Circadian Activity Rhythms and Psychopathology in Major Depressive Episodes

BACKGROUND

Identifying suicidal risk based on clinical assessment is challenging. Suicidal ideation fluctuates, can be downplayed or denied, and seems stigmatizing if divulged. In contrast, vitality is foundational to subjectivity in being immediately conscious before reflection. Including its assessment may improve detection of suicidal risk compared to relying on suicidal ideation alone. We hypothesized that objective motility measures would be associated with vitality and enhance assessment of suicidal risk.

METHODS

We evaluated 83 adult-psychiatric outpatients with a DSM-5 bipolar (BD) or major depressive disorder (MDD): BD-I (n = 48), BD-II (20), and MDD (15) during a major depressive episode. They were actigraphically monitored continuously over 3 weekdays and self-rated their subjective states at regular intervals. We applied cosinor analysis to actigraphic data and analyzed associations of subjective psychopathology measures with circadian activity parameters.

RESULTS

Actigraphic circadian mesor, amplitude, day- and nighttime activity were lower with BD versus MDD. Self-rated vitality (wish-to-live) was significantly lower, self-rated suicidality (wish-to-die) was higher, and their difference was lower, with BD versus MDD. There were no other significant diagnostic differences in actigraphic sleep parameters or in self-rated depression, dysphoria, or anxiety. By linear regression, the difference between vitality and passive suicidal ideation was strongly positively correlated with mesor (p < 0.0001), daytime activity (p < 0.0001), and amplitude (p = 0.001).

CONCLUSIONS

Higher circadian activity measures reflected enhanced levels of subjective vitality and were associated with lesser suicidal ideation. Current suicidal-risk assessment might usefully include monitoring of motility and vitality in addition to examining negative affects and suicidal thinking.

An overview on Hebephrenia, a diagnostic cornerstone in the neurodevelopmental model of Schizophrenia

Pre-Kraepelinian observations converged in Kahlbaum's and Hecker's description of Hebephrenia. For Kraepelin, Hebephrenia was an 'idiopathic incurable dementia whose onset is in adolescence'. It became the core of 'Dementia Praecox', and then Bleulerian 'Schizophrenia'. In recent decades, the resurgence of the 'late neurodevelopment' hypothesis of schizophrenia has brought into focus Hecker's clinical reports of adolescents who, as a result of a putative loss of psychic energy, showed a rapidly progressive cognitive impairment leading to functional and behavioural disorganization. This paper summarizes the nineteenth-century conceptualization of Hebephrenia as a developmental illness.

Exploring depression in schizophrenia

Background

A consistent amount of empirical research suggests that depression, besides interfering with quality of life and social functioning, may influence other symptom dimensions in schizophrenia, thus constituting an important domain for treatment strategies, outcome, and prognosis.

Aim. –

This study investigated the factorial structure of the Calgary depression scale for schizophrenia (CDSS) in a sample of schizophrenic patients and explored the relationships between such factors, major symptom dimensions and subjective experiences.

Methods

One hundred and sixty-one subjects were examined to assess the severity of schizophrenic symptoms (scored according to the five-dimensional model of Toomey et al. [28]), the distress due to the subjective experience of negative symptoms, and the degree of subjectively-felt cognitive-affective vulnerability (i.e. basic symptoms).

Results

Principal component analysis revealed CDSS to include three main factors, namely: “depression-hopelessness” (factor I), “guilty idea of reference-pathological guilt” (factor II) and “early wakening” (factor III).

Whereas the last factor did not correlate with any of the other psychopathological domains, the first two factors revealed multiple correlations with both diagnostic symptoms and subjective experiences.

Conclusions

The results confirm the threefold factorial structure of the CDSS previously reported by the authors of the scale and could shed further light on the psychopathological nature of the components of depression in schizophrenia. The specific correlation patterns with diagnostic and subjective psychopatholgy substantiate the clinical distinction between a general depression factor (“depression-hopelessness”) and a cognitive-guilt factor (“guilty idea of reference-pathological guilt”).

Sensing the Worst: Neurophenomenological Perspectives on Neutral Stimuli Misperception in Schizophrenia Spectrum

While investigating social cognitive impairments in schizophrenia, prominent evidence has been found that patients with schizophrenia show a tendency to misclassify neutral stimuli as negatively valenced. Within this population, patients presenting delusions are more prone to this phenomenon. In a previous study, Schizophrenia spectrum (SzSp) patients rated positive, negative and neutral stimuli that were multimodally presented, while assessed with a checklist exploring anomalous subjective experiences and evaluated for positive and negative symptomatology. In the present work, we aimed to further explore the relationship between neutral stimuli misperception, anomalous experiences and positive/negative symptoms in SzSp patients. To this end, we adopted a dimensional approach by reconstructing from available data: (1) four a priori scales representing essential dimensions of SzSp experiential pathology following Parnas et al. (2005); and (2) five clinically meaningful factors to describe illness severity derived by Toomey et al. (1997). Results showed that although overall patients correctly recognized the target emotions, those who misinterpreted neutral auditory cues as negatively valenced also presented higher scores in Perplexity (PY), Bizarre Delusions (BD) and Disorganization (Di) dimensions. Moreover, a positive association between BD and both PY and Self-Disorder (SD) dimensions emerged, suggesting that psychotic symptoms may be directly linked to patients' subjectivity. In an attempt to comprehensively capture the multilayered neutral stimuli misperception phenomenon in SzSp, we aimed at bridging phenomenology and neurobiology by connecting the levels of molecular neurochemistry (i.e., altered dopaminergic neurotransmission), system neuroscience (aberrant salience of perceptual details) and psychopathology (the chain involving hyper-reflexivity, self-disorders and the emergence of delusions).

Anhedonia in schizophrenia: The role of subjective experiences

BACKGROUND

High levels of anhedonia have been found in patients with schizophrenia; specifically they report higher levels of social anhedonia rather than physical anhedonia, and further, in the anticipatory rather than consummatory facets of pleasure. Nonetheless, contrasting results emerged regarding the underlying mechanisms of this deficit. Basic Symptoms (BS) disturb subjective experiences present for most of the illness' course; this impacts patients' daily lives leading to a loss of the ability to organize the experience of the self and the world in a fluid and automatic way. Considering the role played by negative emotions in the subjective evaluation of anhedonia, the aim of the study is to clarify the role of BS in the assessment of anhedonia in a sample of patients with schizophrenia (n=53) compared with healthy controls (n=46).

METHODS

Participants completed a self-administered trait questionnaire evaluating social anhedonia (Revised-Social Anhedonia Scale), physical anhedonia (Physical Anhedonia Scale), and the consummatory and anticipatory pleasure experiences (Temporal Experience of Pleasure Scale). BS were evaluated with the Frankfurter Beschwerde-Frageboden (FBF) whereas psychopathology was assessed with the Positive and Negative Syndromes Scale.

RESULTS

Patients scored higher than healthy controls in social, physical and anticipatory anhedonia, but not in consummatory anhedonia and these relationships were mediated by the FBF. Basic Symptoms of Memory, Overstimulation and Lack of Automatism were related to some facets of anhedonia, independently from depressive symptoms.

CONCLUSIONS

We hypothesize that a subjective cognitive deficit and a reduced ability in information processing, could prevent patients from retaining a positive experience from past pleasant activities. Therefore the lack of pleasure would be, at least in part, related to an avoidance of potentially stressful new scenarios.

Anomalous echo: Exploring abnormal experience correlates of emotional motor resonance in Schizophrenia Spectrum

Anomalous experiences such as Basic Symptoms (BS) are considered the first subjective manifestation of the neurobiological substrate of schizophrenia. The purpose of this study was to explore whether a low or high emotional motor resonance occurring in Schizophrenia Spectrum (SzSp) patients was related to patients׳ clinical features and to their anomalous subjective experiences as indexed by the Bonn Scale for the Assessment of Basic Symptoms (BSABS). To this aim, we employed a validated paradigm sensitive in evoking a congruent facial mimicry (measured by means of facial electromyographic activity, EMG) through multimodal positive and negative emotional stimuli presentation. Results showed that SzSp patients more resonating with negative emotional stimuli (i.e. Externalizers) had significantly higher scores in BSABS Cluster 3 (Vulnerability) and more psychotic episodes than Internalizers patients. On the other hand, SzSp patients more resonating with positive emotional stimuli (i.e. Externalizers) scored higher in BSABS Cluster 5 (Interpersonal irritation) than Internalizers. Drawing upon a phenomenological-based perspective, we attempted to shed new light on the abnormal experiences characterizing schizophrenia, explaining them in terms of a disruption of the normal self-perception conveyed by the basic, low-level emotional motor mechanisms.

Mirroring the self: testing neurophysiological correlates of disturbed self-experience in schizophrenia spectrum

BACKGROUND

Self-disorders (SDs) have been described as a core schizophrenia spectrum vulnerability phenotype, both in classic and contemporary psychopathological literature. However, such a core phenotype has not yet been investigated adopting a trans-domain approach that combines the phenomenological and the neurophysiological levels of analysis. The aim of this study is to investigate the relation between SDs and subtle, schizophrenia-specific impairments of emotional resonance that are supposed to reflect abnormalities in the mirror neurons mechanism. Specifically, we tested whether electromyographic response to emotional stimuli (i.e. a proxy for subtle changes in facial mimicry and related motor resonance mechanisms) would predict the occurrence of anomalous subjective experiences (i.e. SDs).

SAMPLING AND METHODS

Eighteen schizophrenia spectrum (SzSp) patients underwent a comprehensive psychopathological examination and were contextually tested with a multimodal paradigm, recording facial electromyographic activity of muscles in response to positive and negative emotional stimuli. Experiential anomalies were explored with the Bonn Scale for the Assessment of Basic Symptoms (BSABS) and then condensed into rational subscales mapping SzSp anomalous self-experiences.

RESULTS

SzSp patients showed an imbalance in emotional motor resonance with a selective bias toward negative stimuli, as well as a multisensory integration impairment. Multiple regression analysis showed that electromyographic facial reactions in response to negative stimuli presented in auditory modality specifically and strongly correlated with SD subscore.

CONCLUSIONS

The study confirms the potential of SDs as target phenotype for neurobiological research and encourages research into disturbed motor/emotional resonance as possible body-level correlate of disturbed subjective experiences in SzSp.

Antecedents of manic versus other first psychotic episodes in 263 bipolar I disorder patients

OBJECTIVE

As initial episode type can predict later morbidity in bipolar disorder, we tested the hypothesis that clinical antecedents might predict initial episode types.

METHOD

We studied 263 first-episode, adult, DSM-IV-TR type I bipolar disorder (BD-I) subjects within the McLean-Harvard-International First-Episode Project. Based on blinded assessments of antecedents from SCID examinations and clinical records, we compared first lifetime manic vs. other (mixed, depressive, or non-affective) major psychotic episodes.

RESULTS

We identified 32 antecedents arising at early, intermediate or later times, starting 12.3±10.7 years prior to first lifetime major psychotic episodes. Based on multivariate modeling, antecedents associated significantly and independently with other (n=113) more than manic (n=150) first lifetime major psychotic episodes ranked by odds ratio: more early attentional disturbances, more late depression, more early perplexity, more detoxification, more early unstable mixed affects, more antidepressants, more early dysphoria, more intermediate depression, more early impulsivity, more late anhedonia, longer early-to-intermediate intervals, more intermediate substance abuse, more family history of major depression, and younger at earliest antecedents. Antecedents selectively preceding manic more than other first psychotic episodes included more late behavioral problems and more risk of familial BD-I.

CONCLUSION

Clinical antecedents in adult, BD-I patients, beginning a decade before first major episodes and progressing through sequential stages were dissimilar in manic vs. other first psychotic episodes.

Capgras' syndrome in first-episode psychotic disorders

BACKGROUND

Misidentification phenomena, including the delusion of 'imposters' named after Joseph Capgras, occur in various major psychiatric and neurological disorders but have rarely been studied systematically in broad samples of modern patients. This study investigated the prevalence and correlated clinical factors of Capgras' phenomenon in a broad sample of patient-subjects with first-lifetime episodes of psychotic affective and nonaffective disorders.

METHODS

We evaluated 517 initially hospitalized, first-episode psychotic-disorder patients for the prevalence of Capgras' phenomenon and its association with DSM-IV-TR diagnoses including schizophreniform, brief psychotic, unspecified psychotic, delusional, and schizoaffective disorders, schizophrenia, bipolar-I disorder and major depression with psychotic features, and with characteristics of interest including antecedent psychiatric and neurological morbidity, onset type and presenting psychopathological phenomena, using standard bivariate and multivariate statistical methods.

RESULTS

Capgras' syndrome was identified in 73/517 (14.1%) patients (8.2-50% across diagnoses). Risk was greatest with acute or brief psychotic disorders (schizophreniform psychoses 50%, brief psychoses 34.8%, or unspecified psychoses 23.9%), intermediate in major depression (15%), schizophrenia (11.4%) and delusional disorder (11.1%), and lowest in bipolar-I (10.3%) and schizoaffective disorders (8.2%). Associated were somatosensory, olfactory and tactile hallucinations, Schneiderian (especially delusional perception), and cycloid features including polymorphous psychotic phenomena, rapidly shifting psychomotor and affective symptoms, pananxiety, ecstasy, overconcern with death, and perplexity or confusion, as well as rapid onset, but not sex, age, abuse history, dissociative features, or indications of neurological disorders.

CONCLUSIONS

Capgras' syndrome was prevalent across a broad spectrum of first-episode psychotic disorders, most often in acute psychoses of rapid onset.

Facial reactions in response to dynamic emotional stimuli in different modalities in patients suffering from schizophrenia: a behavioral and EMG study

Emotional facial expression is an important low-level mechanism contributing to the experience of empathy, thereby lying at the core of social interaction. Schizophrenia is associated with pervasive social cognitive impairments, including emotional processing of facial expressions. In this study we test a novel paradigm in order to investigate the evaluation of the emotional content of perceived emotions presented through dynamic expressive stimuli, facial mimicry evoked by the same stimuli, and their functional relation. Fifteen healthy controls and 15 patients diagnosed with schizophrenia were presented with stimuli portraying positive (laugh), negative (cry) and neutral (control) emotional stimuli in visual, auditory modalities in isolation, and congruently or incongruently associated. Participants where requested to recognize and quantitatively rate the emotional value of the perceived stimuli, while electromyographic activity of Corrugator and Zygomaticus muscles was recorded. All participants correctly judged the perceived emotional stimuli and prioritized the visual over the auditory modality in identifying the emotion when they were incongruently associated (Audio-Visual Incongruent condition). The neutral emotional stimuli did not evoke any muscle responses and were judged by all participants as emotionally neutral. Control group responded with rapid and congruent mimicry to emotional stimuli, and in Incongruent condition muscle responses were driven by what participants saw rather than by what they heard. Patient group showed a similar pattern only with respect to negative stimuli, whereas showed a lack of or a non-specific Zygomaticus response when positive stimuli were presented. Finally, we found that only patients with reduced facial mimicry (Internalizers) judged both positive and negative emotions as significantly more neutral than controls. The relevance of these findings for studying emotional deficits in schizophrenia is discussed.

Predicting diagnostic change among patients diagnosed with first-episode DSM-IV-TR major depressive disorder with psychotic features

OBJECTIVE

Longitudinal studies beginning from onset of major depressive disorder (MDD) with psychotic features in young adults are rare; therefore, in this study, subjects across a wide age range were included. Since psychotic MDD may be unstable diagnostically, we systematically evaluated such patients prospectively from first episode to ascertain predictors of later diagnostic change.

METHOD

In this prospective naturalistic study, we recruited patients with DSM-IV-TR psychotic MDD from 1989 through 2003 at psychiatric inpatient units in Massachusetts and Italy and followed them from first hospitalization to compare demographic, antecedent, and first-episode clinical characteristics for associations with later changes of diagnosis based on interviews using the Structured Clinical Interview for DSM-III-R, Patient Version.

RESULTS

Within a mean (SD) of 4.0 (2.7) years, diagnoses among 107 subjects aged 34.6 (16.2) years (range, 10-82 years) who were experiencing a first lifetime DSM-IV-TR psychotic MDD episode changed in 29.9% to DSM-IV-TR bipolar disorder (18.7%) or schizoaffective disorder (11.2%). Factors associated with stable diagnoses of psychotic MDD included ontological anguish (χ(2) = 13.8, P < .0001), nihilistic delusions (χ(2) = 4.47, P = .034), and weight loss (χ(2) = 4.69, P = .030) at initial syndromal presentation. Factors preceding diagnoses of bipolar disorder included antecedent impulsivity (χ(2) = 9.10, P = .003), ICD-10 mixed states at intake (χ(2) = 19.4, P < .0001), and previous hypomanic symptoms (χ(2) = 13.7, P = .002). Factors predicting later schizoaffective diagnoses included mood-incongruent delusions (χ(2) = 9.17, P = .002) and somatosensory hallucinations (χ(2) = 9.53, P = .033) at intake, previous functional decline (χ(2) = 8.13, P = .008), initial Schneiderian first-rank symptoms (χ(2) = 10.6, P = .005), and meeting criteria for ICD-10 schizoaffective disorder at intake (χ(2) = 24.9, P < .0001).

CONCLUSIONS

Among patients who initially met DSM-IV-TR criteria for first-episode psychotic MDD, early indications of features typically associated with bipolar disorder or with nonaffective psychoses, respectively, strongly predicted later diagnostic change to bipolar disorder or schizoaffective disorders. The findings support the value of psychopathological details in improving diagnostic and prognostic criteria for complex illnesses.

Negative Affective Features in 516 Cases of First Psychotic Disorder Episodes: Relationship to Suicidal Risk

OBJECTIVES

Plausible candidates of psychopathological phenomena that may associate with or anticipate suicidal risk, include negative affects, including admixtures of dysphoria, depression and anxiety described mainly in nonpsychotic disorders. We ascertained the distribution of such affective features in various first-episode psychotic disorders and correlated these and other clinical and antecedent features with intake suicidal status.

METHODS

We evaluated 516 adult subjects in first-lifetime episodes of various DSM-IV-TR psychotic disorders. Blinded, protocol-guided, assessments of clinical features ascertained in SCID examinations, self- and family reports and clinical records supported analyses of associations of suicide attempts at first-psychotic episodes with antecedent and intake clinical characteristics, including negative affects and diagnoses, using standard bivariate and multivariate methods.

RESULTS

Negative affective features in various combinations were prevalent (90%) and at >75% in both affective and nonaffective psychotic disorders; anxious depression was most common (22%). We identified antecedent and intake clinical factors preliminarily associated with suicide attempts. Factors remaining independently associated in multivariate logistic modelling (ranked by OR) were: (a) prior suicide attempt, (b) prior aggressive assault, (c) bipolar-mixed state or psychotic major depression diagnosis, (d) prior dysphoria, (e) intake dysphoric-anxiousdepression, (f) prior impulsivity, (g) previous affective instability, (h) previous nonpsychotic depression, (i) previous decline in vital drive, and (j) prior sleep disturbances.

CONCLUSIONS

Various types and combinations of negative affective features (especially anxious depression with and without dysphoria) were prevalent across nonaffective as well as affective first psychotic episodes and strongly associated with suicide attempts. These findings extend previous observations in nonpsychotic disorders.

Patient factors predicting early dropout from psychiatric outpatient care for borderline personality disorder

Despite obvious clinical need, factors underlying early treatment discontinuation among 'real world' borderline personality disorder (BPD) patients are still unknown. This study investigates individual characteristics that can predict early (<three months) dropout among BPD outpatients at a general psychiatric service. Out of a sample of 1437 consecutively treatment-seeking psychiatric outpatients, 162 BPD subjects have been identified by means of the Structured Interview for Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) Personality. Sociodemographic, clinical and personality variables potentially relevant for dropout were assessed for all participants at baseline. Early dropouts (n=54) were compared to continuers (n=108) on all measures. Logistic regression was then used to identify independent predictors of early dropout. A history of suicide attempts predicted early discontinuation, whereas the presence of an eating disorder and of avoidant personality features protected from early dropout. If confirmed, these findings may help clinicians operating in general psychiatric settings with estimating the risk of premature treatment discontinuation, and stress the need to specifically address suicidal behaviours in order to improve treatment retention among borderline outpatients. In this regard, implementing general psychiatric care with specialised, evidence-based psychotherapeutic interventions may be deemed necessary.

Multi-scale motility amplitude associated with suicidal thoughts in major depression

Major depression occurs at high prevalence in the general population, often starts in juvenile years, recurs over a lifetime, and is strongly associated with disability and suicide. Searches for biological markers in depression may have been hindered by assuming that depression is a unitary and relatively homogeneous disorder, mainly of mood, rather than addressing particular, clinically crucial features or diagnostic subtypes. Many studies have implicated quantitative alterations of motility rhythms in depressed human subjects. Since a candidate feature of great public-health significance is the unusually high risk of suicidal behavior in depressive disorders, we studied correlations between a measure (vulnerability index [VI]) derived from multi-scale characteristics of daily-motility rhythms in depressed subjects (n = 36) monitored with noninvasive, wrist-worn, electronic actigraphs and their self-assessed level of suicidal thinking operationalized as a wish to die. Patient-subjects had a stable clinical diagnosis of bipolar-I, bipolar-II, or unipolar major depression (n = 12 of each type). VI was associated inversely with suicidal thinking (r =  –0.61 with all subjects and r =  –0.73 with bipolar disorder subjects; both p<0.0001) and distinguished patients with bipolar versus unipolar major depression with a sensitivity of 91.7% and a specificity of 79.2%. VI may be a useful biomarker of characteristic features of major depression, contribute to differentiating bipolar and unipolar depression, and help to detect risk of suicide. An objective biomarker of suicide-risk could be advantageous when patients are unwilling or unable to share suicidal thinking with clinicians.

Two-year follow-up of borderline personality disorder patients in Italy: a preliminary report on prognosis and prediction of outcome

BACKGROUND AND AIMS

Few naturalistic studies have examined the course of borderline personality disorder (BPD) outside North American countries. The aim of this prospective study was to investigate remission rate, changes in the level of BPD psychopathology and outcome prediction in a sample (n = 46) of Italian BPD outpatients over a two-year follow-up.

METHOD

Two years after baseline, remission rate from BPD and changes in the severity of BPD psychopathology were investigated. Initial measures of borderline, comorbid Axis I and II psychopathology and clinical severity, as well as historical and socio-demographic variables, were used to predict the number of BPD criteria met at follow-up.

RESULTS

At the two-year interview, the mean number of BPD criteria endorsed decreased ( p = 0.04) and 12 participants (26.1%) fell below the diagnostic threshold for BPD. Borderline psychopathology at follow-up was predicted by the presence, at baseline, of substance use disorders and self-defeating personality traits, and by the absence of dependent traits (R(2) = 0.409; p < 0.001). However, these results cannot be generalized to patients lost to follow-up (15 out of an initial sample of 61), who may exhibit a more severe psychopathology at baseline and therefore a poorer prognosis.

CONCLUSIONS

Borderline individuals seeking treatment at Italian public psychiatric centres may show some improvement in BPD psychopathology over a two-year follow-up; however, the remission rate seems to be lower than that found in North American samples. Furthermore, outcome predictors overlap only partially with those detected by North American studies.

McLean-Harvard International First-Episode Project: two-year stability of ICD-10 diagnoses in 500 first-episode psychotic disorder patients

OBJECTIVE

Because clinical and biologic research and optimal clinical practice require stability of diagnoses over time, we determined stability of ICD-10 psychotic disorder diagnoses and sought predictors of diagnostic instability.

METHOD

Patients from the McLean-Harvard International First-Episode Project, conducted from 1989 to 2003, who were hospitalized for first psychotic illnesses (N = 500) were diagnosed by ICD-10 criteria at baseline and 24 months, on the basis of extensive prospective assessments, to evaluate the longitudinal stability of specific categorical diagnoses and predictors of diagnostic change.

RESULTS

Diagnostic stability averaged 90.4%, ranking as follows: schizoaffective disorder (100.0%) > mania with psychosis (99.0%) > mixed affective episode (94.9%) > schizophrenia (94.6%) > delusional disorder (88.2%) > severe depressive episode with psychotic symptoms (85.2%) > acute psychosis with/without schizophrenia symptoms = unspecified psychosis (all 66.7%) >> acute schizophrenia-like psychosis (28.6%). Diagnoses changed by 24 months of follow-up to schizoaffective disorder (37.5%), bipolar disorder (25.0%), schizophrenia (16.7%), or unspecified nonorganic psychosis (8.3%), mainly through emerging affective features. By logistic regression, diagnostic change was associated with Schneiderian first-rank psychotic symptoms at intake > lack of premorbid substance use.

CONCLUSIONS

We found some psychotic disorder diagnoses to be more stable by ICD-10 than DSM-IV criteria in the same patients, with implications for revisions of both diagnostic systems.

Defense mechanisms and symptom severity in panic disorder

BACKGROUND AND AIM OF THE WORK

Whether the use of maladaptive defense style is a trait or a state phenomenon in panic disorder (PD) is still an open question. The aim of the study was to verify whether PD patients used a different defense style than healthy subjects, after controlling for the effect of symptoms severity.

METHODS

Therefore, 61 PD patients and 64 healthy controls participated in the study. All subjects were evaluated with SCID-IV, SCL-90, Ham-A, Ham-D and the Defence Style Questionnaire-40 items (DSQ-40).

RESULTS

PD patients showed higher Ham-A, Ham-D and SCL-90 scores than controls and they used more neurotic and immature defences. The differences in defense style disappeared after controlling for the effect of symptom severity, whereas the differences in symptom severity persisted after controlling for the effect of defense style.

CONCLUSIONS

This finding suggests that the use of less mature defenses in PD was explained by the severity of anxious symptoms, whereas the contrary was not true. Therefore, the use of less mature defense style might be supposed to be a state phenomenon in PD.

Morbidity in 303 first-episode bipolar I disorder patients

OBJECTIVES

To test the hypotheses that: (i) depressive-dysthymic-dysphoric (D-type) morbidity is more prevalent than manic-hypomanic-psychotic (M-type) morbidity even from first episodes of bipolar I disorder (BPD-I) and despite treatment; (ii) initial presentations predict later morbidity; (iii) morbidity varies internationally; and (iv) early and later morbidity are similar.

METHODS

We followed SCID-based, DSM-IV BPD-I patients (n = 303) systematically and prospectively for two years to estimate the percent of weeks in specific morbid states from first lifetime major episodes.

RESULTS

Total morbidity accounted for 44% of the first two years, and D-type exceeded M-type illnesses by 2.1-fold (30%/14%) among morbidities ranking: mixed states (major + minor) >or= dysthymia >or= mania >or= major depression > hypomania > psychosis. In 164 cases, morbidities at 0.5-2.5 and 2.5-4.5 years were very similar. Depressive or mixed initial episodes predicted a 3.6-fold excess of D-type morbidity, and initial M-type episodes predicted a 7.1-fold excess of M-type morbidity over two years. Morbidity in European (EU) sites was nearly half that in the U.S., and 22% greater overall among men than women. In five comparable studies, illness accounted for 54% of follow-up time, and the ratio of D/M morbidity averaged 3.0.

CONCLUSIONS

In accord with four midcourse studies, morbidity from BPD-I onset, despite treatment by community standards, averaged 44%, was 68% D-type morbidity, and was strongly predicted by first-episode polarity. Lower morbidity in EU than U.S. sites may reflect differences in healthcare or social systems.

Obsessive-compulsive disorder followed by psychotic episode in long-term ecstasy misuse

AIM

We report the case of two young subjects who developed an obsessive-compulsive disorder (OCD) during a heavy use of ecstasy. After several months of discontinuation of the drug, major depression with psychotic features developed in one subject and a psychotic disorder in the other individual. No mental disorder preceded the use of ecstasy in any subject.

FINDINGS

A familial and personality vulnerability for mental disorder was revealed in one subject, but not in the other, and all physical, laboratory and cerebral NMR evaluations showed normal results in both patients. Remission of OCD and depressive episode or psychotic disorder was achieved after treatment with a serotoninergic medication associated with an antipsychotic.

CONCLUSIONS

The heavy long-term use of ecstasy may induce an alteration in the brain balance between serotonin and dopamine, which might constitute a pathophysiological mechanism underlying the onset of obsessive-compulsive, depressive and psychotic symptoms. The heavy use of ecstasy probably interacted with a vulnerability to psychiatric disorder in one subject, whereas we cannot exclude that an "ecstasy disorder" ex novo affected the other individual.

McLean-Harvard International First-Episode Project: two-year stability of DSM-IV diagnoses in 500 first-episode psychotic disorder patients

OBJECTIVE

Since stability of DSM-IV diagnoses of disorders with psychotic features requires validation, we evaluated psychotic patients followed systematically in the McLean-Harvard International First Episode Project.

METHOD

We diagnosed 517 patients hospitalized in a first psychotic illness by SCID-based criteria at baseline and at 24 months to assess stability of specific DSM-IV diagnoses.

RESULTS

Among 500 patients (96.7%) completing the study, diagnoses remained stable in 77.6%, ranking as follows: bipolar I disorder (96.5%) > schizophrenia (75.0%) > delusional disorder (72.7%) > major depressive disorder (MDD), severe, with psychotic features (70.1%) > brief psychotic disorder (61.1%) > psychotic disorder not otherwise specified (NOS) (51.5%) >> schizophreniform disorder (10.5%). Most changed diagnoses (22.4% of patients) were to schizoaffective disorder (53.6% of changes in 12.0% of subjects, from psychotic disorder NOS > schizophrenia > schizophreniform disorder = bipolar I disorder most recent episode mixed, severe, with psychotic features > MDD, severe, with psychotic features > delusional disorder > brief psychotic disorder > bipolar I disorder most recent episode manic, severe, with psychotic features). Second most changed diagnoses were to bipolar I disorder (25.9% of changes, 5.8% of subjects, from MDD, severe, with psychotic features > psychotic disorder NOS > brief psychotic disorder > schizophreniform disorder). Third most changed diagnoses were to schizophrenia (12.5% of changes, 2.8% of subjects, from schizophreniform disorder > psychotic disorder NOS > brief psychotic disorder = delusional disorder = MDD, severe, with psychotic features). These 3 categories accounted for 92.0% of changes. By logistic regression, diagnostic change was associated with nonaffective psychosis > auditory hallucinations > youth > male sex > gradual onset.

CONCLUSIONS

Bipolar I disorder and schizophrenia were more stable diagnoses than delusional disorder or MDD, severe, with psychotic features, and much more than brief psychotic disorder, psychotic disorder NOS, or schizophreniform disorder. Diagnostic changes mainly involved emergence of affective symptoms and were predicted by several premorbid factors. The findings have implications for revisions of DSM and ICD.

Is alexithymia a personality trait increasing the risk of depression? A prospective study evaluating alexithymia before, during and after a depressive episode

BACKGROUND

Whether alexithymia is a personality trait that increases the risk of major depression (MD) is still debated. In this prospective study, alexithymic levels were evaluated before, during and after a depressive episode.

METHOD

The alexithymic levels, the presence of MD and the severity of anxious-depressive symptoms were evaluated at intervals of about 1 month in pregnant women attending the Centers for Prenatal Care, using the Toronto Alexithymia Scale (TAS), the Primary Care Evaluation of Mental Disorders (PRIME-MD) and the Hospital Anxiety and Depression Scale (HADS).

RESULTS

Sixteen women affected by MD, 21 affected by subthreshold depression and 112 non-depressed women were included in the study. Women who developed depression, compared to non-depressed women, showed similar TAS and HADS scores during the pre-morbid phase, a significant increase in the scores during depression and a significant decrease after remission, whereas no change was observed in non-depressed women.

CONCLUSIONS

Our data suggest that in pregnant women alexithymia does not represent a personality trait that increases the risk of developing a depressive episode, and they support the hypothesis that alexithymia is a state-dependent phenomenon in depressed pregnant women.

Personality and attrition from behavioral weight-loss treatment for obesity

OBJECTIVE

Some personality features, as measured by the Temperament and Character Inventory (TCI), have recently been found to be related to successful weight outcome after both behavioral and surgical therapies for obesity. However, personality features could possibly influence attendance in obesity treatments as well. Thus, the aim of this study was to explore whether personality variables assessed by the TCI predict attrition from a behavioral weight-loss program for obesity.

METHOD

The TCI was administered to 92 obese patients [body mass index (BMI) >30 kg/m2] applying for a 6-month behavioral weight-loss program. Logistic stepwise regression analysis was performed to evaluate whether TCI scores predicted 6-month treatment attrition, after controlling for baseline psychiatric comorbidity, current age, gender, age at onset of obesity and initial BMI.

RESULTS

Sixty-two subjects (67.4%) completed the 6-month program, while 30 (32.6%) dropped out. Treatment attrition was predicted only by low reward dependence (P=.03) and the presence of mental disorders (P=.004).

CONCLUSION

Personality features denoting difficulty relying on others' support (low reward dependence) are associated with treatment noncompletion in obese patients attending a behavioral weight-loss program. These data may possibly serve to inform clinicians how to proceed in order to reduce dropout risk.

Parental bonding and personality disorder: the mediating role of alexithymia

This study explored whether alexithymic features mediate the effect of perceived adverse parenting during childhood on being diagnosed with a PD in adulthood. Two hundred sixty-five psychiatric outpatients were evaluated with the Toronto Alexithymia Scale (TAS-20), the Parental Bonding Instrument (PBI), the Structured Interview for DSM-IV Personality, the Structured Clinical Interview for DSM-IV Axis I Disorders, the Clinical Global Impression scale, and the Global Assessment of Functioning scale. The statistical model for mediation proposed by Baron and Kenny (1986) was employed to detect whether the TAS scores account for the relation between PBI scores and a PD diagnosis. The results indicated that although altered parental bonding (and specifically, excessive maternal protection) may enhance the risk of PD, its effect is completely mediated by the alexithymic feature Difficulty Describing Feelings to Others (DDF), after controlling for gender, age, educational level, type, severity and age of onset of Axis I disorders. Therefore, this study suggests that the presence of DDF accounts for the effect of maternal overprotection as a risk factor for PD.

Cycloid psychoses revisited: case reports, literature review, and commentary

Emil Kraepelin proposed to separate psychiatric disorders with psychotic features into two major categories, dementia praecox (later schizophrenia) and manic-depressive insanity (later bipolar disorder and major depression). Over the past century, there have been many efforts to categorize conditions that do not fit readily in either group. These conditions include many cases of acute psychotic illnesses of limited duration, with recovery between recurrences. For some of these conditions, Karl Kleist proposed the term cycloid psychosis: acute features were psychotic, as in schizophrenia, but the course was episodic, as in manic-depression. His concept was later elaborated by Karl Leonhard and Carlo Perris, and validated by modern studies. Leonhard described three overlapping cycloid subtypes (anxiety-beatific, excited-inhibited confusional, and hyperkinetic-akinetic motility dysfunction forms); Perris proposed a more unitary syndrome with operational diagnostic criteria; and recent investigators have considered relatively affective versus thought-disordered subtypes. The cycloid concept is not explicitly included in standard international diagnostic schemes, but both DSM-IV and ICD-10 have broad categories for acute, recurrent psychotic disorders, whose validity remains insecure. We present two cases of probable cycloid psychosis, review the history of the concept, and propose that it be reconsidered as a clinically useful category whose validity and utility for prognosis and treatment can be further tested.

Temperament features in adolescents with ego-syntonic or ego-dystonic obsessive-compulsive symptoms

The present study evaluated whether different patterns of temperament may predict a different threshold of acceptability of obsessive-compulsive (OC) symptoms in adolescents. OC symptomatology was detected with the Leyton Obsessional Inventory-Child Version (LOI-CV) and temperament was assessed using the tridimensional personality questionnaire in 2,775 high-school students. According to the LOI-CV scores, the adolescents were classified as high interference (interfering, ego-dystonic symptoms) (HI), supernormal (noninterfering, ego-syntonic symptoms) (Sn) and controls (C) HI were 119 (4.3%), Sn 85 (3.1%) and C 2,571 (92.6%). The best predictor of belonging to HI or Sn groups was the temperament configuration of high Harm Avoidance (HA) and high Persistence (P). The feature that mainly distinguishes the two symptomatic groups were Novelty Seeking (NS) levels. Our data suggest that people characterized by pessimistic worry in anticipation of future problems, passive avoidant behaviour, rapid fatigability (high HA) and irresoluteness, ambitiousness, perseverance, perfectionism, enduring feelings of frustration (high P) might develop OC symptoms. Whether OC symptoms become ego-syntonic or ego-dystonic seems to mainly depend on NS levels: low NS might protect people (with the prevention of "exploratory and active behaviours" that may elicit loss of control on symptoms) from the development of interfering OC symptoms.

Bad little girls

The characters, in little girl style, who more and more often appear in advertisements, glossy magazines, television programs and megastores, and who can be encountered in the streets of many cities, are not the product of an ephimerous fashion dictated by the logic of the market. They come from far away, disquieting and erotic, and have crossed all the cultures of the western world, fascinating and disconcerting the soul with their power of seduction. They are the nymphs of Greek mythology, and not even the gods were able to resist them, knowing very well that their bodies are a place of knowledge that could lead to insanity. The paradox of the nymph is that possessing her means being possessed. After an overview of the myth of possession by nymphs, the author discusses certain illustrious figures of western culture of the 19th and 20th century possessed by a nymph: Aby Warburg, Martin Heidegger, Carl Gustav Jung, Henrik Ibsen and Emil Cioran. In all of them the possession by a nymph unfolded in keeping with the myth: intellectual fervor was common to all, insanity in Warburg, rapacious egotism in Heidegger and Jung, and a metamorphosis of Weltanshaung in Ibsen and Cioran. Nonetheless, they all, in their encounter with a nymph, laid bare their multifaceted identities, the muddy depths and the "heart of darkness" of their souls.

Effect of pharmacological treatment on temperament and character in panic disorder

Temperament and character were evaluated in patients with panic disorder (PD) before and after 1 year of pharmacological therapy to verify whether personality characteristics change after treatment. Therefore, 65 PD patients and 71 healthy subjects participated in the study. All subjects were evaluated with the SCID-IV, the Temperament and Character Inventory (TCI), the SCL-90, the Ham-A and the Ham-D. Patients were treated with paroxetine or citalopram. The TCI was re-administered to the patients at the end of the study. At the end of the study, complete remission was achieved by 31 patients (R), whereas symptoms did not disappear in the remaining 34 patients (NR). Before treatment, NR patients showed higher levels of harm avoidance (HA) and lower levels of persistence (P), self-directedness (SD) and cooperativeness (C) than healthy controls. Only HA levels were higher than normal in R, although they were significantly lower in R than in NR patients. These differences persisted after treatment. However, in NR patients the levels of SD and C worsened, whereas the difference between R patients and controls in HA levels (higher in R patients than in controls) disappeared after controlling the effect of residual phobic anxiety (higher than normal in R patients). Our data suggest that the high levels of HA found after remission may depend on the subsyndromal residual phobic symptoms, observed in R patients. Moreover, the persistence of anxious symptoms may have worsened the low levels of SD and C observed before treatment in patients who did not achieve remission.

Circadian activity rhythm abnormalities in ill and recovered bipolar I disorder patients

OBJECTIVES

Most physiological indicators of bipolar disorder (BPD) reflect current acute illness, and rarely have proved to be state-independent. Activity rhythms are highly abnormal in acute phases of BPD; we compared circadian activity rhythms in BPD I patients during ill and recovered states to those of normal controls to test the hypothesis that some abnormalities may persist.

METHODS

We compared 36 adult DSM-IV BPD I patients during acute mania or mixed states, and during full and sustained clinical recovery, to 32 healthy controls of similar age and sex distribution, using wrist-worn, piezoelectric actigraphic monitoring for 72 h and computed cosinor analysis of circadian activity rhythms.

RESULTS

We verified expected major differences between manic or mixed-state BPD I patients and matched normal controls, including phase advances averaging 2.1 h in ill BPD I patients and 1.8 h in recovered patients. Moreover, recovered BPD patients differed highly significantly from controls in several measures, including acrophase advance, higher percentage of nocturnal sleep, and lower average daily activity (mesor). Actigraphic measures among recovered BPD patients were independent of ratings of mania (on the Young Mania Rating Scale), depression (on the Hamilton Depression Rating Scale), or rating-scale scored subjective distress, as well as the type and dose of concurrent psychotropic medication.

CONCLUSIONS

These findings suggest that abnormal activity rhythms, including sustained phase advances, may represent enduring (trait) characteristics of BPD patients even during clinical recovery. If verified, such indices may be useful in supporting diagnoses and as an objective phenotype for genetic or other biological studies.

Predictors of the evolution towards schizophrenia or mood disorder in patients with schizophreniform disorder

In this study, 56 patients affected by schizophreniform disorder (SFD), as their first lifetime mental disorder, were re-evaluated 7.9+/-4.7 yrs (2-17 yrs) after their first hospitalization. At follow-up, schizophrenia (SC) was diagnosed in 25 patients (46%), a mood disorder (MD) in 19 (35%), a non-SC psychotic disorder in 10 (18%) and no disorder in 2 (4%). The evolution towards SC was predicted by the presence of blunted affect (OR: 1.88) and by poor pre-morbid functioning (OR: 1.10) at the index hospitalization. Our data suggest that SFD may represent the first psychotic presentation of different disorders and the evolution towards SC or a MD seems to be influenced by the pre-morbid level of functioning and by the presence of blunted affect.

Psychopathology factors in first-episode affective and non-affective psychotic disorders

BACKGROUND

Since the onset, prevalence, and course of specific psychopathological features rarely have been analyzed simultaneously from the start of dissimilar psychotic illnesses, we compared symptom-clusters in first-episode DSM-IV affective and non-affective psychotic disorders.

METHODS

Subjects (N=377) from the McLean-Harvard First Episode Project hospitalized for first-lifetime primary psychotic illnesses were followed prospectively for 2 years to verify stable DSM-IV diagnoses. We ascertained initial symptoms from baseline SCID and clinical assessments, applying AMDP and Bonn psychopathology schemes systematically to describe a broad range of features. Final consensus diagnoses were based on intake and follow-up SCID assessments, family interviews, and medical records. Factor-analytic methods defined first-episode symptom-clusters (Factors), and multiple-regression modeling related identified factors to initial DSM-IV diagnoses and to later categories (affective, non-affective, or schizoaffective disorders).

RESULTS

Psychopathological features were accommodated by four factors: I represented mania with psychosis; II a mixed depressive-agitated state; III an excited-hallucinatory-delusional state; IV a disorganized-catatonic-autistic state. Each factor was associated with characteristic prodromal symptoms. Factors I and III associated with DSM-IV mania, II with major depression or bipolar mixed-state, III negatively with delusional disorder, IV with major depression and negatively with mania. Factors I and II predicted later affective diagnoses; absence of Factor I features predicted non-affective diagnoses, and no Factor predicted later schizoaffective diagnoses.

CONCLUSION

The findings contribute to descriptive categorizations of psychopathology from onset of dissimilar psychotic illnesses. This approach was effective in identifying and subtyping affective psychotic disorders early in their clinical evolution, but non-affective and schizoaffective conditions appear to be more complex and unstable.

Socio-demographic and clinical features associated with demoralization in medically ill in-patients

INTRODUCTION

In the present study we tried to identify which socio-demographic and clinical characteristics are associated with demoralization in medically ill in-patients.

METHOD

Patients (n. 296), consecutively admitted to medical wards in a 120 day period, were evaluated with the Demoralization Scale of the Psychiatric Epidemiological Research Interview (PERI-D) to assess demoralization , with the Mini International Neuropsychiatric Interview (MINI) to assess mental disorders (DSM-IV), with the Brief Disability Questionnaire for the evaluation of the functional disability, with the Duke Severity of Illness to assess severity of the medical illness. Moreover, the family support and threatening life events were also evaluated.

RESULTS

A significant effect in increasing the demoralization score was observed for presence of Major Depression or Adjustment Disorder, poor family support, severity of functional disability, number of threatening life events in the past year and female gender.

CONCLUSION

Major Depression needs to be recognized in demoralized medically ill in-patients, because it is one of the most important conditions associated with demoralization, which successfully responds to adequate treatment.

Changes in Body Image Disturbance in Morbidly Obese Patients 1 Year after Laparoscopic Adjustable Gastric Banding

BACKGROUND

The effectiveness of post-surgical weight loss in improving body image disturbance (BID) in morbidly obese patients is still unclear. Providing multidimensional measures of BID and controlling for the effect of co-morbid eating psychopathology may help to clarify this issue. This preliminary study explores whether 1) BID improves 1 year after laparoscopic adjustable gastric banding (LAGB), and whether 2) such improvement is related to post-surgical BMI and/or eating disorder reduction. BID was multidimensionally assessed by means of the Body Uneasiness Test (BUT).

METHODS

35 obese subjects (mean BMI 45.5) were evaluated prior to and 1 year after LAGB using the BUT, and a standardized interview and questionnaire to assess eating psychopathology. BID and eating habit changes during follow-up were also investigated. Postoperative BUT values were entered as outcome measures (dependent variables) in a series of stepwise multiple regression analyses; BMI and binge eating reduction, baseline BUT scores, gender, age, and age of onset of obesity were tested as independent variables.

RESULTS

Some aspects of BID (body image overconcern and related avoidance behaviors, compulsive self-monitoring, and overall severity of BID) improved following LAGB, while others (weight phobia, depersonalization, and uneasiness toward body parts) did not. The post-surgical lower levels of the former were predicted by the overall decrease in binge eating symptoms, irrespective of BMI reduction, age, gender, and age of onset of obesity.

CONCLUSIONS

LAGB may ameliorate some BID aspects in morbidly obese patients, and an improvement in eating behaviors may contribute to this effect.

Psychopathological predictors of compliance and outcome in weight-loss obesity treatment

BACKGROUND

To detect pre-treatment psychopathological predictors of compliance and outcome in a behavioural weight-loss program for obesity.

METHODS

68 consecutive obese outpatients were evaluated on a wide range of psychopathological variables before entering a behavioural weight reduction program. Baseline assessment included detection of psychiatric (Axis I) and personality (Axis II) disorders, anxiety and depression levels, temperament and character patterns, alexithymia, and eating attitudes. These variables were then tested as predictors of compliance and weight loss after eight months of active treatment.

RESULTS

Baseline presence of Axis I diagnoses was found to enhance the likelihood of good compliance to treatment but to lower probability of good outcome. Different psychopathological (and specifically personality) predictors of outcome were found among patients with and without psychiatric disorders.

CONCLUSIONS

These data suggest the need to perform a full psychiatric evaluation, including personality assessment, to implement obesity treatment strategies.

Jealous love and morbid jealousy

Jealous love and morbid jealousy, although inextricably linked, cannot be considered the same: jealous love (trait jealousy) is the behavioral and cognitive-affective precondition of morbid jealousy (state jealousy). Love is jealous when it is devoured by the desire for the exclusive and total possession of the partner, whose unconditional and continued presence is avidly requested. This type of love, in addition, is permeated by the need to know what the other is thinking, in order to scrutinize every minimal flaw in the faithfulness of the partner even in his or her innermost thoughts and fantasies; in it, jealousy is virtually always present, even in the absence of a triggering event, because captative love, by its very nature, includes the expectation of a conflict which inevitably actually takes place in reality. Finally, jealousy emerges as an emotional event (jealous flash) in response to a more or less significant change in the behavior of the partner, and reveals to the jealous individual a dimension which was previously latent or inexistent. This intense and brief experience, leaves a more or less blurred memory behind, and tends to progressively repeat itself and take root as a feeling.

Utility of the temperament and character inventory (TCI) in outcome prediction of laparoscopic adjustable gastric banding: preliminary report

BACKGROUND

Research about personality factors involved in successful outcome after bariatric surgery has led to contrasting results. The reasons for such discrepancies may include the lack of assessment of adaptive personality traits and of psychiatric co-morbidity, which may limit the reliability of personality findings. This study aimed to provide exploratory data regarding preoperative personality dimensions and weight loss prediction 1 year after laparoscopic adjustable gastric banding (LAGB). Both normal and deviant personality patterns were assessed by means of the Temperament and Character Inventory (TCI). Moreover, co-morbid psychiatric disturbances were evaluated both categorically and dimensionally.

METHODS

65 morbidly obese subjects applying for LAGB were evaluated preoperatively by means of the TCI, standardized diagnostic interview, rating scales and questionnaires to assess co-morbid psychopathology. After intake screening, 35 subjects (mean age 41.2, mean BMI 45.5) were accepted for and underwent LAGB. BMI reduction 1 year following LAGB was used as an outcome measure and entered as a dependent variable in a stepwise multiple regression analysis. TCI scores, presence and severity of eating, depressive and anxiety disorders, sex, age, level of education and BMI at baseline were tested as independent variables.

RESULTS

Preoperative TCI 'Persistence' scores explained >40% of variance of BMI reduction 1 year following LAGB, irrespective of preoperative BMI, age, gender, educational level, psychiatric co-morbidity, psychopathology severity and other temperament and character features.

CONCLUSIONS

Some personality dimensions, as measured by the TCI, may be involved in successful weight control after LAGB.

The effect of temperament and character on response to selective serotonin reuptake inhibitors in panic disorder

OBJECTIVE

In this prospective study, temperament and character were evaluated in patients with panic disorder (PD), before 1 year of medication therapy, to verify whether these factors influenced the outcome of treatment.

METHOD

Seventy-one PD patients were evaluated with the SCID-IV, the Temperament and Character Inventory (TCI), the SCL-90, the Ham-A and the Ham-D. Patients were treated with pharmacotherapy and were evaluated monthly over 1 year.

RESULTS

Before treatment, non-remitted patients showed higher levels of harm avoidance (HA) and lower levels of persistence (P), self-directedness (SD) and cooperativeness (C), whereas remitted patients showed only higher levels of HA. After controlling the effect of the confounding variables, the likelihood to achieve remission was positively related to SD score (OR = 1.12; P = 0.002), particularly 'self-acceptance' SD dimension (OR = 1.30; P = 0.02).

CONCLUSIONS

Our data suggest that in PD: i) the evaluation of personality, using the Cloninger's model, confirms the presence of personality pathology as one predictor of non-response to treatment; ii) in patients with low SD a combination of medication and cognitive-behaviour therapy should be the most effective treatment.

Chlorpromazine, clozapine and olanzapine inhibit anionic amino acid transport in cultured human fibroblasts

We report here that chlorpromazine, a first generation antipsychotic drug, inhibits anionic amino acid transport mediated by system X(-) (AG) (EAAT transporters) in cultured human fibroblasts. With 30 microM chlorpromazine, transport inhibition is detectable after 3 h of treatment, maximal after 48 h (>60%), and referable to a decrease in V(max). Chlorpromazine effect is not dependent upon changes of membrane potential and is selective for system X(-) (AG) since transport systems A and y(+) are not affected. Among antipsychotic drugs, the inhibitory effect of chlorpromazine is shared by two dibenzodiazepines, clozapine and olanzapine, while other compounds, such as risperidon, zuclopentixol, sertindol and haloperidol, are not effective. Transport inhibition by clozapine and olanzapine, but not by chlorpromazine, is reversible, suggesting that the mechanisms involved are distinct. These results indicate that a subset of antipsychotic drugs inhibits EAAT transporters in non-nervous tissues and prompt further investigation on possible alterations of glutamate transport in peripheral tissues of schizophrenic patients.

Self-centrality, psychosis and schizotaxia: a conceptual review

The phenomenon of self-centrality denotes a qualitative modification of the psychotic experience. Transitory experiences of self-reference have regularly been found in subjects in the prodromic phase and at the beginning of psychosis or in the post psychotic phase, and are specifically identified in the semeiotics of Basic Symptoms. However, self-centrality, in addition to being a morphological organizer in the psychotic crisis, also manifests itself in schizotypal personality disorders and in first-degree relatives of schizophrenics (where it is correlated to the degree of schizotypal traits). In these subjects, manifestations of self-centrality of a lesser intensity could be an indication of a latent vulnerability trait, which could modulate personal and psychopathological expressions of the schizotaxic diathesis.

Predictors of Symptom Resolution in Panic Disorder After One Year of Pharmacological Treatment: A Naturalistic Study

OBJECTIVE

In this naturalistic and prospective study, patients with panic disorder (PD) were treated for one year 1) to verify the rate of patients achieving the resolution of full-symptom attacks, limited-symptom attacks, anticipatory anxiety, phobic avoidance and depression; and 2) to identify the predictors of symptom resolution for each domain.

METHOD

One hundred patients with PD, according to DSM-IV criteria, participated in the study. In all patients, a baseline and a follow-up with monthly evaluations of SCL-90, Ham-A, Ham-D and panic diaries were carried out over a one-year period. All patients were treated with paroxetine or citalopram.

RESULTS

Seventy-one patients completed the study, whereas the remaining 29 dropped out. Among completers, remission of full- and limited-symptom panic attacks was observed in 76 % of patients, whereas complete remission (resolution of panic attacks, anticipatory anxiety, phobic anxiety, and depression) was achieved by only 46 % of patients. Predictors of absence of symptom remissions were obsessive-compulsive disorder (OCD) and recurrent major depression (MD) comorbidity (for panic attacks), pre-treatment severity of anxious symptoms (for anticipatory anxiety), phobic anxiety (for phobic avoidance), and depressive symptoms (for depression).

CONCLUSION

This naturalistic study shows that the high comorbidity of OCD and MD and the greater pre-treatment severity of anxious, phobic and depressive symptoms reduced the likelihood of achieving complete remission of symptoms in PD patients who completed the protocol, even though they were adequately treated with SSRI medication.

The effect of pharmacotherapy on personality disorders in panic disorder: a one year naturalistic study

BACKGROUND

In this prospective study, Personality Disorders (PersD) were evaluated in patients with Panic Disorder (PD), before and after one year of pharmacotherapy to verify whether personality characteristics changed after treatment.

METHOD

Sixty PD patients and 60 sex and age-matched normal controls participated in the study. All subjects were evaluated with the SCID-IV, the Structured Interview for DSM-IV Personality Disorders (SIDP), the SCL-90, the Ham-A and the Ham-D. Patients were treated with paroxetine or citalopram and were evaluated monthly for one year to assess the remission of symptoms. The SIDP was re-administered to the patients at the end of the study.

RESULTS

Before treatment, PD patients showed a higher prevalence (60%) of PersD than normal subjects (8%). After treatment, PersD rate decreased (43%) due to the reduction of the rate of paranoid, avoidant and dependent PersD. When the effect of the treatment on personality traits was evaluated, we found that avoidant traits decreased only in remitted patients, paranoid traits decreased both in remitted and in non-remitted patients, and dependent traits decreased only in patients with major depression comorbidity.

LIMITATIONS

The small sample size and the short length of the follow-up period of our study suggest caution in the generalization of our results.

CONCLUSIONS

In our PD patients, an improvement of symptoms was associated with a reduction of paranoid, avoidant and dependent traits, with a normalization of paranoid traits and a persistence of avoidant and dependent characteristics. Therefore, our data suggest that in PD patients not only paranoid traits but also avoidant and dependent traits show, at least in part, a state phenomenon.

Manic-depressive illness: evolution in Kraepelin's Textbook, 1883-1926

BACKGROUND

The syndrome of manic-depressive insanity (MDI), as conceptualized by Emil Kraepelin a century ago, with later refinements, continues to dominate research and clinical practice with mood disorder patients. Current understanding of Kraepelin's views by Anglophones is heavily influenced by the late, highly developed, MDI concept represented in the 1921 partial English translation of the last complete edition of his textbook, the product of gradual development over several decades.

METHOD

We reviewed all nine editions and revisions of Kraepelin's Textbook (1883-1926) and other writings by him to document the evolution of his views of MDI, and characterized salient developments within biographical and historical contexts.

RESULTS

We found support for the traditional impression that Kraepelin's clinical perception of similarities of various forms of periodic psychiatric disorders marked by fundamental dysregulation of excitation and inhibition of thought and behavior, as well as of mood--as distinct from chronic psychotic illnesses--encouraged his broad, mature concept of MDI. However, our findings indicate a complex evolution of Kraepelin's MDI concept in the 1880s and 1890s, his use of more creative and less empirical clinical methods than traditionally believed, and his considerable personal uncertainty about making clear distinctions among MDI, dementia praecox, intermediate conditions, and paranoid disorders--an uncertainty that persisted to the end of his career in the 1920s.

CONCLUSIONS

Kraepelin responded to a compelling international need for diagnostic order in nineteenth-century psychiatry, and effectively promoted his diagnostic proposals with a widely used and influential textbook. Though his methods were less empirical than is usually realized, his legacy includes analysis of large clinical samples to describe psychopathology and illness-course, along with efforts to define psychobiologically coherent and clinically differentiable entities, as steps toward defining psychiatric syndromes. Modern international "neo-Kraepelinian" enthusiasm for descriptive, criterion-based diagnosis should be tempered by Kraepelin's own appreciation of the tentative and uncertain nature of psychiatric nosology, particularly in classifying illnesses with both affective and psychotic features.

Experiential anomalies and self-centrality in schizophrenia

BACKGROUND

Contemporary psychopathological research has shown that some qualitative anomalies of the first-person experiential givenness qualify the subjective experience of schizophrenia. Such essential clinical features of schizophrenia have recently been condensed into 7 phenomenologically coherent clusters derived from the Bonn Scale for the Assessment of Basic Symptoms (BSABS). The experimental intent of this study was to test whether subapophanic self-centrality (i.e. a protopathic nondelusional form of intersubjective spatial disattunement) empowers the discriminant capacity of such a set of subjective experiential disturbances among different diagnostic groups.

METHOD

Three comparably sized samples of outpatients with schizophrenia, obsessive-compulsive or mood disorders were examined with the BSABS. Logistic regression analysis was performed with diagnosis as the outcome variable.

RESULTS

Elevated scores in self-perceived cognitive disorders and abnormal self-centrality were associated with DSM-IV diagnosis of schizophrenia. Self-centrality increased the discriminant capacity of the 7 designed a priori dimensions.

CONCLUSIONS

These findings confirm the previously reported aggregation of some subtle qualitative alterations of subjective experience in schizophrenia, and suggest that a careful consideration of autocentric disturbances of intersubjectivity might enrich current heuristics on schizophrenic experiential vulnerability.

Relationship between alexithymia and panic disorder: a longitudinal study to answer an open question

BACKGROUND

In the present study, we evaluated whether patients with panic disorder (PD) in complete remission were more alexithymic than normal controls.

METHODS

Fifty-two PD patients (both during the acute phase of the disorder and after at least 2 months of complete remission) and 52 age- and sex-matched normal subjects completed the Toronto Alexithymia Scale-20 and the Hamilton Rating Scales for Anxiety (Ham-A) and for Depression.

RESULTS

A higher rate of alexithymia was found in PD patients than in controls (3.8%) both during the acute phase (44.2%; p < 0.001) and after remission of the disorder (21.2%; p = 0.008). During remission, PD patients showed: (1) Ham-A scores significantly higher than controls (p < 0.001); (2) only an elevation of the 'difficulty in identifying feeling' (DIF) dimension of alexithymia, and (3) a positive relationship between Ham-A scores and DIF levels (p < 0.001).

CONCLUSION

After remission of panic attacks, phobic avoidance and anticipatory anxiety, PD patients are more alexithymic (even though the levels of alexithymia decreased after the resolution of the acute phase of PD) and anxious than controls. This finding might be explained by an overlap between cognitive aspects of PD and the DIF dimension of alexithymia, since alexithymic and anxious levels are positively related.