc), psychopharmacologiques, de réadaptation psychiatrique, et les traitements psychopédagogiques. Notre approche est herméneutique et non pas systématique. Les conclusions de l'étude, décrites dans cet article, sont que tout fonctionnement psychotique commence avec un problème psychique central en lien avec le développement émotionnel. Nous décrivons comment les symptômes les plus significatifs de manifestations psychotiques aigues (délires et perceptions erronées) emploient un sens psychologique encrypté, qui peut être décodé par le biais du langage symbolique du patient. Ce langage est un élément clé dans le diagnostic et dans le choix du traitement. Cet article décrit comment nous avons révisé notre compréhension de la psychose, la considérant au départ comme une maladie du cerveau, puis finalement comme un processus visant le réaménagement du fonctionnement psychique. Nous décrivons ici nos importants résultats.

Este es el segundo de dos ensayos acerca de nuestro estudio sobre un abordaje integrado de los trastornos psicóticos, conducido en la Unidad Policlínica Psiquiátrica de la Universidad de Palermo durante aproximadamente 15 años. El presente trabajo da cuenta del fenómeno clínico. El estudio está orientado a encontrar el mejor tratamiento posible y a mejorar la prognosis de este grupo de pacientes. Hemos explorado la eficacia de un espectro de psicoterapias (cognitivo-conductual, sistémica-relacional, psicodinámica, de grupo, y otras), psico-farmacología, rehabilitación psiquiátrica, y tratamientos psico-educacionales, con un abordaje hermenéutico en lugar de uno sistemático. Las conclusiones del estudio descripto en el trabajo, dan cuenta que todas las funciones psicóticas comienzan con un problema psíquico nuclear conectado al desarrollo emocional. Describimos como los síntomas más significativos de las manifestaciones psicóticas agudas (delirios y percepciones erróneas) hacen uso de un sentido psicológico encriptado que puede ser decodificado a través del lenguaje simbólico del paciente. Este lenguaje es un elemento clave para el diagnóstico y elección del tratamiento. El artículo describe el modo en que hemos revisado nuestra comprensión de la psicosis, desde ser considerada una enfermedad cerebral hasta ser un proceso destinado a la reorganización del funcionamiento psíquico. Se describen nuestros resultados significativos.

Infliximab for Refractory Cardiac Sarcoidosis.

Cardiac sarcoidosis (CS) is frequently difficult to treat. Infliximab (IFX) is useful for extracardiac sarcoidosis, but its use in CS has been limited due to concerns about cardiotoxicity and an FDA blackbox warning about use in heart failure. We reviewed 36 consecutive patients treated with infliximab for CS refractory to standard therapies. IFX was initiated for patients with refractory dysrhythmias, moderate to severe cardiomyopathy, and evidence of persistent F-18 fluorodeoxyglucose uptake on positron emission tomography scan, despite standard therapies. We compared the prednisone dose, ejection fraction (EF), and dysrhythmias before and after IFX therapy. The prednisone-equivalent steroid dose decreased from a median of 20 mg at initiation of infliximab to 7.5 at 6 months and 5 mg at 12 months postinitiation of infliximab (p <0.001). In the 25 patients with serial EF measurements, no statistically significant difference was detected in EF (41% at baseline, 42% at 6 months). Of the 16 patients with serial dysrhythmia data, there was a trend toward reduction of percent of patients with ventricular tachycardia (VT), from 32% at baseline, to 22% at 6 months and 19% at 12 months (p = 0.07). Adverse events were common, occurring in 6 of 36 patients, with 3 of 36 patients stopping infliximab for a prolonged period. In responder analysis, 24 patients improved in at least 1 of 3 outcome categories. In conclusion, infliximab may be useful for refractory cardiac sarcoidosis.

[Heart ischemia and psychosomatics: the role of stressful events and lifestyles]. / Ischemia cardiaca e psicosomatica: ruolo di eventi stressanti e stili di vita.

OBJECTIVE: the aim of our study was to evaluate the role of stressful events, lifestyles and various socio-environmental factors in the beginning of ischemic cardiac diseases, together with cardiovascular factors. MATERIALS AND METHODS: 64 patients with recent cardiac ischemia and 64 controls matched 1:1, according to their sex and age, have been evaluated. The study required the filling in of clinico-anamnestic reports and the evaluation of stressful events, using the Holmes Rahe scale. RESULTS: in the 44% of the patients who had a heart ischemia, an emotional striking event occurred few days before, with a 28% incidence of work and family problems. The mean score of the Holmes Rahe Social Readjustment Rating Scale was statistically significantly higher among cases (p<0,05). The percentage of the subjects who experienced a stressful event during the last year was significantly higher among those with an ischemic event even though the heart disease factors were similar in the 2 groups of cases and controls. CONCLUSIONS: although the known heart risk factors predispose to ischemic event, our results suggest that stressful and emotional factors play a fundamental role in increasing the risk.