Predicting outcome with Intranasal Esketamine treatment: A machine-learning, three-month study in Treatment-Resistant Depression (ESK-LEARNING)

Treatment-resistant depression (TRD) represents a severe clinical condition with high social and economic costs. Esketamine Nasal Spray (ESK-NS) has recently been approved for TRD by EMA and FDA, but data about predictors of response are still lacking. Thus, a tool that can predict the individual patients' probability of response to ESK-NS is needed. This study investigates sociodemographic and clinical features predicting responses to ESK-NS in TRD patients using machine learning techniques. In a retrospective, multicentric, real-world study involving 149 TRD subjects, psychometric data (Montgomery-Asberg-Depression-Rating-Scale/MADRS, Brief-Psychiatric-Rating-Scale/BPRS, Hamilton-Anxiety-Rating-Scale/HAM-A, Hamilton-Depression-Rating-Scale/HAMD-17) were collected at baseline and at one month/T1 and three months/T2 post-treatment initiation. We trained three different random forest classifiers, able to predict responses to ESK-NS with accuracies of 68.53% at T1 and 66.26% at T2 and remission at T2 with 68.60% of accuracy. Features like severe anhedonia, anxious distress, mixed symptoms as well as bipolarity were found to positively predict response and remission. At the same time, benzodiazepine usage and depression severity were linked to delayed responses. Despite some limitations (i.e., retrospective study, lack of biomarkers, lack of a correct interrater-reliability across the different centers), these findings suggest the potential of machine learning in personalized intervention for TRD.

RISK aversion in Italian forensic and non-forensic patients with schizophrenia spectrum disorders

BACKGROUND

Goal-directed decision-making is a central component of the broader reward and motivation system, and requires the ability to dynamically integrate both positive and negative feedback from the environment in order to maximize rewards and minimize losses over time. Altered decision-making processes, in which individuals fail to consider the negative consequences of their decisions on both themselves and others, may play a role in driving antisocial behaviour.

AIM

The main study aim was to investigate possible differences in loss and risk aversion across matched patients, all with a schizophrenia spectrum disorder (SSD), but who varied according to whether they had a history of serious interpersonal violence or not, and a sample of healthy controls with no history of violence.

RESULTS

The sample included 14 forensic and 21 non-forensic patients with SSD, and 41 healthy controls. Among the three decision-making variables under investigation, risk aversion was the only significant predictor of membership of the three groups, with greater risk aversion among non-forensic patients with SSD compared to healthy controls. No differences were observed across groups in loss aversion and choice consistency.

CONCLUSIONS

This evidence suggests a new potential treatment target for rehabilitative measures aimed at achieving functional improvements in patients with SSD by selectively leveraging the neuro-cognitive processing of reward.

Difference between forensic patients with schizophrenia spectrum disorders in Italy and other European countries: Results of the EU-VIORMED project

BACKGROUND

There has been a substantial change in the law on the provision of secure health services for offender-patients in Italy, a country currently with the lowest general psychiatry bed availability per head of the population in Europe, raising questions about possible differences in offender-patient admissions between European countries.

AIMS

In this multicentre case-control study, our aim was to compare the socio-demographic, clinical and criminological characteristics of a sample of Italian forensic in-patients with schizophrenia or similar psychosis with patients in a similar diagnostic range in specialist in-patient services elsewhere in Europe.

METHODS

Secure hospital unit in-patients with psychosis were recruited across five European countries (Italy, Austria, Germany, Poland and England). Consenting patients were interviewed by researchers and assessed using a multidimensional standardised process. Within country similarities between Austria, Germany, Poland and England were confirmed.

RESULTS

Overall, 39 Italian participants had had fewer years of education than the 182 patients in the other countries and were less likely to have ever had skilled or professional employment. The Italian patients had been older at first contact with any mental health services than the other Europeans. Diagnosed comorbidity rates were similar, but the Italian group reported higher levels of disability. Although the other European forensic patients were more likely to be undergoing treatment at the time of their index offence, they were also more likely to have been poorly compliant with treatment. The rate of suicide-related behaviours was significantly lower among the Italian patients than among the others.

CONCLUSIONS

Notwithstanding similar diagnoses, important differences emerged between patients in Italian forensic mental health resident services and those in four other European countries, some possibly reflecting less access to earlier relevant services in Italy. Others, including lower disability ratings among the Italian patients and a lower rate of suicide-related behaviours, may indicate that the Italian reforms carry benefits. This is worthy of further evaluation.

Metacognitive interpersonal therapy in borderline personality disorder: Clinical and neuroimaging outcomes from the CLIMAMITHE study-A randomized clinical trial

Different psychotherapeutic approaches demonstrated their efficacy but the possible neurobiological mechanism underlying the effect of psychotherapy in borderline personality disorder (BPD) patients is poorly investigated. We assessed the effects of metacognitive interpersonal therapy (MIT) on BPD features and other dimensions compared to structured clinical management (SCM). We also assessed changes in amygdala activation by viewing emotional pictures after psychotherapy. One hundred forty-one patients were referred and 78 BPD outpatients were included and randomized to MIT or SCM. Primary outcome was emotional dysregulation assessed with the Difficulties in Emotion Regulation Scale (DERS). We also assessed BPD symptomatology, number of PD criteria, metacognitive abilities, state-psychopathology, depression, impulsiveness, interpersonal functioning, and alexithymia. A subset of 60 patients underwent functional magnetic resonance imaging before and after 1 year of psychotherapy to assess amygdala activation by viewing standardized emotional pictures (secondary outcome). DERS scores decreased in both groups (time effect p < .001). The Cohen's d effect size for change (baseline posttreatment) on DERS was very large (d = 0.84) in MIT, and large (d = 0.76) in SCM. Both groups significantly improved in depressive symptoms, state-psychopathology, alexithymia, and interpersonal functioning. MIT showed larger effect on metacognitive functions than SCM (Time × Group p < .001). Both interventions showed a significant effect on BPD symptomatology although SCM group showed a larger decrease. On the contrary, MIT group showed larger decrease in impulsivity and number of PD criteria. Interestingly, both MIT and SCM modulated amygdala activation in BPD patients. MIT is a valid and effective psychotherapy for BPD with an impact on amygdala activation. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Men.Phys - Reducing sedentary behavior and increasing physical activity in people with severe mental illness in an acute psychia- tric ward: a research protocol for a randomized controlled trial

Background

People with Severe Mental Illness (SMI) (schizophrenia, bipolar disorder, major depressive disorder, and personality disorders) experience a considerable risk of premature mortality because of cardiovascular disease, smoking, metabolic syndrome, etc. Recent research has demonstrated that this population spends almost 13 h per day being sedentary. Sedentary behavior (SB) is an independent risk factor for cardiovascular disease and mortality. Given the potential for physical activity (PA) to improve health and well-being in people with SMI, we developed a pilot randomized controlled trial (RCT) to evaluate a group intervention aimed at reducing SB and increasing PA of inpatients with SMI. Our primary aim is to assess the acceptability and feasibility of Men.Phys protocol, a new integrated treatment protocol for psychiatric inpatients. Secondary aims are to verify if the Men.Phys protocol decreased sedentary behavior and increased well-being, in terms of quality sleep, quality of life, and psychopathological symptoms and other measures.

Methods

Will be enrolled people with SMI consecutively admitted to the emergency psychiatric ward in Colleferro, near Rome. Participant's physical activity, health, psychiatric and psychological status will be assessed at baseline. Randomised participants will receive treatment as usual (TAU) or the Men.Phys intervention. Men.Phys involves a group activity conducted by a mental health practitioner, during which patients repeat exercises that showed through a monitor. The protocol provides that, during hospitalization, the patient follow at least 3 sessions consecutively. Lazio 1 ethics Committee approved this research protocol.

Results and Conclusions

To our knowledge, Men.Phys is the first RCT to investigate the impact of a group intervention targeting sedentary behavior in people with SMI during psychiatric hospitalization. If the intervention should be feasible and acceptable, further large-scale study can be developed and then implemented in routine care.

Treating bipolar depression with esketamine: Safety and effectiveness data from a naturalistic multicentric study on esketamine in bipolar versus unipolar treatment-resistant depression

BACKGROUND

Bipolar depression accounts for most of the disease duration in type I and type II bipolar disorder (BD), with few treatment options, often poorly tolerated. Many individuals do not respond to first-line therapeutic options, resulting in treatment-resistant bipolar depression (B-TRD). Esketamine, the S-enantiomer of ketamine, has recently been approved for treatment-resistant depression (TRD), but no data are available on its use in B-TRD.

OBJECTIVES

To compare the efficacy of esketamine in two samples of unipolar and bipolar TRD, providing preliminary indications of its effectiveness in B-TRD. Secondary outcomes included the evaluation of the safety and tolerability of esketamine in B-TRD, focusing on the average risk of an affective switch.

METHODS

Thirty-five B-TRD subjects treated with esketamine nasal spray were enrolled and compared with 35 TRD patients. Anamnestic data and psychometric assessments (Montgomery-Asberg Depression Rating Scale/MADRS, Hamilton-depression scale/HAM-D, Hamilton-anxiety scale/HAM-A) were collected at baseline (T0), at one month (T1), and three months (T2) follow up.

RESULTS

A significant reduction in depressive symptoms was found at T1 and T2 compared to T0, with no significant differences in response or remission rates between subjects with B-TRD and TRD. Esketamine showed a greater anxiolytic action in subjects with B-TRD than in those with TRD. Improvement in depressive symptoms was not associated with treatment-emergent affective switch.

CONCLUSIONS

Our results supported the effectiveness and tolerability of esketamine in a real-world population of subjects with B-TRD. The low risk of manic switch in B-TRD patients confirmed the safety of this treatment.

[Covid-19 emergency and telemedicine: multifamily psychoeducational intervention in a forensic setting.]

AIM

The aim is to describe remote multifamily psychoeducational intervention led by REMS "Castore" team (an Italian health care facility for offenders who suffer from mental disorders and socially dangerous) in ASL Roma 5, a local health authority, during covid-19 emergency.

METHODS

The applied theoretical models have been the integrated psychoeducational intervention by I. Falloon and the multifamily psychoeducational intervention based on problem solving by F. Veltro. The multifamily psychoeducational intervention was attempted by inpatients' relatives from June to August 2020 with 8 weekly meetings of 90' each led by two psychiatric rehabilitation therapists and healthcare experts. Six families were involved in the study and its members were assessed by questionnaire on family problems, Brief-COPE and general health questionnaire tests. Users were assessed by Level of Expressed Emotion Scale test for their expressed emotion.

RESULTS

Data analysis highlighted the general low level of subjective and objective burden for family members in association with a high perception of that support provided by REMS. Furthermore, the study has shown those coping approaches oriented to the research of practical solutions, acceptance of events and assertive communication.

DISCUSSION

The low subjective and objective burden may be attributed to implicit security conditions in REMS and the absence of tasks mainly carried out by experts. Those coping styles oriented to more practical than emotional approaches suggest an emotional hyper control or stigma perception leading to isolation and loneliness.

CONCLUSIONS

The multifamily psychoeducational intervention has allowed a trustworthy relationship with REMS. Considering that the families involved in the study have never benefited by other psychoeducational interventions before, their early involvement appears to be a potential tool for preventing and managing crisis as well as minimizing recidivism.

Real-world experience of esketamine use to manage treatment-resistant depression: A multicentric study on safety and effectiveness (REAL-ESK study)

BACKGROUND

Treatment-resistant Depression (TRD) represents a widespread disorder with significant direct and indirect healthcare costs. esketamine, the S-enantiomer of ketamine, has been recently approved for TRD, but real-world studies are needed to prove its efficacy in naturalistic settings.

OBJECTIVES

Evaluate the effectiveness and safety of esketamine nasal spray in a clinical sample of patients with TRD from several Italian mental health services.

METHODS

REAL-ESK study is an observational, retrospective and multicentric study comprising a total of 116 TRD patients treated with esketamine nasal spray. Anamnestic data and psychometric assessment (MADRS, HAMD-21, HAM-A) were collected from medical records at baseline (T0), one month (T1) and three month (T2) follow-ups.

RESULTS

A significant reduction of depressive symptoms was found at T1 and T2 compared to T0. A dramatic increase in clinical response (64.2 %) and remission rates (40.6 %) was detected at T2 compared to T1. No unexpected safety concerns were observed, side effects rates were comparable to those reported in RCTs. No differences in efficacy have been found among patients with and without psychiatric comorbidities.

LIMITATIONS

The open design of the study and the absence of a placebo or active comparator group are limitations. The study lacks an inter-rater reliability evaluation of the assessments among the different centres. Side effects evaluation did not involve any specific scale.

CONCLUSIONS

Our findings support the safety and tolerability of esketamine in a real-world TRD sample. The later response and the non-inferiority in effectiveness in patients with comorbidities represent novel and interesting findings.

Medium and long-term efficacy of psychoeducational family intervention for bipolar I disorder: Results from a real-world, multicentric study

OBJECTIVES

This study aims to explore the long-term efficacy of a psychoeducational family intervention (PFI) in bipolar I disorder at one and five years post-intervention in terms of improvement of: (1) patients' symptoms and global functioning and (2) relatives' objective and subjective burden and coping strategies.

METHODS

This is a multicentre, real-world, controlled, outpatient trial. Recruited patients and key-relatives were consecutively allocated to the experimental intervention or treatment as usual. Patients were assessed at baseline, and after one and five years.

RESULTS

One hundred and thirty-seventh number families have been recruited; 70 have been allocated to the experimental intervention, and 67 have been allocated to the control group. We observed an increasing positive effect of the PFI on patients' clinical status, global functioning and objective and subjective burden after one year. We also found a reduction in the levels of relatives' objective and subjective burden and a significant improvement in the levels of perceived professional support and of coping strategies. The efficacy of PFI on patients' clinical status was maintained at five years from the end of the intervention, in terms of relapses, hospitalizations and suicide attempts.

CONCLUSIONS

The study showed that the provision of PFI in real-world settings is associated with a significant improvement of patients' and relatives' mental health and psychosocial functioning in the long term. We found that the clinical efficacy of the intervention, in terms of reduction of patients' relapses, hospitalization and suicide attempts, persists after 5 years. It is advisable that PFI is provided to patients with BD I in routine practice.

Revealing the corporate contribution to sustainable development goals through integrated reporting: a worldwide perspective

Purpose

This study aims to contribute to the existing literature by presenting new knowledge about sustainable development goals’ (SDGs) reporting practices through integrated reporting (IR). This paper’s ultimate goal is to dig to light companies’ main approaches to incorporating SDG disclosures into IRs.

Design/methodology/approach

This study puts forward both deductive content analysis and an inductive thematic analysis on a sample of worldwide leading IR adopters to assess what SDGs they disclose and how they integrate SDGs into the reports. Meaningful narratives and graphical illustrations are selected, categorised and discussed from a symbolic/substantive legitimacy perspective.

Findings

The results of this study highlighted that although a fair number of leading IR adopters addressed SDG issues, their pathways to disclosure were not uniform. In some cases, SDGs inspired substantive changes to internal management and process, communicated through an integrated approach. However, there was a persistent trend of using SDGs as camouflage and symbolic tool to enhance company’s reputation and obtain a licence to operate.

Originality/value

To the best of the authors’ knowledge, this was the first study that performed a deductive/inductive thematic analysis to engender insight into the most meaningful patterns followed by leading IR reporters worldwide to disclose their contributions to SDGs and address their legitimacy.

The Prevalence of PTSD in a Forensic Psychiatric Setting: The Impact of Traumatic Lifetime Experiences

Background

Several studies have identified traumatic history among forensic patients and its association with criminal behaviors and psychiatric diagnoses. Post-traumatic stress disorder (PTSD) is highly prevalent in forensic settings causing a serious deterioration of the primary psychiatric disorder.

Aims

Our study aims to evaluate the prevalence of PTSD and the role of traumatic experiences and abuse in the development of severe psychiatric disorders in a sample of psychiatric offenders.

Methods

Fifty-three patients admitted in Italian high intensity therapeutic facilities-the Residenze per l'Esecuzione delle Misure di Sicurezza (REMS)-were evaluated with the Trauma Experience Checklist (TEC) and the Millon Clinical Multiaxal Inventory (MCMI-III) to study lifetime traumatic memories and general psychopathology, respectively.

Results

Preliminary findings show that about 41% (N = 22) of psychiatric offenders were affected by PTSD, often not due to a single episode but to multiple lifetime traumas. Therefore, lifetime traumatic experiences and specifically sexual abuse are significant risk factors for the development of a personality disorder, which is present in the 38% (N = 20) of the sample.

Conclusions

The high PTSD prevalence and the strong association found between trauma and abuse with the development of a personality disorder emphasizes the importance of an early evaluation and intervention on traumatic experiences in this difficult population of psychiatric patients; in fact, the treatment of psychiatric offenders is actually vague and devoid of scientific evidence. Our results open up the perspective on the use of known and specific interventions for trauma, such as EMDR and Mindfulness.

Metacognitive Abilities as a Protective Factor for the Occurrence of Psychotic-Like Experiences in a Non-clinical Population

Psychotic-like experiences (PLEs) are a phenomenon that occurs in the general population experiencing delusional thoughts and hallucinations without being in a clinical condition. PLEs involve erroneous attributions of inner cognitive events to the external environment and the presence of intrusive thoughts influenced by dysfunctional beliefs; for these reasons, the role played by metacognition has been largely studied. This study investigates PLEs in a non-clinical population and discriminating factors involved in this kind of experience, among which metacognition, as well as psychopathological features, seems to have a crucial role. The aim of this study was to extend the knowledge about the relationship between metacognition, psychopathology, and PLEs, orienting the focus on metacognitive functioning. The sample consisted of 207 Italian participants (men = 32% and women = 68%) voluntarily recruited online, who gave consent to participate in the study. The average age of the sample was 32.69 years (SD: 9.63; range: 18-71). Subjects affected by psychosis, neurological disease, and drug addiction were excluded from the analyses. The following scales were used to investigate PLEs: Peters et al. Delusions Inventory (PDI), Launay-Slade Hallucinations Scale-Extended Revised (LSHSE), Prodromal Questionnaire-Brief (PQ-B), and Revised Hallucination Scale (RHS). To assess general psychopathological features, the Behavior and Symptom Identification Scale (BASIS-32) was administrated. The Metacognition Self-Assessment Scale (MSAS) was chosen to evaluate metacognitive functioning. From hierarchical regression analyses, it emerged that the presence of anxiety, depression, and impulsive/addictive symptoms constitute a remarkable vulnerability factor for PLEs, in line with previous evidence regarding the relationship between general psychopathology and PLEs. Metacognition negatively predicts PLEs, and its presence does not affect the significance of psychopathological variables, suggesting that metacognitive abilities seem to play a protective role for the occurrence of PLEs among non-clinical individuals, and such ability operates as an independent predictor along with other variables. These results are explained by the role of metacognitive functions, which allow individuals to operate many mental processes such as interpreting sensorial events as real or illusory, understanding behaviors, thoughts, and drives of others, and questioning the subjective interpretation of facts.

Onset psychosis and PTSS after severe respiratory symptomatology caused by SARS-CoV-2 infection: a case report

Covid-19 is an infective respiratory illness caused by a novel virus, which might present different degrees of severity: from mild or even asymptomatic carriers to severe pneumonia, requiring intubation and intensive care unit (ICU) management. SARS-CoV-2 may cause also central nervous system involvement, including psychiatric manifestations. Some cases of psychosis apparently covid-related have been reported since the start of the pandemic; we will briefly review some of them here, then we will report a case concerning a patient with emerging psychosis during the disease caused by the virus. Our case describes a man with no prior personal or familiar psychiatric history, who developed delusion and a post-traumatic stress symptoms (PTSS) which required hospitalization in a psychiatric unit. The patient was treated with antipsychotic medications and underwent a brief follow-up.

[The management of long-term treatment of patient with schizophrenia: results of a survey carried out in Italy]

The management plan of patients with schizophrenia includes a multidimensional and integrated approach, consisting of pharmacological, psychological and psychosocial interventions. Among pharmacological approaches, the development of long-acting injectable antipsychotics (LAI) has radically changed the treatment plan of patients with schizophrenia. LAI can be successfully used in patients with multiple episodes, with partial or poor adherence to treatments and are very useful also in first episode patients. LAIs have been proven to be effective and with a good safety and tolerability profile, but they are still used in a few cases in the clinical routine practice. Therefore, the present study aims to evaluate attitudes and preferences of psychiatrists in the Italian routine care towards LAI and to identify the communication skills adopted in the routine care for the prescription of LAI. The final sample consists of 274 clinicians, recruited by phone call (n=257) and online (n=17). The main findings are: the psychoeducational approach is essential for improving patients' adherence to pharmacological treatments and their personal and social functioning; the involvement of family members is essential for improving adherence to treatments; LAIs are frequently used due to their efficacy and good tolerability profile, compared to first generation depot antipsychotics. Based on our findings, the ideal patient to be switched to LAI treatment is represented by a person with poor adherence to treatments, at the onset of the disorder, or with a poor tolerability to side effects.

Unveiling the link between performance and Intellectual Capital disclosure in the context of Italian Public universities

This work aims to explore the relationship between academic performance and voluntary Intellectual Capital (IC) disclosure in the context of Italian Public Universities. This study applies a content analysis to investigate the extent of voluntary Intellectual Capital disclosure (ICD) provided through performance reports by a sample of 59 Italian public universities. Four multivariate regression models are estimated to examine the associations between academic performance and the level of ICD and its sub-components, namely Human Capital, Structural Capital and Relational Capital. The content analysis findings show that Italian public universities place a high value on disclosing human capital information. The results based on the multivariate analysis confirm the view that, in the case of higher performance, Italian Public Universities tend to convey a greater extent of information on both IC and its sub-components. This study broadens the scope of mainstream ICD literature's actions by bringing new expertise about the interconnections between university performance and voluntary ICD provided via performance reports. Connecting university performance to ICD can enhance the practical and theoretical understanding of the role that ICD may exert for universities to signalling their excellence and explain to stakeholders how they create value and achieve superior performance, focusing on their strategic - IC-based resources.

Metacognition and emotion regulation as treatment targets in binge eating disorder: a network analysis study

BACKGROUND

This study aims to examine the underlying associations between eating, affective and metacognitive symptoms in patients with binge eating disorder (BED) through network analysis (NA) in order to identify key variables that may be considered the target for psychotherapeutic interventions.

METHODS

A total of 155 patients with BED completed measures of eating psychopathology, affective symptoms, emotion regulation and metacognition. A cross-sectional network was inferred by means of Gaussian Markov random field estimation using graphical LASSO and the extended Bayesian information criterion (EBIC-LASSO), and central symptoms of BED were identified by means of the strength centrality index.

RESULTS

Impaired self-monitoring metacognition and difficulties in impulse control emerged as the symptoms with the highest centrality. Conversely, eating and affective features were less central. The centrality stability coefficient of strength was above the recommended cut-off, thus indicating the stability of the network.

CONCLUSIONS

According to the present NA findings, impaired self-monitoring metacognition and difficulties in impulse control are the central nodes in the psychopathological network of BED whereas eating symptoms appear marginal. If further studies with larger samples replicate these results, metacognition and impulse control could represent new targets of psychotherapeutic interventions in the treatment of BED. In light of this, metacognitive interpersonal therapy could be a promising aid in clinical practice to develop an effective treatment for BED.

Survey on centres and procedures for the diagnosis and treatment of adult ADHD in public services in Italy

Attention deficit/hyperactivity disorder (ADHD) often persists into adulthood. Although its persistence and relative high prevalence, ADHD in adults is often underdiagnosed and undertreated in Italy, leading to poor clinical and functional outcomes, and higher costs of illness. The aims of the study were to identify the Italian mental health services for ADHD in adults, describe the diagnostic and treatment procedures they follow, and compare this offer with the recommendations of the German and English guidelines. The centres, that adopt a clinical and assessment protocol for adult ADHD diagnosis (carried out by specifically trained personnel) and prescribe pharmacological treatment for adult ADHD, were selected from the list of accredited services provided by the Appendix B.2 of the ISTISAN 16/37 Reports of the ISS. An ad-hoc survey including open-ended and close-ended questions was sent to each selected centre in February 2020. The overall picture resulting from the data analysis was compared with the recommendations of the German and English guidelines. The present survey shows that only a few centres are specialised in the diagnosis and treatment of ADHD in adults in Italy. Furthermore, there are no national guidelines for adult ADHD in Italy. The collected data also suggest that there is no a unified practice shared by the Centres both for the patient's transition from child and adolescent to adult mental health services and for the diagnostic-therapeutic process. It is therefore crucial to create specific protocols and develop national guidelines to better identify and diagnose ADHD in adults and provide targeted and more efficient multimodal treatments.

[Cognitive-Behavioural group interventions and Multifamily Psychoanalysis group in a Psychiatric Ward]

AIM

This paper aims to study, evaluate and compare the effectiveness of two group interventions within a Psychiatric Intensive Care Unit (PICU). The outcome indicators of the satisfaction of patients and their families with the ward were evaluated with a Satisfaction Questionnaire on the department, and their satisfaction with the groups were evaluated with the Satisfaction Questionnaire for the groups. The two theoretical orientations examined are the cognitive-behavioural therapy, with group cognitive-behavioural intervention in the context of SPDC, and psychoanalysis, with multifamily psychoanalysis groups, according to the model of Jorge García Badaracco.

METHODS

The sample is composed of 83 users (42 males and 41 females) participating in the groups; 41 users (23 males and 18 females) not participating in the groups; 54 family members participating in the groups; 41 family members not participating in the groups.

RESULTS

The results show an improvement of satisfaction with activities compared to the hospitalisation into the ward (p<.01), an improvement in the perception of the ward climate (p<.01) of the users participating in the groups, regardless of the orientation of reference, but it shows a greater effectiveness of groups with cognitive-behavioral group orientation (p<.001).

DISCUSSION AND CONCLUSIONS

The results indicate a greater effectiveness of the groups with cognitive-behavioural orientation, but confirm that psychotherapeutic groups in psychiatric contexts, even in emergency, not only seems to be well accepted and perceived positively by users and family members, but it also contributes to increasing satisfaction with the ward.

Do Competitive Contexts Affect Mindreading Performance?

Mindreading is contingent upon interpersonal context. Little is known about how competitive contexts influence mindreading skills. The idea was that the capacity to think about mental states would decline when individuals experiencing failure in competition. This study aims to assess effects of a competitive experience (a computer competitive PC game) on a sample of healthy subjects (119 participants). The sample was divided into two sub-samples. The experimental group underwent an experience of failure, consisting in a PC game of logic against a hypothetical opponent. The control group was required instead only to discuss past personal experiences of competitive interactions. The Metacognitive Assessment Interview was administered to each sub-sample for evaluating mindreading capacities. Self-report tests were additionally provided for evaluation of trait-based dispositions: self-esteem, perfectionism, narcissism. Results supported our hypothesis: induction of sense of failure compromises ability to describe one’s own mental states and mental states of others. This effect was more pronounced in the domain of self-reflection. Results remained significant after controlling for self-esteem, perfectionism, and narcissism. We discuss possible clinical implications of these findings and the importance of evaluating mindreading capacities under the pressure of social rank as well as of other social motive.

The role of self-monitoring metacognition sub-function and negative urgency related to binge severity

OBJECTIVE

This study aims to test a model where low self-monitoring (a sub-function of first-person domain of metacognition) and high negative urgency lead to a worsening of binge severity through the mediation of emotional dysregulation in patients with binge eating disorder (BED).

METHOD

Forty non-BED-obese and 46 BED-obese patients completed a battery of tests assessing metacognition and psychopathology. To test our hypothesized model, a structural equation model (SEM) using maximum likelihood estimation was conducted.

RESULTS

BED-obese patients had significantly higher scores in BES, UPPS-P Negative urgency, and DERS total score, and lower MSAS self-monitoring than non-BED-obese, while no differences emerged in the MSAS others-monitoring subscale. The structural model demonstrated very good fit indexes (χ² = 1.377, df = 2; p = .502, CMIN/DF = 0.688, CFI = 1.000, RMSEA = 0.000, TLI = 1.047) and all paths were significant in the predicted directions.

CONCLUSIONS

These preliminary findings show that, low self-monitoring and high negative urgency lead BED-obese patients to express the worsening of binge severity through the mediation of emotional dysregulation. This knowledge may be helpful in the clinical practice to develop a tailor-made treatment. Accordingly, an approach through Metacognitive Interpersonal Therapy could be attempted in BED-obese patients with these characteristics. Highlights Patients with BED exhibited low self-monitoring and high negative urgency. Binge severity was mediated by high level of emotional dysregulation. Metacognitive Interpersonal Therapy may be useful for BED patients.

The role of shared decision-making in improving adherence to pharmacological treatments in patients with schizophrenia: a clinical review

Shared decision-making (SDM) is a process in which the doctor provides clear and complete medical information to patients about their treatment, and patients provide information on his/her preferences. Patients and clinicians bring different, but equally important, knowledge to the decision-making process. Through the adoption of SDM, it should be possible to overcome the barriers that hinder the acceptance of long-acting injectable antipsychotics (LAIs) by patients, and often also by psychiatrists. The present paper is a critical appraisal of recent literature on the impact of SDM in improving adherence to pharmacological treatments and in implementing the use of LAIs in the treatment of patients with schizophrenia. SDM is recognized as a promising strategy to improve collaboration between clinicians and patients in achieving recovery. When considering drug treatments, clinicians must evaluate the patient's preferences, expectations and concerns towards the development of a personalized treatment strategy. Moreover, an active involvement in the decision process could reduce the patient's perception of being coerced into the use of LAIs. Involving patients in the choice of therapy is not sufficient to increase pharmacological adherence if, at the same time, there is no constant work of comparison and communication with the reference psychiatric team. SDM can be particularly effective for LAI prescription, since patient can have prejudices and unjustified fears related to the LAI formulation, which the doctor must resolve.

Aggressive behavior and metacognitive functions: a longitudinal study on patients with mental disorders

BACKGROUND

Metacognitive functions play a key role in understanding which psychological variables underlying the personality might lead a person with a severe mental disorder to commit violent acts against others. The aims of this study were to: (a) investigate the differences between patients with poor metacognitive functioning (PM group) and patients with good metacognitive functioning (GM group) in relation to a history of violence; (b) investigate the differences between the two groups in relation to aggressive behavior during a 1-year follow-up; and (c) analyze the predictors of aggressive behavior.

METHODS

In a prospective cohort study, patients with severe mental disorders with and without a lifetime history of serious violence were assessed with a large set of standardized instruments and were evaluated bi-monthly with MOAS in order to monitor any aggressive behavior. The total sample included 180 patients: 56% outpatients and 44% inpatients, and the majority were male (75%) with a mean age of 44 (± 9.8) years, and half of them had a history of violence. The sample was split into two groups: poor metacognition (PM) group and good metacognition (GM) group, according to MAI evaluation scores.

RESULTS

The PM patients reported a history of violence more frequently than GM patients, during the 1-year follow-up, but no differences between groups in aggressive and violent behavior were found. The strongest predictors of aggressive behavior were: borderline and passive-aggressive personality traits and a history of violence, anger, and hostility. The metacognitive functions alone did not predict aggressive behavior, but metacognitive functions interacted with hostility and angry reactions in predicting aggressive behavior.

CONCLUSIONS

This study led to some important conclusions: (a) some aspects closely related to violence are predictive of aggressive behavior only in patients with poor metacognition, thus good metacognition is a protective factor; (b) poor metacognition is associated with a history of violence, which in turn increases the risk of committing aggressive behavior.

Forensic psychiatric evaluations of defendants: Italy and the Netherlands compared

BACKGROUND

Forensic psychiatric practices and provisions vary considerably across jurisdictions. The diversity provides the possibility to compare forensic psychiatric practices, as we will do in this paper regarding Italy and the Netherlands.

AIM

We aim to perform a theoretical analysis of legislations dealing with the forensic psychiatric evaluation of defendants, including legal insanity and the management of mentally ill offenders deemed insane. This research is carried out not only to identify similarities and differences regarding the assessment of mentally ill offenders in Italy and the Netherlands, but, in addition, to identify strengths and weaknesses of the legislation and procedures used for the evaluation of the mentally ill offenders in the two countries.

RESULTS

Italy and the Netherlands share some basic characteristics of their criminal law systems. Yet, forensic psychiatric practices differ significantly, even if we consider only evaluations of defendants. A strong point of Italy concerns its test for legal insanity which defines the legal norm and enables a straightforward communication between the experts and the judges on this crucial matter. A strong point of the Netherlands concerns more standardized practices including guidelines and the use of risk assessment tools, which enable better comparisons and scientific research in this area.

CONCLUSIONS

We argue that there appears to be room for improvement on both sides with regards to the evaluation of mentally ill offenders. More generally, a transnational approach to these issues, as applied in this paper, could help to advance forensic psychiatric services in different legal systems.

Dialectical behaviour therapy (DBT) for forensic psychiatric patients: An Italian pilot study

BACKGROUND

Several previous randomised controlled trials of dialectical behaviour therapy (DBT) since Linehan's original have shown that it has an advantage over standard care or other psychological treatments, but focus is usually on suicide-related behaviours, and little is known about its effect with offender-patients.

AIMS

To evaluate DBT with a group of offender-patients in the Italian high intensity therapeutic facilities-the Residenze per l'Esecuzione delle Misure di Sicurezza (REMS), established under the Italian Law 81/2014.

METHODS

Twenty-one male forensic psychiatric in-patients with borderline personality disorder were enrolled and randomly assigned to 12 months of standard DBT together with all the usual REMS treatments (n = 10) or usual REMS treatments alone (n = 11). All participants completed the same pretreatment and posttreatment assessments, including the Barratt Impulsiveness Scale (BIS-11), Difficulties in Emotion Regulation Scale (DERS), and Toronto Alexithymia Scale 20 (TAS-20).

RESULTS

Men receiving DBT showed a significantly greater reduction in motor impulsiveness, as measured by the BIS-11, and emotional regulation, as reflected by the DERS total score, than the controls. There were no significant differences between groups in alexithymia scores.

CONCLUSIONS

Italy has innovative forensic psychiatric facilities with a new recovery-rehabilitation approach, but the ambitious goals behind these cannot be achieved by pharmacology alone. For the first time in clinical forensic settings in Italy, there has been limited access to DBT. This small pilot study suggests this is likely to help ameliorate traits associated with violent and antisocial behaviours, so a full-scale randomised controlled trial should follow.

Metacognition as a Predictor of Improvements in Personality Disorders

Personality Disorders (PDs) are particularly hard to treat and treatment drop-out rates are high. Several authors have agreed that psychotherapy is more successful when it focuses on the core of personality pathology. For this reason, therapists dealing with PDs need to understand the psychopathological variables that characterize this pathology and exactly what contributes to maintaining psychopathological processes. Moreover, several authors have noted that one key problem that characterizes all PDs is an impairment in understanding mental states - here termed metacognition - which could also be responsible for therapy failures. Unfortunately, a limited number of studies have investigated the role of mentalization in the process of change during psychotherapy. In this paper, we assume that poor metacognition corresponds to a core element of the general pathology of personality, impacts a series of clinical variables, generates symptoms and interpersonal problems, and causes treatment to be slower and less effective. We explored whether changes in metacognition predicted an improvement among different psychopathological variables characterizing PDs; 193 outpatients were treated at the Third Center of Cognitive Psychotherapy in Rome, Italy, and followed a structured path tailored for the different psychopathological variables that emerged from a comprehensive psychodiagnostic assessment that considered patients' symptoms, metacognitive abilities, interpersonal relationships, personality psychopathology, and global functioning. The measurements were repeated after a year of treatment. The results showed that changes in metacognitive abilities predicted improvements in the analyzed variables.

Expanding the validity of the malignant self-regard construct in an Italian general population sample

Malignant self-regard (MSR) was proposed as a particular type of self-structure that may account for similarities among a set of clinically relevant Personality Disorders (PDs) such as masochistic/self-defeating and depressive PDs that yet have failed to be adequately represented in the diagnostic manuals. The investigation on the MSR may provide a better framework upon which to understand the nature of these personality types and their discrimination from related constructs. The present study examines the psychometric properties of the Italian adaptation of the Malignant Self-Regard Questionnaire (MSRQ). Reliability and validity indicators are determined in a large sample of adults from general population (n = 2574). The measure was found to be reliable and valid, given its correlations with measures of depressive personality, negative affectivity, self-defeating, and vulnerably narcissistic personalities. MSR also can be meaningfully differentiated from a nomological network of related constructs, including sadness rumination, depression, neuroticism, extraversion, and grandiose narcissism. These findings suggest that MSR may be a personality component which includes a negativistic self-representation, vulnerability and hypersensitivity to judgment, sometimes compensated by perfectionistic tendencies. As a whole, results seem to support the reliability and the validity of the Italian adaptation of the MSRQ as a measure of the MSR.

Primary Tumor Site, Size, Patients Age and Axillary Lymph Nodes in Breast Cancers

This study considers the correlations between some characteristics of the primary tumor and level of lymph node involvement in 185 primary breast cancers. The average number of lymph nodes was higher in N + women than in N— women. Primary tumors with a diameter of more than 4 cm yielded the highest mean number of lymph nodes (17.5). The risk of developing lymph node metastases was fourfold in tumors with a diameter greater than 2 cm when compared to those with a diameter less than or equal to 2 cm. The most commonly metastasized lymph node level, in both large and small tumors, was the first; however, one-fifth of the patients had simultaneous lymph node metastasis in all three axillary levels. Although the left breast was the most affected (58.9 %), there was no evidence of a different risk of metastasis between the two breasts; 34.1 % of the tumors were multifocal. Lymph node involvement was higher in women under 50 years of age with a primary tumor larger than 2 cm.

A novel SCL-90-R six-item factor identifies subjects at risk of early adverse outcomes in public mental health settings

To increase access to treatment, Italy made assessment at community mental health centers (CMHCs) independent of medical referral, resulting in increased numbers of patients to be triaged efficiently. To support this process, we evaluated SCL-90-R item-ratings to identify factors that best predicted adverse early outcomes among persons seeking first-time CMHC care in a 24-month period in Rome. A psychiatric nurse screened subjects with a brief interview and self-administered SCL-90-R and psychiatrists provided CGI ratings and ICD-9 diagnosis. Of 832 screened subjects, 32 (3.85%) were hospitalized or attempted suicide within 90 days. Six SCL-90 items (15,41,55,57,78,88) scored much higher with than without such adverse outcomes; their sum is proposed as a predictive measure ("SCL-6″). In binary multivariable logistic modeling, this factor, but not age, sex, diagnosis, or other SCL-90-derived subscales strongly predicted adverse outcomes. A ROC curve for SCL-6 reflected a strong separation between subjects with versus without adverse outcomes (AUC = 0.76). This simple screening tool may support timely identification of patients at risk of early adverse clinical outcome who require especially close follow-up.

Symptom severity and mindreading in narcissistic personality disorder

BACKGROUND

Grandiose narcissism has been associated with poor ability to understand one's own mental states and the mental states of others. In particular, two manifestations of Narcissistic Personality Disorder (NPD) can be explained by poor mindreading abilities: absence of symptomatic subjective distress and lack of empathy.

METHODS

We conducted two studies to investigate the relationships between mindreading capacity, symptomatic subjective distress and narcissistic personality. In the first study (N = 246), we compared mindreading capacities and symptomatic distress in three outpatient samples: narcissistic patients (NPD); patients with other Personality Disorders (PD); patients without PD. In the second study (N = 1357), we explored the relationships between symptomatic distress, mindreading and specific NPD criteria.

RESULTS

In the first study, the NPD patients showed poorer mindreading than the patients without PD and comparable to patients with other PDs. Symptomatic subjective distress in the narcissistic group was less severe than in the other PDs group and comparable to the group without PDs. However, no relationship emerged between mindreading and symptomatic subjective distress. In the second study, taking the clinical sample as a whole, symptomatic distress appeared negatively linked to grandiosity traits, while mindreading scores were negatively linked to empathy.

CONCLUSIONS

NPD showed specific mindreading impairments. However, mindreading capacity did not appear to be directly connected with subjective distress, but did appear to be connected with specific aspects of narcissistic pathology.

Focus on aggressive behaviour in mental illness

Background

Aggression is a behaviour with evolutionary origins, but in today’s society it is often both destructive and maladaptive. Increase of aggressive behaviour has been observed in a number of serious mental illnesses, and it represents a clinical challenge for mental healthcare provider. These phenomena can lead to harmful behaviours, including violence, thus representing a serious public health concern. Aggression is often a reason for psychiatric hospitalization, and it often leads to prolonged hospital stays, suffering by patients and their victims, and increased stigmatization. Moreover, it has an effect on healthcare use and costs in terms of longer length of stay, more readmissions and higher drug use.

Materials and methods

In this review, based on a selective search of 2010-2016 pertinent literature on PubMed, we analyze and summarize information from original articles, reviews, and book chapters about aggression and psychiatric disorders, discussing neurobiological basis and therapy of aggressive behaviour.

Results

A great challenge has been revealed regarding the neurobiology of aggression, and an integration of this body of knowledge will ultimately improve clinical diagnostics and therapeutic interventions. The great heterogeneity of aggressive behaviour still hampers our understanding of its causal mechanisms. Still, over the past years, the identification of specific subtypes of aggression has released possibilities for new and individualized treatment approaches.

Conclusions

Neuroimaging studies may help to further elucidate the interrelationship between neurocognitive functioning, personality traits, and antisocial and violent behaviour. Recent studies point toward manipulable neurobehavioral targets and suggest that cognitive, pharmacological, neuromodulatory, and neurofeedback treatment approaches can be developed to ameliorate urgency and aggression in schizophrenia. These combined approaches could improve treatment efficacy. As current pharmacological and therapeutic interventions are effective but imperfect, new insights into the neurobiology of aggression will reveal novel avenues for treatment of this destructive and costly behaviour.

Informed Consent Decision-Making in Deep Brain Stimulation

Deep brain stimulation (DBS) has proved useful for several movement disorders (Parkinson’s disease, essential tremor, dystonia), in which first and/or second line pharmacological treatments were inefficacious. Initial evidence of DBS efficacy exists for refractory obsessive-compulsive disorder, treatment-resistant major depressive disorder, and impulse control disorders. Ethical concerns have been raised about the use of an invasive surgical approach involving the central nervous system in patients with possible impairment in cognitive functioning and decision-making capacity. Most of the disorders in which DBS has been used might present with alterations in memory, attention, and executive functioning, which may have an impact on the mental capacity to give informed consent to neurosurgery. Depression, anxiety, and compulsivity are also common in DBS candidate disorders, and could also be associated with an impaired capacity to consent to treatment or clinical research. Despite these issues, there is limited empirical knowledge on the decision-making levels of these patients. The possible informed consent issues of DBS will be discussed by focusing on the specific treatable diseases.

Value of Multiple Forceps Biopsies in Assessing the Malignant Potential of Colonic Polyps

Fifty-nine colo-rectal polyps were detected at endoscopy and repeatedly biopsied before removal by endoscopic snare polypectomy. The aim of the present paper was to evaluate the reliability of multiple forceps biopsies in assessing both the malignant potential and the presence or absence of invasive cancers (IC) in colo-rectal adenomas (CRA). In order to achieve the first objective, the histologic types and the degree of dysplasia have been defined. The data obtained by means of multiple biopsies examination, compared with those of polyp in toto study, show that fractional biopsies were of value in the histologic classification of only the smallest 41 polyps (agreement 88.09 %), whilst no reliability of biopsies was demonstrated in the 18 largest polyps (agreement 27.68 %). In the field of dysplasia grading, the agreement was 55 % and 61 % for the smallest and the largest CRA respectively. These last figures are hardly acceptable. Biopsies examination gave also under- and overestimation of the histologic severity and of dysplasia as well as a significant incidence of false negative results in IC detection. It is concluded that polypectomy is the only method which provides adequate material for precise diagnosis, no matter how large a polyp. Therefore it should be performed whenever possible. Finally the authors discuss the management of small sessile adenomas.

Localization of the Sentinel Lymph Node in Breast Cancer by Combined Lymphoscintigraphy, Blue DYE and Intraoperative Gamma Probe

Axillary lymph node status represents the most important prognostic factor in patients with operable breast cancer. A severe limitation of this technique is the relatively high rate of false negative sentinel lymph nodes (>5%). We studied 284 patients suffering from breast cancer; 264 had T1 tumors (16 T1a, 37 T1b and 211 T1c), while 20 had T2 tumors. All patients underwent lymphoscintigraphy 18-h before surgery. At surgery, 0.5 mL of patent blue violet was injected subdermally, and the sentinel lymph node (SN) was searched by gamma probe and by the dye method. The surgically isolated SN was processed for intraoperative and delayed examinations.

The SN was successfully identified by the combined radioisotopic procedure and patent blue dye technique in 278/284 cases (97.9%). Analysis of the predictive value of the SN in relation to the status of the axillary lymph nodes was limited to 191 patients undergoing standard axillary dissection irrespective of the SN status. Overall, 63/191 (33%) identified SNs were metastatic, the SN alone being involved in 37/63 (58.7%) patients; a positive axillary status with negative SN was found in 10/73 (13.7%) patients with metastatic involvement. In T1a-T1b patients the SN turned out to be metastatic in 9/53 patients (17.0%). In 7/9 patients the SN was the only site of metastasis, while in 2/9 patients other axillary lymph nodes were found to be metastatic in addition to the SN. None of the 44 patients in whom the SN proved to be non-metastatic showed any metastatic involvement of other axillary lymph nodes.

Our results demonstrate a good predictive value of SN biopsy in patients with breast cancer; the predictive value was excellent in those subjects with nodules smaller than 1 cm.

Gastric Carcinoma: Preliminary Data of a Cooperative Program for Early Diagnosis

The results of a program of early gastric cancer detection, carried out in the Oncologic Institutes of Genoa, Forlì and Florence, are evaluated. General practitioners screened subjects, according to possible anamnestic and clinical risk indicators (age, family history, previous gastric lesions, digestive complaints, etc.). The diagnostic procedure consisted of medical examinations, endoscopy with cytology and/or directed biopsy, and possibly air contrast barium X-ray. Of 3,180 subjects examined, 224 had gastric cancers (7 %), 29 of which were early cancers, and 688 had high risk lesions; 1,478 cases of other pathology were detected. The authors stress that the proportion of early cancer is clearly higher than that found in routine diagnosis, yet still lower compared to the results of screening programs carried on the general population. Moreover, the high diagnostic sensitivity of each method in early gastric cancer detection and, on the other hand, the difficulties in the detection of high risk lesions, which require systematic multiple biopsies, are emphasized.

Economic burden of schizophrenia in Italy: a probabilistic cost of illness analysis

OBJECTIVES

Schizophrenia is a chronic, debilitating psychiatric disease with highly variable treatment pathways and consequent economic impacts on resource utilisation. The aim of the study was to estimate the economic burden of schizophrenia in Italy for both the societal and Italian National Healthcare perspective.

METHODS

A probabilistic cost of illness model was applied. A systematic literature review was carried out to identify epidemiological and economic data. Direct costs were calculated in terms of drugs, hospitalisations, specialist services, residential and semiresidential facilities. Indirect costs were calculated on the basis of patients' and caregivers' loss of productivity. In addition, the impact of disability compensation was taken into account using a database from the Italian National Social Security Institute -Italy (INPS).

RESULTS

Overall, 303 913 prevalent patients with schizophrenia were estimated. Of these, 212 739 (70%) were diagnosed and 175 382 (82%) were treated with antipsychotics. The total economic burden was estimated at €2.7 billion (95% CI €1771.93 to €3988.65), 50.5% due to indirect costs and 49.5% to direct costs. Drugs corresponded to 10% of direct costs and hospitalisations (including residential and semiresidential facilities) accounted for 81%.

CONCLUSIONS

This study highlighted that indirect costs and hospitalisations (including residential and semiresidential facilities) play a major role within the expenses associated with schizophrenia in Italy, and this may be considered as a tool for public decision-makers.

Multiple Bilateral Choroidal Metastatic Tumors from a Small-Cell Neuroendocrine Carcinoma of Unknown Primary Site

PURPOSE

To report one case of multiple and bilateral choroidal tumors from a poorly differentiated small cell neuroendocrine carcinoma of unknown primary.

METHODS

The case of a 30-years-old white female who developed multiple and bilateral choroidal tumors from a poorly differentiated small cell neuroendocrine carcinoma of unknown primary is presented.

RESULTS

The patient had a disseminated disease and died 6 months after. The oncologic work-up, including physical examination, laboratory and radiographic study, fails to identify the primary site.

CONCLUSIONS

Intraocular involvement from a poorly differentiated small cell neuroendocrine carcinoma of unknown primary has not yet reported. We describe this case together with a review of the literature.

Avoidant personality disorder and social phobia: Does mindreading make the difference?

OBJECTIVE

Avoidant personality disorder (AvPD) is closely related to and partially overlaps with social phobia (SP). There is an ongoing debate as to whether AvPD and SP can be classified as separate and distinct disorders or whether these diagnoses rather reflect different degrees of severity of social anxiety. The hypothesis of this study is that in patients with AvPD and in those with AvPD and comorbid SP both interpersonal functioning and metacognitive abilities (the ability to understand mental states) are more severely impaired than they are in patients with SP only. We also hypothesise that the interpersonal and metacognitive functioning of these patients (both AvPD and AvPD+SP) is comparable to that of patients with other PD diagnoses.

METHODS

To test this hypothesis, we compared four groups (22 patients with SP, 32 patients with AvPD, 43 patients with both AvPD and SP and 50 patients with other personality disorders without SP and AvPD criteria) on metacognitive abilities, interpersonal functioning and global symptomatic distress.

RESULTS

Metacognitive ability showed significant variation among the four groups, with the lowest score observed in the AvPD group. As far as the interpersonal functioning is concerned, the lack of sociability was more severe in the AvPD group compared with the SP group. These differences were maintained even after controlling for global symptomatic distress.

CONCLUSION

Results are in line with the alternative model of PD, proposed in the DSM-5, as dysfunction of the self and relationships. They suggest that specific impairments in critical areas of self domains and interpersonal domains of personality functioning may serve as markers distinguishing AvPD from SP.

Levels of Social Sharing and Clinical Implications for Severe Social Withdrawal in Patients with Personality Disorders

Social sharing capacities have attracted attention from a number of fields of social cognition and have been variously defined and analyzed in numerous studies. Social sharing consists in the subjective awareness that aspects of the self's experience are held in common with other individuals. The definition of social sharing must take a variety of elements into consideration: the motivational element, the contents of the social sharing experience, the emotional responses it evokes, the behavioral outcomes, and finally, the circumstances and the skills which enable social sharing. The primary objective of this study is to explore some of the diverse forms of human social sharing and to classify them according to levels of complexity. We identify four different types of social sharing, categorized according to the nature of the content being shared and the complexity of the mindreading skills required. The second objective of this study is to consider possible applications of this graded model of social sharing experience in clinical settings. Specifically, this model may support the development of graded, focused clinical interventions for patients with personality disorders characterized by severe social withdrawal.

Aripiprazole once-monthly as treatment for psychosis in Turner syndrome: literature review and case report

Turner syndrome (TS) is a neurogenetic disorder characterized by partial or complete monosomy-X, usually resulting of a sporadic chromosomal nondisjunction. It is one of the most common sex chromosome abnormalities, affecting approximately 1 in 2,000 live born females. There are sporadic few case reports of concomitant TS with schizophrenia worldwide. No defined psychiatric condition has been traditionally related to TS, and it is not mentioned in DSM-IV. Although it is not associated with any psychiatric syndrome, several case reports in the literature describe a similar constellation of symptoms in TS that may represent a biologically-based entity. Aripiprazole once-monthly is a second generation antipsychotic recently developed. Its efficacy and non-inferiority to oral aripiprazole have been demonstrated in preventing relapse in patients with schizophrenia. Experience with oral aripiprazole and the current availability of the long-acting formulation suggest a potential benefit in a variety of clinical scenarios and therefore consideration as a treatment option in the treatment of schizophrenia and psychotic symptoms in several disease like TS.

[Pathophysiology of aggressive behavior: evaluation and management of pathological aggression]

This work aims to define the aggression in all its forms, with notes on management and rapid tranquilization. The pathological aggression is described as a non-homogeneous phenomenon, it is variable in according to social, psychological and biological agents. The distinction of violence between affective aggression and predatory aggression can be functional to the prediction of outcome of any treatment. In general, a pattern of predatory violence tend to match with patients unresponsive and not compliant to treatment, a low probability to predict future violence and, therefore, a difficulty in managing risk. The affective aggressor, however, shows increased probability of treatment response, with more predictability of violent actions in reaction to situations perceived as threatening and, therefore, greater management of future violence risk. Those who act affective violence tend to show a wide range of emotional and cognitive problems, while those who act with predatory patterns show greater inclination to aggression and antisocial behavior. Aggression that occurs in psychiatry mostly appears to be affective, therefore susceptible to modulation through treatments.

Metacognitive dysfunctions in personality disorders: correlations with disorder severity and personality styles

Metacognitive impairment is crucial to explaining difficulties in life tasks of patients with personality disorders (PDs). However, several issues remain open. There is a lack of evidence that metacognitive impairments are more severe in patients with PDs. The relationship between severity of PD pathology and the extent of metacognitive impairment has not been explored, and there has not been any finding to support the linking of different PDs with specific metacognitive profiles. The authors administered the Metacognitive Assessment Interview to 198 outpatients with PDs and 108 outpatients with no PDs, differentiating overall severity from stylistic elements of personality pathology. Results showed that metacognitive impairments were more severe in the group with PDs than in the control group, and that metacognitive dysfunctions and the severity of the PD were highly associated. Positive correlations were found between specific metacognitive dysfunctions and specific personality styles. Results suggest that metacognitive impairments could be considered a common pathogenic factor for PDs.

[Psychiatric case management. Chronic Disease Management application experience in a public Mental Health Service]

AIM

Aim of this study is to investigate the possible effectiveness of a specific program management needs of patients at high impact health care, case management (CM). The welfare impact is evaluated in terms of the severity of the presented disorder or to other characteristic factors of the individual patient, such as: adherence to the proposed treatments, possible resistance to drug treatment, cognitive structure, the presence of comorbid medical pathologies, abuse/addiction and, more generally, all bio-psycho-social functioning variables that can complicate the treatment of the patient.

METHODS

Twenty five outpatients with chronic schizophrenia (age mean 49,5 yrs) were evaluated through the Camberwell Assessment of Need (CAN20) and Life Skill Profile (LSP) before and after 1 year of CM treatment. General psychopathology was assessed by the Clinical Global Impression (CGI) and the Brief Psychiatric Rating Scale (BPRS). Demographic data were collected, as well as data related to the severity of the disorder: number of hospitalizations and number of switch in drug treatment in the year before the study.

RESULTS

Between T0 and T1 there is a significant improvement on CGI-G, BPRS (total and HOST factor), LSP and CAN TOT in patients treated with CM. Moreover, in CM treated patients a 58% reduction of hospitalizations is noted in the year of study.

CONCLUSIONS

There is a possible effectiveness of CM in improving patient's clinical and social needs in chronic psychiatric diseases. The CM reduces the number of hospitalizations.

[Basic symptoms and neurocognition: preliminary comparison of first-episode psychosis vs multi-episode long-term illness]

BACKGROUND

Schizophrenia is preceded by basic symptoms which may persist after long time and include subjective cognitive impairment. Furthermore, it is characterised by cognitive deficits that may deteriorate with the progression of illness. To examine the relationship between neurocognition and basic symptoms along the course of schizophrenia, we compared the cognitive performance and the basic symptoms of one population with first episode psychosis (FEP) and one with a chronic, multi-episode course (MEP).

METHODS

We tested 8 FEP (5 male) and 7 MEP (7 male) in- and outpatients, for basic symptoms with the Schizophrenia Proneness Instrument-Adult version (SPI-A) and for neurocognition with Raven's Color Progressive Matrices (CPM), Rey-Osterrieth's complex figure (Rey), Corsi's and Buschke-Fuld tests, the Wisconsin Card Sorting Test (WCST), the Stroop test, and the Trail Making Test (TMT).

RESULTS

FEP patients did not differ from MEP patients as for SPI-A scores. MEP patients were significantly more impaired on several subtests of Buschke-Fuld, the Rey, and the WCST with respect to FEP. Impairment on the cognitive subscale of the SPI-A correlated with non-perseverative WCST errors, and on the self subscale of the SPI-A with impaired performance on the Buschke-Fuld. Further, in MEP, impairment on the body subscale of the SPI-A correlated inversely with number of categories completed of the WCST.

CONCLUSIONS

Basic symptoms persist throughout the phases of schizophrenia and are relatively independent of cognitive performance. A chronic, multi-episode course is associated with increased cognitive impairment in schizophrenia.