Phenomenology of Somatization in Immigrants: An Idealtypical Approach.

INTRODUCTION: Somatization in immigrants is frequent but standard studies do not differentiate between various forms of somatization. In this qualitative study, we used an idealtypical approach with the aim of phenomenologically differentiating between different forms of somatization in immigrants. METHODS: The clinical description of the ideal types was based on seven levels: medical examination; description of somatization symptoms; the patients' own interpretation of their somatic experience; concomitant psychopathological phenomena; genetic understanding; clinician's interpretation; and course and treatment. RESULTS: Five different ideal typologies of patients emerged: anxious hypochondriasis, somatization with cultural features playing a pathogenetic role, culturally shaped somatization (through pathoplastic effects), somatization as part of adjustment reactions due to migratory living difficulties, and somatization as post-traumatic reaction. CONCLUSION: These differences are useful to highlight the complex interrelationship between socioeconomic, migratory, cultural, and value factors in the construction of somatization among immigrants. Implications for research methodology, nosology, clinical management, and organization of medical facilities are also discussed.

The influence of Max Weber on the concept of empathic understanding (Verstehen) in the psychopathology of Karl Jaspers.

This paper explores key concepts in the writings of Weber in the years preceding the publication of the first edition of Karl Jaspers' Allgemeine Psychopathologie, focusing on the concept of understanding (Verstehen). This is a key hermeneutic concept and is discussed within the larger context of the epistemological and methodological reflections of both authors. They similarly tried to import the understanding within the humanistic disciplines as a rigorous but anti-reductionist scientific method. However, while Weber tried to mix explanation and understanding according to a legal metaphor, Jaspers retained Dilthey's sharper distinction between explanation in natural sciences and understanding in humanistic sciences. Finally, Jaspers' understanding is relatively more empathic, while Weber's understanding is more rationalistic.

[The concept of "understanding" (Verstehen) in Karl Jaspers]. / El concepto de "comprensión" (Verstehen) en Karl Jaspers.

This article explores the relationship between empathy and psychopathology. It deals with the concept of "understanding" in Jaspers' General Psychopathology, 100 years after the publication of its first edition. The Jaspersian proposal has the person and his/her experience as its primary object of study, just as in Ortegas' vital reason. Jaspers' understanding is not rational but empathetic, based on the co-presence of emotional content and detailed descriptions. Jaspers' methodology is essentially pluralistic, considering both explanation and understanding, necessary for psychopathology. Despite certain limits, the concept of understanding is the backbone of the psychopathological reasoning, and has proven useful over a century of clinical practice. However, it needs a review covering the recent epistemological and clinical findings. "To be understandable" is a relational property that emerges from a semiotic process. Therefore, an effective psychology should encompass an inter-subjective process, and get away from strict rationalism.

Unitary psychosis (Einheitspsychose): A conceptual history.

AIMS: The objective of this paper is to explore the evolution of the forms of madness and the model that accounts for it over time. The classical distinction between several categories of mental disorders is contrasted with the idea of unitary psychosis. METHODS: Historical conceptual analysis. The concept of unitary psychosis is explored in its basic features. Its origins in the nineteenth century and developments during the twentieth century are considered. RESULTS: Following the publication of Kraepelin's fundamental handbook, the debate was shaped as pro or against the Kraepelinian dichotomy between dementia praecox and manic-depressive illness. However, the origins of the concept of unitary psychosis as well as some more recent developments are independent from it. CONCLUSIONS: This article argues that, when viewed pragmatically, both positions (the pluralist and the unitary) bring advantages that can be complementary rather than mutually exclusive. The pluralist position allows us to recognize the qualitative differences between phenomena and structures of experience, while the unitary model prevents us from reifying them. This is achieved by paying attention to the diachronic evolution and the pathogenetic dynamics.

Philosophy of clinical psychopharmacology.

The renewal of the philosophical debate in psychiatry is one exciting news of recent years. However, its use in psychopharmacology may be problematic, ranging from self-confinement into the realm of values (which leaves the evidence-based domain unchallenged) to complete rejection of scientific evidence. In this paper philosophy is conceived as a conceptual audit of clinical psychopharmacology. Its function is to criticise the epistemological and methodological problems of current neopositivist, ingenuously realist and evidence-servant psychiatry from within the scientific stance and with the aim of aiding psychopharmacologists in practicing a more self-aware, critical and possibly useful clinical practice. Three examples are discussed to suggest that psychopharmacological practice needs conceptual clarification. At the diagnostic level it is shown that the crisis of the current diagnostic system and the problem of comorbidity strongly influence psychopharmacological results, new conceptualizations more respondent to the psychopharmacological requirements being needed. Heterogeneity of research samples, lack of specificity of psychotropic drugs, difficult generalizability of results, need of a phenomenological study of drug-induced psychopathological changes are discussed herein. At the methodological level the merits and limits of evidence-based practice are considered, arguing that clinicians should know the best available evidence but that guidelines should not be constrictive (due to several methodological biases and rhetorical tricks of which the clinician should be aware, sometimes respondent to extra-scientific, economical requests). At the epistemological level it is shown that the clinical stance is shaped by implicit philosophical beliefs about the mind/body problem (reductionism, dualism, interactionism, pragmatism), and that philosophy can aid physicians to be more aware of their beliefs in order to choose the most useful view and to practice coherently. In conclusion, psychopharmacologists already use methodological audit (e.g. statistical audit); similarly, conceptual clarification is needed in both research planning/evaluation and everyday psychopharmacological practice.

Neopositivism and the DSM psychiatric classification. An epistemological history. Part 1: Theoretical comparison.

Recent research suggests that the DSM psychiatric classification is in a paradigmatic crisis and that the DSM-5 will be unable to overcome it. One possible reason is that the DSM is based on a neopositivist epistemology which is inadequate for the present-day needs of psychopathology. However, in which sense is the DSM a neopositivist system? This paper will explore the theoretical similarities between the DSM structure and the neopositivist basic assumptions. It is shown that the DSM has the following neopositivist features: (a) a sharp distinction between scientific and non-scientific diagnoses; (b) the exclusion of the latter as nonsensical; (c) the faith on the existence of a purely observable basis (the description of reliable symptoms); (d) the introduction of the operative diagnostic criteria as rules of correspondence linking the observational level to the diagnostic concept.

Neopositivism and the DSM psychiatric classification. An epistemological history. Part 2: Historical pathways, epistemological developments and present-day needs.

Little is known about the concrete historical sources for the use of neopositivist operational criteria by the DSM-III. This paper suggests that distinct sources operated implicitly. The current usefulness of the operational approach is questioned. It is shown that: (a) in epistemology, neopositivism has been replaced by more adequate accounts; (b) psychologists rejected operational definitions because these were unable to define the majority of mental phenomena; (c) mental symptoms cannot be directly described as such, because they already make part of the psychiatric diagnosis to which they belong. In conclusion, diagnosing is based on the hermeneutical co-construction of mental symptoms. The failure of the neopositivist programme suggests that it is time to reconcile scientific formalization and semiotic activity.

Two years of COVID-19. Impacts on accessibility of a mental health service for immigrants and individuals in socio-economic difficulties.

OBJECTIVES: Mental health services utilization decreased dramatically during the COVID-19 pandemic. For persons who are highly vulnerable and at risk of health and social care exclusion, restrictions negatively affected the accessibility to treatments and their mental conditions. METHODS: All psychiatric and psychological interviews carried out at National Institute for Health, Migration and Poverty (INMP) Italy from January 2018 to February 2022 were included in the study. To measure services use, an interrupted time-series analysis using March 2020 as the starting data of COVID-19 pandemic period was considered, and first visits vs follow-up session numbered. RESULTS: A significant decrease was observed in March 2020 due to the lockdown restrictive measures (p<0.001). Later on, the number of psychological interventions significantly increased (p<0.05), whereas the increment of the psychiatric interventions was not significant. By the end of February 2022 the number of visits returned to pre-COVID-19 levels, although recovery was slower than expected, especially for psychiatric visits. CONCLUSIONS: After a dramatic drop during the lockdown, access to mental health out-patient clinics slowly returned to pre-pandemic levels in the next two years. Considering that mental health needs have increased during the pandemic, mental health services should improve their efforts to reduce barriers of access and to implement outreach referral.

Impact of the COVID-19 pandemic on Italian students' mental health and relationships: differences between adolescent males and females.

BACKGROUND: The negative effects of the COVID-19 pandemic on the mental health of young people have been reported, often with possible differences between the sexes. This study explores the impact of the COVID-19 pandemic on the differences in mental health status and healthy behaviors between adolescent males and females. METHODS: An online questionnaire exploring sociodemographic characteristics, living conditions, mental health, behaviors, and relationships during the implementation of the COVID-19 social restriction measures, was administered to 16-18 years old high school students living in the metropolitan area of Turin. The World Health Organization-5 Well-Being Index (WHO-5) questionnaire was used to evaluate self-perceived psychological health status. Descriptive analyses of the sample were carried out by sex. Chi-squared test and the associated P value were evaluated. The spatial sign method was used to assess multivariate differences by sex. RESULTS: Seventy-two Italian high school students completed the questionnaire. Sixty-eight percent of the students reported psychological problems, more often females (86% vs. 50%). Those living with multiple cohabitants and in dwellings with less personal space reported lower well-being. Females were also more likely to report stress when talking about COVID-19, difficulties in concentration and in falling asleep, daytime sleepiness, less physical activity, and concerns about losing control of eating. Finally, females spent more time with family members and, compared to males, found it harder to spend time and share experiences with friends and schoolmates. CONCLUSIONS: The pandemic has greatly impacted adolescents in terms of their mental well-being, routines, relationships with friends, and sleeping and eating patterns. Females reported more stress, boredom, bad mood, eating concerns, reduced relationships with friends, and possible difficulty in falling asleep than did males. These issues should be addressed when developing and promoting support programs, particularly at school.

Somatization in a primary care service for immigrants.

AIM: To study somatization in a large sample of immigrants attending a first visit to a primary care service. Differences in somatization among four large immigrant groups (Europeans, Asians, South Americans, and Africans) and 16 subgroups based on nationality were assessed. DESIGN: A total of 3105 patients were asked to participate in the study, of whom 3051 completed the 21-item version of the Bradford Somatic Inventory (BSI-21). Patients scoring 14 or higher on the BSI-21 were considered to be somatizers. A multiple logistic regression analysis adjusting for intervening variables tested the relative risk of somatization in and among the groups. RESULTS: Among the 3051 patients who completed the BSI-21, 782 (25.6%) were somatizers. Somatizers were significantly more prevalent among South Americans (30.1%). After adjusting for covariates, Asians and Europeans, but not Africans, showed a significantly lower risk of somatization compared to South Americans. Among national subgroups, somatization occurred more frequently in Peruvians (32.9%). Compared to Peruvians, migrants from Eastern Europe, Morocco, the Philippines, Sri Lanka, and El Salvador demonstrated a significantly lower risk of somatization. CONCLUSIONS: Approximately one-fourth of socially disadvantaged immigrants who accessed primary care services used somatization to express their distress. However, the likelihood of somatization varied widely among the different groups, and was significantly higher in South Americans and in some African groups, and lower in some Asian groups.

Psychopathological effects of the Coronavirus (Sars-CoV-2) imposed lockdown on vulnerable patients in treatment in a mental health outpatient department for migrants and individuals in poor socioeconomic conditions.

BACKGROUND: The effects of Sars-Cov-2 pandemic may increase vulnerability of migrants. AIMS: To investigate the effects of the governmental lockdown on the mental health of vulnerable migrants in treatment at an outpatient department. METHOD: In a telephone survey post-migration living difficulties and psychopathological symptoms were investigated, particularly post-traumatic thoughts and nightmares, anxiety, depression, feelings of tension and irritability, other sleep problems, as well as COVID-19 related fears. Psychopathological changes during the lockdown were detected and rated by clinicians. Rates of treatment discontinuation and reasons why were also recorded. RESULTS: Of 103 eligible patients, 81 answered the phone call and were included in the study. Mental symptoms were frequent but not as severe as expected. About 32% of patients in psychopharmacological treatment and almost 52% of patients in psychotherapy had discontinued treatment. Patients who were globally considered to have worsened if compared to their pre-coronavirus mental health conditions had in fact higher scores on several mental symptoms but mild specific fears about coronavirus issues, similar to those of patients improved or stable. Worsening was significantly associated with unemployment, lack of VISA, and treatment discontinuation. Shifting the way of providing psychotherapy into a web-based modality was significantly more frequent in stable/improved patients. CONCLUSION: Findings suggest that concrete life problems and treatment discontinuation more than the coronavirus fear, have predominantly affected the mental health conditions of our patients.

The lived experience of psychosis: a bottom-up review co-written by experts by experience and academics.

Psychosis is the most ineffable experience of mental disorder. We provide here the first co-written bottom-up review of the lived experience of psychosis, whereby experts by experience primarily selected the subjective themes, that were subsequently enriched by phenomenologically-informed perspectives. First-person accounts within and outside the medical field were screened and discussed in collaborative workshops involving numerous individuals with lived experience of psychosis as well as family members and carers, representing a global network of organizations. The material was complemented by semantic analyses and shared across all collaborators in a cloud-based system. The early phases of psychosis (i.e., premorbid and prodromal stages) were found to be characterized by core existential themes including loss of common sense, perplexity and lack of immersion in the world with compromised vital contact with reality, heightened salience and a feeling that something important is about to happen, perturbation of the sense of self, and need to hide the tumultuous inner experiences. The first episode stage was found to be denoted by some transitory relief associated with the onset of delusions, intense self-referentiality and permeated self-world boundaries, tumultuous internal noise, and dissolution of the sense of self with social withdrawal. Core lived experiences of the later stages (i.e., relapsing and chronic) involved grieving personal losses, feeling split, and struggling to accept the constant inner chaos, the new self, the diagnosis and an uncertain future. The experience of receiving psychiatric treatments, such as inpatient and outpatient care, social interventions, psychological treatments and medications, included both positive and negative aspects, and was determined by the hope of achieving recovery, understood as an enduring journey of reconstructing the sense of personhood and re-establishing the lost bonds with others towards meaningful goals. These findings can inform clinical practice, research and education. Psychosis is one of the most painful and upsetting existential experiences, so dizzyingly alien to our usual patterns of life and so unspeakably enigmatic and human.

[Immigration, trauma, living difficulties and psychopathology: a preliminary study in a primary care setting]. / Immigrazione, traumi, difficoltà vitali e psicopatologia: uno studio preliminare in un setting di medicina generale.

AIM: Investigate the prevalence of Post-Traumatic Stress Disorder (PTSD), anxiety, depression and somatizations in a sample of immigrants visited in a transcultural primary care service. The relationship among psychopathological symptoms, pre-migratory events and post-migration living difficulties is also considered. METHODS: We studied 101 outpatients, attending the "Caritas" Primary Care Unit for immigrants in Rome. All participants fulfilled a socio-demographic questionnaire, a checklist of traumatic events (Harvard Trauma Questionnaire, HTQ), a checklist of post-migration living difficulties (Post-Migration Living Difficulties, PMLD) and the following questionnaires: the HTQ for the assessment of post-traumatic symptoms, the Hopkins Symptom Checklist (HSCL-25) for anxiety and depression, the Bredford Somatic Inventory (BSI) for somatization. RESULTS: 40 patients (39.60%) had an anxiety disorder, 47 (46.13%) a depressive disorder, 16 (15.84%) a PTSD and 39 (38,6%) a somatization syndrome. All these syndromes were significantly correlated. The number of traumatic events and of post-migration difficulties significantly increased the scores on the psychopathological scales. DISCUSSION: The prevalence of psychopathological syndromes in our primary care transcultural unit was high. This not only in refugees, but also in immigrants for other reasons. Moreover, the levels of psychopathological distress were significantly influenced by the number of pre-migratory traumas and of living difficulties in the host country.

The relationship between somatization and posttraumatic symptoms among immigrants receiving primary care services.

Traumatic experiences and somatization are related in studies on complex trauma, though this relation is rarely studied in immigrants. The relationship between somatization and self-reported traumatic experiences and posttraumatic symptoms in patients attending a primary care service for immigrants was studied. The sample consisted of 101 patients attending a primary healthcare service dedicated to immigrants. Participants completed two self-assessment questionnaires specifically designed for use in transcultural research: the Bradford Somatic Inventory and the Harvard Trauma Questionnaire. Both were translated and back-translated into eight languages. Somatization was significantly related to traumatic events and posttraumatic symptoms. In primary care centers for immigrants, physicians should give particular attention to somatization as a possible sign of unreported posttraumatic symptoms.

Influence of post-migration living difficulties on post-traumatic symptoms in Chinese asylum seekers resettled in Italy.

BACKGROUND: Little is known about mental health and resettlement difficulties of Chinese asylum seekers fleeing China due to religious persecutions. AIM: This study explores main post-migration living difficulties (PMLD) in this population, with a focus on their role in post-traumatic stress disorder (PTSD). METHODS: A total of 67 patients (95.52% women, mean age 34.75 ± 7.63) were included in the study. The Harvard Trauma Questionnaire (HTQ) was used to assess PTSD, the List of Migration Experiences (LiMEs) was used for pre-migration and post-migration experiences (potentially traumatic events as well as living difficulties). The t-test was used to examine the differences in pre-migration and post-migration mean scores. Logistic regression was used to test the effect of pre-migration traumatic experiences (PMTE) and most frequent PMLD on having a PTSD. RESULTS: A total of 49 patients scored above the HTQ cut-off score for PTSD. As expected, traumatic experiences were concentrated in the pre-migration phase, while living difficulties were present in both phases but more frequently in the post-migration period. PMTE were significantly related to PTSD (OR 1.29, p = .01). However, three PMLD ('Feeling that you do not know where you will lend up tomorrow', 'Loneliness and boredom' and 'Not being able to find work') showed a significant interaction with PMTE, suggesting that their presence in the post-migration phase has a modulation effect by increasing the likelihood of PTSD. CONCLUSION: This study extends to Chinese asylum seekers the previous evidence that PMLD have a significant role in the likelihood to have a PTSD after landing in the host country.

DSM-IV-TR "pain disorder associated with psychological factors" as a nonhysterical form of somatization.

BACKGROUND: Elevated Minnesota Multiphasic Personality Inventory (MMPI) scores on the hysteria (Hy) scale are reported in several forms of pain. Previous results were possibly biased by diagnostic heterogeneity (psychogenic, somatic and mixed pain syndromes included in the same index sample) or Hy heterogeneity (failure to differentiate Hy scores into clinically meaningful subscales, such as admission of symptoms [Ad] and denial of symptoms [Dn]). METHODS: To overcome this drawback, 48 patients diagnosed as having a Diagnostic and Statistical Manual of Mental Disorders, 4th edn, Text Revision (DSM-IV-TR) diagnosis of "pain disorder associated with psychological factors" were compared with 48 patients experiencing somatic pain excluding psychological factors, and 42 somatic controls without pain. RESULTS: MMPI Hy and hypochondriasis (Hs) scores were significantly higher in the pain disorder group than in control groups, who scored similarly. MMPI correction (K) scores and Dn scores were similar in the three groups, whereas Ad was significantly higher in the pain disorder group and lower and similar in the two control groups, respectively. In the pain disorder group, Ad and Dn were negatively correlated, whereas in control groups they were unrelated. CONCLUSIONS: These findings suggest that whereas a pattern of high Hs and Hy scores together with a normal K score might characterize patients with a pain disorder associated with psychological factors, elevated Hy scores per se do not indicate hysterical traits. In the pain disorder group, elevated Hy scores reflected the Ad subscale alone, indicating a strikingly high frequency of distressing somatic symptoms. They tend not to repress or deny the emotional malaise linked to symptoms, as the hysterical construct expects. The pain disorder designation should be considered a nonhysterical form of somatization.

The Impact of Translational Neuroscience on Revisiting Psychiatric Diagnosis: State of the Art and Conceptual Analysis.

This paper reviews translational research in psychiatry, focusing on those programs addressing the problem of the validity of psychiatric diagnoses. In medicine in general, and in psychiatry in particular, the term "translational" is used with different meanings. A conceptual analysis suggests that there are at least seven different types of translational research in psychiatry: T1 ("bench-to-bedside" development of tools and treatments), T2 (application of animal models to human psychiatry), T3 (papers focusing on the mind-brain gap, studying biological, neurobiological and cognitive dysfunctions), T4 (personalised therapies and prediction of treatment responses), T5 ("bedside-to-bench" translation of population data for laboratories), T6 (implementation of treatments at the population level, including accessibility and quality of services), and T7 (improving translational knowledge in residents' trainings and researchers' careers). Concerning the problem of validity of psychiatric diagnoses, new neurocognitive models like the Research Domain Criteria project are considered, in particular the translational program of cross-validation aimed at reducing the gap between neuroimaging data and psychopathological scores derived from rating-scales. It is shown that these programs are useful, filling some of the current research gaps, but it is also stressed that they carry implicit realist and reductionist assumptions. It is finally suggested that the formation of mental symptoms is a complex process involving both neurocognitive and semantic factors, which raises doubts about the possibility of complete translations, without residuals.

Obesity is associated with lack of inhibitory control and impaired heart rate variability reactivity and recovery in response to food stimuli.

Recent theories compare obesity with addiction in terms of lack of inhibitory control in both clinical populations. The present study hypothesized impaired inhibition in obese patients reflected both in executive functions and reduced vagal tone (indexed by a decrease in heart rate variability; HRV) in response to food stimuli. Twenty-four inpatients with obesity (19 women) and 37 controls (24 women) underwent ECG monitoring during baseline, food stimuli viewing, and a recovery phase. Tests and questionnaires assessing inhibitory control and psychopathological dispositions were also administered. As hypothesized, patients were characterized by deficits in all the tests measuring inhibitory capacities. Results also show greater HRV reduction and impaired HRV recovery in response to food stimuli in obese patients compared to controls. The drive to eat experienced by obese patients in the absence of caloric need may rely on impairments in inhibitory and vagal functioning. Results are discussed in terms of implications for therapy.

Neural functional correlates of empathic face processing.

OBJECTIVES: Empathy is a human trait related to the ability to share someone else's feelings, and emotional face processing is one of its measures. Functional Magnetic Resonance Imaging (fMRI) studies showed significant neural correlates of empathic face processing. We aimed to identify those brain areas most consistently involved in empathy for emotional faces. METHODS: We carried ALE meta-analysis of whole-brain data from fMRI studies during empathic face-processing tasks. We included 23 studies conducted on a total of 568 participants (247 males and 321 females, mean age 32.2 years). RESULTS: Emotional vs. control faces processing significantly correlated with activations of the left anterior cingulate cortex (BA 32), right precentral gyrus (BA 6), left amygdala, right superior frontal gyrus (BA 9), left middle occipital gyrus (BA 37), right insula (BA 13), left putamen, and left posterior cingulate cortex (BA 31). CONCLUSIONS: Empathy is a complex process correlating with bi-hemispheric cortico-limbic activations involved in emotional cue processing, self-other/same-different discrimination, perspective-taking, theory of mind, emotional arousal, and decision-making.