Theory of mind profile and cerebellar alterations in remitted bipolar disorder 1 and 2: a comparison study.

The literature on social cognition abilities in bipolar disorder (BD) is controversial about the occurrence of theory of mind (ToM) alterations. In addition to other cerebral structures, such as the frontal and limbic areas, the processing of socially relevant stimuli has also been attributed to the cerebellum, which has been demonstrated to be involved in the above-mentioned disorder. Nevertheless, the cerebellar contribution to ToM deficits in bipolar patients needs to be elucidated further. To this aim, two tests assessing different components of ToM were used to evaluate the ability to appreciate affective and mental states of others in 17 individuals with a diagnosis of BD type 1 (BD1) and 13 with BD type 2 (BD2), both in the euthymic phase, compared to healthy matched controls. Cerebellar gray matter (GM) volumes were extracted and compared between BD1 and controls and BD2 and controls by using voxel-based morphometry. The results showed that BD1 patients were compromised in the cognitive and advanced components of ToM, while the BD2 ToM profile resulted in a more widespread compromise, also involving affective and automatic components. Both overlapping and differing areas of cerebellar GM reduction were found. The two groups of patients presented a pattern of GM reduction in cerebellar portions that are known to be involved in the affective and social domains, such as the vermis and Crus I and Crus II. Interestingly, in both BD1 and BD2, positive correlations were detected between lower ToM scores and decreased volumes in the cerebellum. Overall, BD2 patients showed a more compromised ToM profile and greater cerebellar impairment than BD1 patients. The different patterns of structural abnormalities may account for the different ToM performances evidenced, thus leading to divergent profiles between BD1 and BD2.

Involuntary psychiatric hospitalization among migrants in Italy: A matched sample study.

BACKGROUND: Immigrants in Europe appear to be at higher risk of psychiatric coercive interventions. Involuntary psychiatric hospitalization poses significant ethical and clinical challenges. Nonetheless, reasons for migration and other risk factors for involuntary treatment were rarely addressed in previous studies. The aims of this study are to clarify whether immigrant patients with acute mental disorders are at higher risk to be involuntarily admitted to hospital and to explore clinical and migratory factors associated with involuntary treatment. METHODS: In this cross-sectional matched sample study, we compared the rates of involuntary treatment in a sample of first-generation immigrants admitted in a Psychiatric Intensive Care Unit of a large metropolitan academic hospital to their age-, gender-, and psychiatric diagnosis-matched native counterparts. Clinical, sociodemographic, and migratory variables were collected. The Brief Psychiatric Rating Scale-expanded (BPRS-E) and the Clinical Global Impression-Severity (CGI-S) scale were administered. McNemar test was used for paired categorical variables and a binary logistic regression analysis was performed. RESULTS: A total of 234 patients were included in the analysis. Involuntary treatment rates were significantly higher in immigrants as compared to their matched natives (32% vs. 24% respectively; p < .001). Among immigrants, involuntary hospitalization was found to be more frequent in those patients whose length of stay in Italy was less than 2 years (OR = 4.2, 95% CI [1.4-12.7]). CONCLUSION: Recently arrived immigrants appear to be at higher risk of involuntary admission. Since coercive interventions can be traumatic and negatively affect outcomes, strategies to prevent this phenomenon are needed.

Aberrant Cerebello-Cerebral Connectivity in Remitted Bipolar Patients 1 and 2: New Insight into Understanding the Cerebellar Role in Mania and Hypomania.

Bipolar disorder (BD) is a major mental illness characterized by periods of (hypo) mania and depression with inter-episode remission periods. Functional studies in BD have consistently implicated a set of linked cortical and subcortical limbic regions in the pathophysiology of the disorder, also including the cerebellum. However, the cerebellar role in the neurobiology of BD still needs to be clarified. Seventeen euthymic patients with BD type1 (BD1) (mean age/SD, 38.64/13.48; M/F, 9/8) and 13 euthymic patients with BD type 2 (BD2) (mean age/SD, 41.42/14.38; M/F, 6/7) were compared with 37 sex- and age-matched healthy subjects (HS) (mean age/SD, 45.65/14.15; M/F, 15/22). T1 weighted and resting-state functional connectivity (FC) scans were acquired. The left and right dentate nucleus were used as seed regions for the seed based analysis. FC between each seed and the rest of the brain was compared between patients and HS. Correlations between altered cerebello-cerebral connectivity and clinical scores were then investigated. Different patterns of altered dentate-cerebral connectivity were found in BD1 and BD2. Overall, impaired dentate-cerebral connectivity involved regions of the anterior limbic network specifically related to the (hypo)manic states of BD. Cerebello-cerebral connectivity is altered in BD1 and BD2. Interestingly, the fact that these altered FC patterns persist during euthymia, supports the hypothesis that cerebello-cerebral FC changes reflect the neural correlate of subthreshold symptoms, as trait-based pathophysiology and/or compensatory mechanism to maintain a state of euthymia.

Comparison of Cerebellar Grey Matter Alterations in Bipolar and Cerebellar Patients: Evidence from Voxel-Based Analysis.

The aim of this study was to compare the patterns of cerebellar alterations associated with bipolar disease with those induced by the presence of cerebellar neurodegenerative pathologies to clarify the potential cerebellar contribution to bipolar affective disturbance. Twenty-nine patients affected by bipolar disorder, 32 subjects affected by cerebellar neurodegenerative pathologies, and 37 age-matched healthy subjects underwent a 3T MRI protocol. A voxel-based morphometry analysis was used to show similarities and differences in cerebellar grey matter (GM) loss between the groups. We found a pattern of GM cerebellar alterations in both bipolar and cerebellar groups that involved the anterior and posterior cerebellar regions (p = 0.05). The direct comparison between bipolar and cerebellar patients demonstrated a significant difference in GM loss in cerebellar neurodegenerative patients in the bilateral anterior and posterior motor cerebellar regions, such as lobules I-IV, V, VI, VIIIa, VIIIb, IX, VIIb and vermis VI, while a pattern of overlapping GM loss was evident in right lobule V, right crus I and bilateral crus II. Our findings showed, for the first time, common and different alteration patterns of specific cerebellar lobules in bipolar and neurodegenerative cerebellar patients, which allowed us to hypothesize a cerebellar role in the cognitive and mood dysregulation symptoms that characterize bipolar disorder.

The role of stress and psychiatric comorbidities as targets of non-pharmacological therapeutic approaches for migraine.

This narrative review addresses the interconnections among stress, mental disorders and migraine with a specific focus on non-pharmacological interventions that may be effective in improving both migraine and the psychiatric comorbidity. Migraine is often comorbid with depression, anxiety, personality disorders, and sleep disorders. Subjective stress and stressors are common triggers for migraine attacks and are risk factors for chronification, whilst mental disorders and stress responses are closely linked in a bidirectional relation. Recent studies show that psychiatric comorbidity is associated with migraine severity, worse outcomes, increased disability and reduce quality of life. Numerous studies on non-pharmacological interventions for migraine were published and behavioural treatments included biofeedback, cognitive-behavioural therapy, relaxation training, stress management and brief psychodynamic psychotherapy. Taken together, psychological interventions proved to be effective in migraine treatment and a combination of pharmacological and psychological treatment appear to be more effective than either medication or psychotherapy alone. Non-pharmacological interventions effectiveness should be due to the improvement of migraine, stress-related vulnerability and mental disorders together and the combined treatment could prevent the chronification circuit of migraine. Well-designed long-term studies are needed to clarify comparative effectiveness of non-pharmacological techniques in the treatment and the prevention of migraine.

Differences in MMPI-2 personality profiles among filicide and homicide women.

INTRODUCTION: Filicide is an act of terrible violence that generates dismay and astonishment and invites everybody to ask: why? AIM: As the transition to motherhood is a critical period for any woman, requiring the activation of deep personality resources, the aim of this study was to deepen our knowledge of the personality profiles of new mothers by comparing a sample of 16 women who had killed their own child ("filicide mothers") with women who had murdered someone outside of their family ("non-family homicide women"). METHOD: All of the women had a similar psychiatric diagnosis, as assessed by the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). All were assessed by the Minnesota Multiphasic Personality Inventory 2 (MMPI-2) 2 to 4 years after the court's judgment. A Kruskal-Wallis test and two-step cluster analysis were performed to determine whether a specific personality profile could distinguish filicide mothers from non-family homicide women. RESULTS: Years after the act, few filicide mothers showed symptoms of psychopathology; rather, they appeared functional and untroubled. In contrast, non-family homicide women showed a pathological mean profile. CONCLUSIONS: The results may indicate conscious attempts made by filicide mothers to avoid negative evaluations, minimize symptoms, and deny psychological suffering. These may indicate personality risk factors that could help clinicians recognize and intervene in cases where a woman presents a severe mental illness before, during, and following the birth of her child.

[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.

Personality traits in a sample of Italian filicide mothers.

Several studies focused on mothers' psychopathological and environmental risk factors linked to filicide, to understand the genesis of this violent act. Considering the transition to motherhood a critical period for any woman, requiring the activation of deep personality resources, the aim of this study was to detect, in a sample of 16 filicide women hospitalized in Italian Forensic Psychiatric Hospitals, the recurrent characteristics with a specific focus on personality traits. Women were assessed using Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), Big Five Inventory (BFI) and Temperament and Character Inventory (TCI). The BFI and TCI profiles seem to overlap showing a personality profile characterized by a rigid control of aggressive impulses, the avoiding of unconscious fears and the masking of feelings of negativity. Examining the mother's mental state with respect to personality traits, could help clinicians to detect specific temperament patterns that may carry out impulsive violent behaviors, if correlated with other psychopathological and environmental factors.

Psychopathology and personality in problematic internet users.

Few studies have addressed the issue of psychopathology and personality of individuals with problematic use of internet. In this study we research psychopathological symptoms, personality traits and predictive variables associated with problematic internet use. The study was conducted on a total of 343 students from four Italian Universities using Pathological Internet Use Scale, Big Five Questionnaire, and Symptom Check List 90 Revised. According to this study 52.7% of the sample shows a problematic internet use while only 7.6% don't suffer from any symptom. More than half of subjects admits to have got into arguments with a significant other over being online, and to have missed social engagements because of online activities. Subjects with problematic internet use scored higher in psychopathological scales. Low levels of Friendliness and Emotional Stability could predict the problematic use of internet. Problematic internet use may be associated with higher psychopathology levels and personality traits.

[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.

Residual depressive symptoms, sleep disturbance and perceived cognitive impairment as determinants of functioning in patients with bipolar disorder.

BACKGROUND: Many patients with bipolar disorder (BD) experience residual symptoms during their inter-episodic periods. The study aimed to analyse the relationship between residual depressive symptoms, sleep disturbances and self-reported cognitive impairment as determinants of psychosocial functioning in a large sample of euthymic BD patients. METHODS: This was a cross-sectional study of 468 euthymic BD outpatients. We evaluated the residual depressive symptoms with the Bipolar Depression Rating Scale, the sleep disturbances with the Pittsburgh Sleep Quality Index, the perceived cognitive performance using visual analogic scales and functioning with the Functioning Assessment Short Test. Structural equation modelling (SEM) was used to describe the relationships among the residual depressive symptoms, sleep disturbances, perceived cognitive performance and functioning. RESULTS: SEM showed good fit with normed chi square=2.46, comparative fit index=0.94, root mean square error of approximation=0.05 and standardized root mean square residuals=0.06. This model revealed that residual depressive symptoms (path coefficient =0.37) and perceived cognitive performance (path coefficient=0.27) were the most important features significantly related to psychosocial functioning. Sleep disturbances were indirectly associated with functioning via residual depressive symptoms and perceived cognitive performance (path coefficient=0.23). CONCLUSIONS: This study contributes to a better understanding of the determinants of psychosocial functioning during the inter-episodic periods of BD patients. These findings should facilitate decision-making in therapeutics to improve the functional outcomes of BD during this period.

Mood stabilizers and antipsychotics during breastfeeding: Focus on bipolar disorder.

Breast milk is considered the best source of nutrients and provides much better protection than immune modified milk. However, the postpartum period is a phase of increased risk for all women to experience psychiatric symptoms and recurrences or new episodes of bipolar disorder (BD), especially in those who have discontinued treatment. This is a systematic review of the risks and benefits of mood stabilizers and antipsychotics during breastfeeding as they relate to the health and well-being of mothers and their infants. Evidence-based treatment advice for women with BD during lactation is also provided. This systematic review has been conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. We included studies examining the exposure and the effects of antipsychotics and mood stabilizers used to treat BD on infants during breastfeeding clearly reporting the estimated amount of drug or effects on infants. The final selection included 56 studies. The available data supports the use of lithium as a possible treatment option during breastfeeding. Carbamazepine and valproic acid are also considered relatively safe. Lamotrigine can be used but at the lowest doses and considered for individual cases. Among the antipsychotics, quetiapine and olanzapine should be considered as first-line treatment options. Risperidone may be compatible with breastfeeding under medical supervision. Clozapine and amisulpiride are currently contraindicated. Long-term outcome studies evaluating the infant׳s health and psychosocial and cognitive functioning are needed.

Persistence of subsyndromal residual symptoms after remission of major depression in patients without cardiovascular disease may condition maintenance of elevated platelet factor 4 and ß-thromboglobulin plasma levels.

BACKGROUND: Depressive patients show a state dependent platelet activation that may heighten their cardiovascular risk, specially when comorbid with Coronary Artery Disease (CAD). We still have little information however on the possibility that residual symptoms that often persist after recovery from a major depressive episode may contribute to drive forward platelet activation, thus extending the exposure to the associated cardiovascular risk. METHODS: Nineteen major depressed inpatients treated with electroconvulsive therapy (ECT) were enrolled and tested for platelet aggregation by measuring platelet factor-4 (PF4) and ß-thromboglobulin (ß-TG) plasma levels, and for psychometric evaluation by using the 20-item Hamilton Depression Rating Scale (HDRS) and the Symptom Checklist 90 Revised (SCL-90R). Subjects were tested at the beginning of treatment (baseline) and after clinical remission (endpoint). RESULTS: At baseline the patients showed high HDRS (31±6) and total SCL-90R (200±38) scores, followed by a significant decrease at endpoint. However, even if all patients showed full syndromal recovery, SCL-90R "Hostility" and "Psychoticism" subscores showed no significant reduction from baseline, indicating the persistence of subtle residual symptoms. Baseline PF4 and ß-TG plasma levels were found remarkably higher and no significant reduction was observed at the endpoint. LIMITATIONS: Small study population. No follow-up evaluation. CONCLUSIONS: Despite of clinical remission obtained with ECT in patients with major depression, persistence of subsyndromal residual symptoms may contribute to maintain a condition of platelet hyperactivation at the endpoint, increasing their cardiovascular risk and making them more vulnerable to develop cardiovascular disease.