Donation of the body and its parts in the construction of parenthood

The developments of science and technology make possible today unprecedented exchanges of body parts by multiplying the figures and links that intervene in the process of building parenthood and generating significant ethical and judicial controversies. Body donation in the procreative field constitutes an anthropological and social phenomenon of increasing attention, which contributes to one of the most intimate and profound aspirations of the human being and which requires a careful evaluation of the various interests involved and a thorough reflection on the statute and characteristics of the parental bond. The interest of the child, the dignity of women and the quality of human relations are the parameters of this analysis and, at the same time, the perimeter of the judgment. However, the approach to these issues is complicated not only by the extreme heterogeneity of legislation but also by suspicions and prejudices that hinder reflection appropriate to the complexity of the issues involved. Investigate the reasons for the choice of donation, the criticalities, and possible drifts, without closing in their subjective value horizon, is an unavoidable prerequisite for a comparison with the new social realities of the family that respects the fundamental rights of the person.

Self-Assessed Personality Traits and Adherence to the COVID-19 Lockdown

Introduction: The COVID-19 pandemic, caused by the SARS-CoV-2 coronavirus, has forced all countries affected by it to introduce quarantine and isolation to prevent the spread of the virus, as well as masking and distancing. Not everyone is equally willing to follow the rules related to limit the extent of the coronavirus epidemic. This might be connected with personality traits, especially openness, positive attitude, and optimism. Materials and Methods: An online survey was created and completed by participants in April-May 2020. Self-assessment of personality traits and adherence to lockdown recommendations were assessed. A total of 7404 participants took part in the study, mainly from Poland (83.6%) and Italy (12.7%). Univariate and multivariate regression analysis was performed. Results: The participants were divided into groups depending on the degree of compliance with the lockdown rules. In the multivariate analysis, variables that increased the odds for stricter lockdown compliance were temporary work suspension OR 1.27 (95% CI 1.10-1.48), income level "we can't handle this situation" OR 1.67 (95%CI 1.20-2.33), and junior high school education OR 1.68 (95% CI 1.13-2.50). Other significant factors included age and place of residence. Each point of self-assessed sociability OR 1.07 (95% CI 1.00-1.13) also increased the likelihood of adhering to lockdown rules. Conclusions: Taking the basic demographic characteristics as well as working and health environment conditions traits into account may be helpful when forecasting epidemiological compliance during a pandemic, as well as in other public health tasks. The key role of self-assessed personality traits was not confirmed in this study. Reliability of the results is limited by significant disproportions in the size of the study groups.

The Association of Conflict-Related Trauma with Markers of Mental Health Among Syrian Refugee Women: The Role of Social Support and Post-Traumatic Growth

Background

Syrian refugee women not only suffered the refuging journey but also faced the burden of being the heads of their households in a new community. We aimed to investigate the mental health status, traumatic history, social support, and post-traumatic growth (PTG) of Syrian refugee women.

Methods

A cross-sectional study was conducted using a structured interviewer-administered survey between August and November 2019. Syrian refugee women who head their households and live outside camps were eligible. The survey included items investigating socio-demographic characteristics and conflict-related physical trauma history. The Refugee Health Screener-15 (RHS-15) scale was used to screen for emotional distress symptoms of depression, anxiety, and post-traumatic stress disorder (PTSD), with a score range of 0−4 and higher scores indicating emotional distress. The Multidimensional Scale of Perceived Social Support (MSPSS) was utilized to assess the perceived support from family, friends, and significant others (score range 1−7), with scores of 3−5 and 5.1−7.0 representing moderate and high support, respectively. The PTG Inventory (PTGI) scale investigated the positive transformation following trauma; the score range was 0−5, and the cutoff point of ≥3 defined moderate-to-high growth levels.

Results

Out of 140 invited refugee women, 95 were included, with a response rate of 67.9%. Their mean (SD) age was 41.30 (11.75) years, 50.5% were widowed, and 17.9% reported their husbands as missing persons. High levels of conflict-related traumatic exposure were found, including threats of personal death (94.7%), physical injury (92.6%), or both (92.6%); and a history of family member death (92.6%), missing (71.6%), or injury (53.7%). The mean (SD) RHS-15 score was above average (2.08 (0.46)), and most women (90.5%) were at high risk for depression, anxiety, and PTSD symptoms. The mean (SD) MSPSS score was 5.08 (0.71), representing moderate social support, with friends’ support being the highest (5.23 (0.85)). The mean (SD) PTGI score was 2.44 (0.48), indicating low growth, with only 12.6% of women experiencing moderate-to-high growth levels. Spiritual change and personal strength had the highest sub-scores, with moderate-to-high growth levels experienced by 97.9% and 84.2%, respectively. Most women were more optimistic and religious, had feelings of self-reliance and better difficulties adapting, and were stronger than they thought. Statistically significant correlations of MSPSS and its subscales with RHS-15 and PTGI were detected.

Conclusion

Significant but unspoken mental health problems were highly prevalent among Syrian refugee women and an imminent need for psychological support to overcome traumatic exposure. The role of social support seems to be prominent and needs further investigation.

Suicide of women and girls during the COVID-19 pandemic

While no evidence of significant increase in suicide was detected during the very first phase of the pandemic, death rates and suicide attempts increased in several settings in subsequent phases, especially among women and girls.

Are "cases", "waves", "tests" and "modeling" deceiving indicators to describe the COVID-19 pandemic?

This commentary elaborates on different methodological aspects complicating the interpretation of epidemiological data related to the current COVID-19 pandemic, thus preventing reliable within and across-country estimates. Firstly, an inaccuracy of epidemiological data maybe arguably be attributed to passive surveillance, a relatively long incubation period during which infected individuals can still shed high loads of virus into the surrounding environment and the very high proportion of cases not even developing signs and/or symptoms of COVID-19. The latter is also the major reason for the inappropriateness of the abused "wave" wording, which gives the idea that health system starts from scratch to respond between "peaks". Clinical data for case-management on the other hand often requires complex technology in order to merge and clean data from health care facilities. Decision-making is often further derailed by the overuse of epidemiological modeling: precise aspects related to transmissibility, clinical course of COVID-19 and effectiveness of the public health and social measures are heavily influenced by unbeknownst and unpredictable human behaviors and modelers try to overcome missing epidemiological information by relying on poorly precise or questionable assumptions. Therefore the COVID-9 pandemic may provide a valuable opportunity to rethink how we are dealing with the very basic principles of epidemiology as well as risk communication issues related to such an unprecedented emergency situation.

Attitudes and Perceptions of Health Protection Measures Against the Spread of COVID-19 in Italy and Poland

Background: During the first wave of the COVID-19 pandemic (April to May 2020), 6,169 Polish and 939 Italian residents were surveyed with an online questionnaire investigating socio-demographic information and personality traits (first section) as well as attitudes, position, and efficacy perceptions on the impact of lockdown (second section) and various health protection measures enforced (third section). Methods: The "health protection attitude score" (HPAS), an endpoint obtained by pooling up the answers to questions of the third section of the survey tool, was investigated by multiple linear regression models, reporting regression coefficients (RC) with 95% confidence intervals (95% CI). Results: Concerns for business and health due to COVID-19 were associated with a positive attitude toward risk reduction rules. By contrast, male sex, concerns about the reliability of information available online on COVID-19 and its prevention, along with the feeling of not being enough informed on the transmissibility/prevention of SARS-CoV-2 were associated with a negative attitude toward risk mitigation measures. Discussion: A recent literature review identified two social patterns with different features in relation to their attitude toward health protection rules against the spread of COVID-19. Factors positively associated with adherence to public health guidelines were perceived threat of COVID-19, trust in government, female sex, and increasing age. Factors associated with decreased compliance were instead underestimation of the COVID-19 risk, limited knowledge of the pandemic, belief in conspiracy theories, and political conservativism. Very few studies have tested interventions to change attitudes or behaviors. Conclusion: To improve attitude and compliance toward risk reduction norms, a key intervention is fostering education and knowledge on COVID-19 health risk and prevention among the general population. However, information on COVID-19 epidemiology might be user-generated and contaminated by social media, which contributed to creating an infodemic around the disease. To prevent the negative impact of social media and to increase adherence to health protection, stronger content control by providers of social platforms is recommended.

Lithium Use During Pregnancy in a Patient With Bipolar Disorder and Multiple Sclerosis

Although lithium is widely used as a first-line treatment for mood disorders, its mood-stabilizing effects remain not fully understood. A growing body of data are stressing that lithium seems to show broader properties, including neuroprotective effects. Lithium's ability to inhibit glycogen synthase kinase 3β, an enzyme that participates in the phosphorylation of τ, a microtubule-associated protein, stimulated interest in its possible therapeutic role in Alzheimer disease and other neurodegenerative disorders. Preliminary data also support exploration of lithium's potential therapeutic role in multiple sclerosis, an autoimmune disorder that is associated with co-occurring mood disorders. Lithium is associated with teratogenic risks to the developing fetus; however, recently revised downward estimates of its teratogenic risk of causing fetal cardiac malformation suggest that its potential therapeutic benefit to both mothers with bipolar disorder and their offspring should be considered in at least some cases. A 43-year-old woman previously diagnosed with bipolar disorder and MS was treated with lithium and thyroid hormone supplementation as her sole medications during her pregnancy. The patient remained euthymic throughout her pregnancy and over the course of her 5-year follow-up evaluations on this medication regimen. In addition to her stable mood, there has been no symptomatic progression or relapse of her MS, and her daughter continues to develop normally.The case supports consideration of balancing lithium's mood-stabilizing benefit with its known teratogenic risk during pregnancy. The case also supports exploration of possible additional benefit in the context of MS co-occurring with bipolar disorder.

Six things to know about the homicides of doctors: a review of 30 years from Italy

Background

Healthcare workers have a 16 times greater risk of suffering workplace violence than workers in other sectors and around 50% experience workplace violence in the course of their career. The objective of this study is to explore the characteristics and circumstances of work-related killings of doctors.

Methods

Work-related homicides of doctors over the period 1988–2019 were identified retrospectively through the Italian national statistical agencies. Variables such as perpetrator, motive and location of the crime were obtained through forensic psychiatric work. After classification, the absolute and percent values of the main characteristics of the homicides were calculated.

Results

Over the period considered, 21 doctors were killed in Italy in connection with their professional activity. In 52% (n = 11) of cases, the killer was one of the doctor’s patients, in 29% (n = 6) of cases it was a patient’s relative, in 19% (n = 4) an occasional patient (first consultation). The location of the homicide was a community clinic in 48% (n = 10) of cases, the street in 19% (n = 4) of cases, the doctor’s home in 14% (n = 3), the hospital in 14% (n = 3) and the patient’s home in 5% (n = 1). In 57% (n = 12) of cases the perpetrator was not affected by any mental disorders. The motive for the homicide was revenge in 66.7% (n = 14) of cases; in 28.6% (n = 6) the revenge was preceded by stalking.

Conclusions

Doctors should be aware that the risk of being killed is not limited to hospital settings and that their patients’ family members might also pose a threat to them.

Social Isolation During COVID-19 Pandemic. Perceived Stress and Containment Measures Compliance Among Polish and Italian Residents

BACKGROUND

In this study, we analyze the association of social isolation in the first phase of the pandemic with perceived stress among residents of Poland and Italy with a look at how these populations adjust to and comply with implemented regulations, guidelines, and restrictions.

MATERIALS AND METHODS

Internet survey with Perceived Stress Scale (PSS-10) and questions regarding mobility patterns, attitude, and propensity to adjust toward the implemented measures and current health condition was made among Polish and Italian residents (Cronbach's alpha 0.86 and 0.79, respectively). The sample size was 7,108 (6,169 completed questionnaires in Poland and 939 in Italy).

RESULTS

The Polish group had a higher stress level than the Italian group (mean PSS-10 total score 22,14 vs 17,01, respectively; p < 0.01). There was a greater prevalence of chronic diseases among Polish respondents. Italian subjects expressed more concern about their health, as well as about their future employment. Italian subjects did not comply with suggested restrictions as much as Polish subjects and were less eager to restrain from their usual activities (social, physical, and religious), which were more often perceived as "most needed matters" in Italian than in Polish residents.

CONCLUSION

Higher activity level was found to be correlated with lower perceived stress, but the causality is unclear. Difference in adherence to restrictions between Polish and Italian residents suggests that introducing similar lockdown policies worldwide may not be as beneficial as expected. However, due to the applied method of convenience sampling and uneven study groups, one should be careful with generalizing these results.

Impact of intensive training on mental health, the experience of Port Said, Egypt

Background

Mental disorder is extremely common globally and integration of mental health in primary health services represents a critical gap especially in low- and middle-income Countries like Egypt. The World Health Organization has repeatedly called for effective training and support of primary care providers in the identification and treatment of mental health problems over the last decades.

Methods

This paper aimed to evaluate attitudes and knowledge of health care providers toward mentally ill patients and measure knowledge and retention of training messages over time. A 3-day mental health training workshop for nurses of public health facilities in the Governorate of Port Said was organized. Pre-training and post-training questionnaires (immediately after the workshop and 3 months later) were used. Significance of gain in scores was examined between baseline and following cross sectional rounds.

Results

The 73 participants in the study revealed a statistically significant improvement in knowledge and attitude toward mental health from the baseline (pre-training), from a general mean score for desirable answers of 10.5 (± 1.2) to 21.2 (± 0.6). However, results slightly declined three months after from the workshop (18.5 (± 0.6)).

Conclusions

Intensive short-term training on mental illness could be instrumental in improving knowledge and attitudes in countries like Egypt with extensive needs in terms of quality of comprehensive healthcare at primary and secondary level. However, additional evidence is needed to improve retention of information over time and to translate knowledge into clinical practice.

Key words for 2020: Pandemic, emergency, anomie

Dear Editor, In 2020, global society was disrupted by the COVID-19 pandemic, which has confronted everyone with an unusual, unknown situation, an unprecedented humanitarian emergency. The sudden outbreak has put health systems under enormous pressure and has caused major organisational problems, operational uncertainties and ethical conflicts. In particular, health workers had to deal with the emergency in both their personal and their working lives. While we wanted and had to treat our patients, we risked and feared getting infected too. (...)

Mood Reactive Disorders among COVID-19 Inpatients: Experience from a Monocentric Cohort

OBJECTIVE

We aimed to investigate the presence and severity of depressive symptoms among coronavirus disease 2019 (COVID-19) inpatients and any possible changes after their discharge.

SUBJECT AND METHODS

We collected data of patients admitted to the Infectious Disease Unit in Sassari, Italy, for COVID-19, from March 8 to May 8, 2020. The Beck Depression Inventory-II (BDI-II) was performed 1 week after admission (T0) and 1 week after discharge (T1). The cutoff point chosen to define the clinical significance of depressive symptoms was 20 (at least moderate).

RESULTS

Forty-eight subjects were included. Mean age was 64.3 ± 17.6 years, and 32 (66.7%) were male. Most frequent comorbidities were cardiovascular diseases (19; 39.6%) and hypertension (17; 35.4%). When performing BDI-II at T0, 21 (43.7%) patients reported depressive symptoms at T0, according to the chosen cutoff point (BDI-II = 20). Eight (16.7%) patients had minimal symptoms. Mild mood disturbance and moderate and severe depressive symptoms were found in 24 (50%), 14 (29.2%), and 2 (4.2%) patients, respectively, at T0. The comparison of the BDI-II questionnaire at T0 with T1 showed a significant improvement in the total score (p < 0.0001), as well as in 4 out of the 5 selected questions of interest (p < 0.05). Univariate analysis showed that kidney failure and the death of a roommate were significantly associated with severity of mood disorders.

CONCLUSION

Mood disturbances and depressive symptoms commonly occur among COVID-19 inpatients. Our results show that COVID-19 inpatients might be at higher risk for developing depressive reactive disorders and could benefit from an early psychological evaluation and strategies improving sleep quality.

[The investigation of non-verbal behavior through Nonverbal Behavior Analysis Matrix in the forensic setting]

The application of the neuroscience in forensic sciences has long opened up new scenarios within the legal world. While on one hand we tend to emphasize the benefits of the new research methods based on the recent neuroscience knowledge, on the other hand the use of these new tools has sparked a justified debate at the international level that touches all the areas that directly or indirectly approach forensics. Factors like lack of responsability or mitigation provided by science are part of those topics that, thanks to neurosciences, are back in the spotlight on a highly empirical basis. At the same time, these factors mentioned above influence our way to interpret reality. NBAM takes place within this debate as a new scientifically proven protocol and technologically supported, making way for an objective development of the neuroscience research.

[Guidelines in psychiatry: clinical and forensic issues]

Treatment guidelines (GL) in psychiatry represent a useful and functional tool to be explored and enhanced in terms of the contribution of patient care and the promotion of scientific improvement. However, they show some limitations, both clinical and forensic. The objective of this paper is to examine the objectives, the clinical limitations and the applicability of the GL on professional liability (forensic aspects). From a clinical point of view, the GL have objectives that are functional to the promotion of physical and mental health, among which the constitutional observance of the right to health, the improvement of public health, the implementation of best clinical practices, the promotion of scientific research, the professional training of operators in the field of physical and mental health. However, GL cannot replace a contextualized clinical judgment. GL must be applied, in the single clinical case, in light of their multiple criticalities, including the limits of the methodology used for their formulation, the differences between the GL' recommendations, the difficulty of their application in daily clinical practice, the lack of specific treatment interventions. From a forensic psychiatric point of view, GL, as currently conceived, cannot be used in terms of professional liability without their interpretation on a legal basis with forensic psychiatric methodology, similarly to any other clinical and scientific information, with its qualifications and criticalities.

[Regulatory evolution of the crime of infanticide]

The objective of the present study consists of the juridic-anthropological analysis of the infanticide, a phenomenon that nowadays is highly existent within the context of crime-settings. Particular consideration has been given to the legal developments of the infanticide act, which occurred simultaneously with the mutation of the socio-cultural contexts. Because the legislative process of the infanticide act has not evolved since 1981, it was possible to underline the criticisms and the inadequacy of such norm. Indeed, the legal norm has not always been able to provide an exhaustive answer concerning cases of infanticide. The process of humanisation of the law led to the introduction of a legal system, which describes the infanticide act as a condition of material and moral abandonment. This has become uncertain and ambiguous to interpret, risking to relegate the legislative matters of infanticide only to exceptional cases. The current study aims to highlight the criticisms and hypothesised different reform perspectives.

[Professional liability in psychiatry: evolution and critical issues]

The aim of the article is to present the evolution of professional liability in psychiatry from law 36 of 1904 to today. Through an examination of the doctrinal positions and of the jurisprudential expression it was possible to highlight three distinct phases in which professional responsibility has declined over the years. A custodial phase, in which the spirit that animated the law of psychiatric assistance was inspired by principles of social defense and the responsibility of the psychiatrist was recognized mainly in the lack of custody of the psychiatric patient. A phase of indulgence, in which, like other disciplines, the psychiatrist was recognized with "reduced impunity" due to an alleged "special difficulty" in exercising the medical profession. A phase of empowerment, in which the doctor in general, and the psychiatrist in particular, was confronted with empowering positions that led to convictions. An examination of the application of the guarantee position to psychiatry allows us to highlight current difficulties, sometimes a legacy of the past.

Everything is going to be all right. Psychopathology in the time of an epidemic in Italy

Scopo del presente lavoro è descrivere alcune reazioni umane e alcuni elementi di psicopatologia durante la pandemia. La pandemia ha messo in luce diversi aspetti dell'animo umano negli operatori sanitari, nei pazienti e nelle altre persone. Vi sono medici, infermieri, operatori che lavorano 24 ore su 24 per curare e assistere i malati, accompagnare chi non ce la fa. Incuranti del rischio di contagio, della fatica, dei propri bisogni hanno un'unica priorità : aiutare, fare il proprio dovere. Molti di loro si sono ammalati, molti sono morti. Tra loro vi è un alto tasso di contagiati, malati, qualcuno muore. Tutti sono stremati. Sono stati chiamati eroi, ma non tutti sono eroi. I nostri pazienti psichiatrici, inizialmente, sono i più adeguati, prudenti, saggi, responsabili. Con poche, semplici parole esprimono tanta consapevolezza e sana umanità. Al contrario, altre persone, quelle che normalmente si sentono "al di sopra delle cose", entrano nel panico Questa pandemia ci ha fatto capire (se ancora lo ignoravamo) che la vita è fragile, che tutto ciò che ci circonda e su cui costruiamo le nostre sicurezze è precario e incerto.

[Homophobic bullying: critical considerations, and legal-institutional interventions]

Instances in the increase of homophobic bullying mean a major interest in order to develop strong bullying prevention programming which should be a major priority for adults, governments and institutions responsible to promote and ensure a responsible development of society. The complexity of the problem requires a multidisciplinary approach of a comprehensive nature. Starting from the construction of gender identities, and taking into account and understanding the biological aspects, external influences, and arising contrasts during the process, a young person faces adolescence: a transition period when sexual orientation or preference faces higher risks as the person has to come to terms with a mismatch between scales of knowledge. The outcome will result in an inter-generational conflict which becomes a prejudice. By acquiring the desired characteristics of mind and body, adolescents develop their own cognitive skills. Thus we can consider homophobic bullying in its psycho-sociological implications. The aim of this paper is to delineate an explanation of the topic in a scientific, educational and professional way, and at the same time to take into account all legal and institutional issues.

[The psychiatrization and unpredictability of interpersonal violent behavior]

The relationship between mental illness and violent behavior is a complex phenomenon. Scientific literature indicates that the presence of a mental disorder, even severe, is not sufficient, alone, to predict or motivate violent behavior, which seems to be more associated with other intermediate variables. The phenomenon of psychiatrization of violent behavior can be defined, from a psychiatric-forensic point of view, as the prejudicial and erroneous attribution to mental illness as a causal factor in relation to violent behavior. This phenomenon has consequences in psychiatric clinical practice, but also at the level of social stigmatization, management of organizational and economic resources, and the judicial system. In this paper, clinical criticalities related to the psychiatrization of violent behavior will be analyzed, including the need to differentiate clinical etiology and legal causality, predictability and avoidability, protective clinical factors and clinical risk factors, the limits of categorical psychiatric diagnosis, the need for specific victimological information, the criticalities of pharmacotherapy. Some forensic criticalities will also be analyzed, including errors in clinical and forensic methodology (psychiatrization of the symptom, prejudicial contamination, diagnostic overshadowing, legal causalization of protective and risk factors, the use of categorical diagnosis in the forensic field, the psychiatrization of non-pathological human experiences, the criminalization of the subject with mental disorder). In conclusion, it is highlighted that an individual can have a psychic disorder, even severe, but this disorder is not necessarily in a causal relationship with violent behavior. The lack of a causal relationship makes predictability of violent behavior difficult, even impossible depending on the case, both in the general population and in individuals with psychiatric disorders.

[Clinical, diagnostic and forensic features of a REMS patient's sample]

INTRODUCTION

Residential Services for the Execution of Security Measures (REMS) are specialist psychiatric units for forensic patients created in 2015 after OPG (Italian Security Psychiatric Forensic Hospitals) have been closed.

AIMS

to describe the clinical, diagnostic and forensic features of patients and evaluate the relevance of 3 elements: use of alcohol and substance, antisociality, cognitive disability. A further aim is the evaluation of the level of pre and post admission diagnostic concordance.

METHODS

A specific database has been set for the purpose of the study, which collects data of patients admitted in 5 years of activity of the unit. Data have been analysed through a descriptive approach.

RESULTS

4 main clusters have been identified: Psychosis, Use of Alcohol/Substance Disorder, Personality Disorder, Cognitive Disability. Alcohol/substance use, antisociality, cognitive disability elements are relevant in the sample. Diagnostic concordance level pre- and post- admission is overall good, sometimes partial.

CONCLUSIONS

alcohol/substance use, antisociality and cognitive disability, often in comorbidity mode, represent core features in part of the sample. This finding emphasizes a complexity level which is linked to social and judicial aspects, in addition to the health component.

Eating disorders and diabetes: behavioural patterns and psychopathology. Two case reports

The relationship between eating disorders and diabetes is complex in terms of both reciprocity and comorbidity. In some cases, patients with eating disorders and diabetes develop 'purging' behaviours through the use of insulin as a bodyweight control tool, with serious physical complications that can compared to those of untreated diabetes (diabulimia). The clinical cases presented have in common the distorted use of insulin: one patient failed to take the required amounts of insulin, incurring hyperglycaemia, while the other overused it, incurring hypoglycaemia. From a psychopathological point of view, both patients were diagnosed with Borderline Personality Disorder. While these are just two case reports, it is our clinical experience that female diabetic patients with eating disorders who use insulin as a tool for weight control (purging) following binge eating should be assessed for borderline personality disorder in order to tailor a more effective therapeutic approach.

Violence against women in Italy during the COVID-19 pandemic

COVID‐19 and violence against women are interrelated pandemics. Measures to ensure that policies address violence against women in a comprehensive and integrated fashion are critical.

The Italian Version of the Borderline Personality Disorder Severity Index IV: Psychometric Properties, Clinical Usefulness, and Possible Diagnostic Implications

Borderline personality disorder (BPD) has a core embodied in affective and behavioral dysregulations, impulsivity, and relational disturbance. Clinical presentation might be heterogeneous due to a combination of different symptoms listed in the DSM-5. Clinical diagnosis and assessment of the severity of manifestations might be improved through the administration of structured interviews such as the Borderline Personality Disorder Severity Index, 4th edition (BPDSI-IV). The psychometric properties of the Italian version of the BPDSI-IV were examined for the first time in 248 patients affected by BPD and 113 patients affected by bipolar disorder, proving to be a valid and accurate instrument with good internal consistency and high accuracy. The Italian version also demonstrates significant validity in the discrimination between these clinical groups (p < 5001).

[Trazodone prolonged release in bipolar disorder II-obsessive-compulsive disorder comorbidity: a case report]

Approximately 21% of patients with bipolar disorder (BD) also have an additional diagnosis of obsessive-compulsive disorder (OCD). This condition is associated with a more severe prognosis and complicates the treatment of BD. In our case report we provide documentary evidence of our experience with trazodone prolonged release in the treatment of depressive phase in a patient with BD II-OCD comorbidity. Rationality in the choise of treatment was based on the need to manage depressive and obsessive symptoms without facilitating hypomania switches.

[Clinical interview in psychiatric difficult situations]

There are here described a number of basic principles underlying an effective clinical interview in psychiatric difficult situations (violent or suicidal patients, victims of serious physical and psychological damages, authors of inadequate or anti-social requests to the therapist). The aim of the present study is to provide the psychiatric operator with useful skills for the optimal management of the interview in difficult situations both at diagnostically and therapeutically level. The methodology was based on examination of the literature and personal experience of the authors. The authors highlighted 18 working hypothesis that may represent beneficial instruments in situations of difficult psychiatric interview. Further studies will deepen under the clinical, actuarial and statistical validity the principles covered in various clinical and crisis situations with difficulty to the interview, in relation also to specific types of patients for a more updated training of the operators in the field of mental health.

Unblending Borderline Personality and Bipolar Disorders

Borderline Personality (BPD) and Bipolar (BP) disorders stimulate an academic debate between their distinction and the inclusion of Borderline in the Bipolar spectrum. Opponents to this inclusion attribute the important differences and possible diagnostic incomprehension to overlapping symptoms. We tested 248 Borderline and 113 Bipolar patients, consecutively admitted to the Psychiatric Unit, through DSM-IV Axis I and II Disorders (SCID-I/II), Hamilton Depression Rating Scale (HAM-D), Hamilton Anxiety Rating Scale (HAM-A), Young Mania Rating Scale (YMRS) and Borderline Personality Disorder Severity Index-IV (BPDSI-IV). All the tests statistically discriminated the disorders (p < 0.0001). Overlapping symptoms resulted significantly different (impulsivity = 5.32 in BPD vs 1.55 in BP, p < 0.0001; emotional instability = 7.11 in BPD vs 0.55 in BP, p < 0.0001) and the range of their scores gives the opportunity for an even more precise discrimination. Distinctive traits (e.g. irritability or sexual arousal) are also discussed in order to try to qualify the core of these disorders to a higher degree. Comorbidity proves to be extremely small (3.6%). However, Borderline patients with manic features offer a privileged point of view for a deeper analysis. This allows for the possibility of a more precise examination of the nature and load of each symptom. Borderline Personality and Bipolar Disorders can be distinguished with high precision using common and time-sparing tests. The importance of discriminating these clinical features may benefit from this evidence.

[Charges and convictions of psychiatrists for the violent behavior of the patient: psychiatric-forensic remarks]

Purpose of the present study is to point-out a number of psychiatric-forensic remarks about the management of violent behavior against the person (VBP) amongst psychiatric patients. The study is the authors' personal contribution based on clinical and forensic experience as experts in the management of psychiatric patients with VBP. Twelve psychiatric-forensic remarks have been highlighted in the present study: 1) VBP is a multifactorial event; 2) the risk of VBP against the person may change rapidly over time in quantity and quality; 3) there are no methods for reliable prediction of VBP in a single clinical-case; 4) there are no medications with an indication of "heal" the VBP; 5) there are no therapeutic measures that neutralize always, quickly and without recurrences VBP; 6) there exist clinical hypotheses to assess VBP; 7) there exist principles of victimology to assess VBP; 8) there are emotional reactions that can affect the evaluation and clinical and forensic management of VBP; 9) the responsibility of the psychiatrist has to be evaluated at the moment of the events; 10) the responsibility of the psychiatrist must be contextualized in the single clinical-case; 11) there is the need to clarify the individual professional responsibility of psychiatrists who treated a patient; 12) there is the need to clarify the criteria for the definition of the guarantee role. The above-mentioned twelve psychiatric-forensic remarks have implications in the assessment and management of psychiatric patients with violent behavior. They may constitute a basis for further discussion aiming to obtain consensus amongst psychiatrists about good clinical practice and forensic implication in the management of psychiatric patients with VBP and to avoid charges and convictions.

Dissociative Symptoms in Borderline Personality Disorder

Objective

To study the association of dissociative symptoms and specific psychopathological dimensions in a sample of patients with Borderline Personality Disorder (BPD).

Methods

An observational analytic study was conducted. Patients with BPD were administered the Diagnostic Interview for Borderline (DIB-R) and Dissociative Experience Scale (DES–II).

Results

Participants were 34 adult patients with BPD. The majority presented with dissociative symptoms (65.6%; n = 21). A statistical significant correlation was found between DES total score and DIB-R subscales: depression (P = 0.04), feeling of loneliness and emptiness (P = 0.005), sexual deviation (P = 0.002) and intolerance to loneliness (P = 0.01). Furthermore, depersonalization was statistically correlated with the severity of borderline psychopathology (DIB-R total score- P = 0.04), suicidal behavior (P = 0.001) and interpersonal problems (P = 0.04). Derealization was significantly correlated with cognition (P = 0.02), psychotic thought (P = 0.004) and intolerance to loneliness (P = 0.02).

Conclusions

Dissociative symptoms are not easy to detect in the clinical daily work. More than a half of patients with BPD presented with dissociative symptoms detected with a specific rating scale. Particularly, only some specific psychopathological dimensions are correlated with dissociation and need to be assessed in patients with BPD.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Effectiveness of long-acting aripiprazole in schizoaffective disorders: A naturalistic longitudinal study

Introduction

Intramuscular paliperidone palmitate (PP) is a long-acting, atypical anti-psychotic for once monthly intramuscular (IM) administration in the treatment of patients with schizophrenia.

Objective

To study the effectiveness (efficacy and quality of life) of ARP in the maintenance treatment of schizoaffective disorder.

Methods

A non-randomized, prospective naturalistic study was performed in out-patients with schizoaffective disorder unsuccessfully treated with oral anti-psychotics. Efficacy of ARP over time was evaluated by using brief psychiatric rating scale (BPRS 24-items), quality of life was evaluated by using QL-Index, both at T0 and at most recent visit (T1). Data were analyzed with Student's t-tests and Pearson correlations (α value, two tailed). Paired t-test was applied for BPRS and for Ql-Index total scores (T0–T1).

Results

Data were available for 8 outpatients consecutively prescribed ARP and naturalistically treated attending at the psychiatric clinic, university of Sassari. Mean time on ARP treatment was 207.14 days (sd 137.2). BPRS mean total score at T0 was 57 (sd 13.2) and at T1 was 39.7 (sd 10.8). QL-Index mean total score was at T0 5.43 (sd 1.6) and at T1 7.14 (sd 2.7). Paired sample test showed a statistically significant difference in decreasing symptoms at BPRS over time (P = 0.001) and QL-Index total score (P = 0.023). The analyses showed a significant improving at the following BPRS sub-items: anxiety (P = 0.005), mood elevation (P = 0.014) conceptual disorganization (P = 0.048), emotional withdrawal (P = 0.05), tension (P = 0.02) and distractibility (P = 0.03).

Disclosure of interest

The authors have not supplied their declaration of competing interest.

[Murder of the doctor]

AIM

To examine possible risk factors for the doctor to be killed by the patient in the clinical practice by examining a series of murders that involved physicians.

METHODS

This aim has been achieved through a retrospective review on clinical cases of doctors killed by patients within the period between 1988 and 2013, in Italy.

RESULTS

In this period 18 Italian doctors have been killed in the workplace, with a rate of 0.3/100,000. In 7 cases, the murder resulted in the context of doctor-dissatisfaction; in 7 cases the murder was committed by a psychiatric patient; 1 case in the context of a stalking; 3 cases occurred in a workplace which was not safe enough. Four categories of at-risk contexts have been identified. One category includes a murder in the context of a doctor-dissatisfaction, perceived by patient. The second category concerns murders committed by patients suffering from mental illness. A third category includes homicides in a workplace which is not safe. The last category comprises the murder in the context of stalking.

CONCLUSIONS

These categories identify specific dangerous situations for physicians, in which are highlighted elements that have played a crucial role in the murder and for which special precautions are suggested preventive.

Pattern of psychotropic medications use in a cohort of patients with uninvestigated dyspepsia undergoing upper endoscopy: A retrospective study

The prevalence of psychotropic drugs usage is growing in the general population. Moreover, patients with dyspeptic symptoms are increasingly referred to the use of psychiatric and antianxiety drugs in addition to the primary medical treatment. The focus of this observational retrospective study was to investigate the burden of psychotropic drugs usage in a cohort of patients with uninvestigated dyspepsia scheduled for esophagogastroduodenoscopy.Medical records of 11,275 patients (4377 men and 6898 women, age range 18-96 years) referred to the Gastroenterology Unit of the University of Sassari, Sardinia, between January 1995 and December 2013 were reviewed. Information regarding any taken medications including psychiatric and antianxiety drugs was collected. Age- and gender-specific frequency of drug usage was calculated, and their association with marital status, smoking habits, place of residence, socioeconomical status, and polypharmacy was investigated by multiple logistic regression analysis.Psychiatric drugs usage was detected in 531 out of 11,275 (4.7%) patients, with preponderance of women (6.1% vs 2.6%, P < 0.0001). The most prescribed drug categories were selective serotonin-reuptake inhibitors and tricyclic antidepressants.The frequency of antianxiety medication use was 9.8% (1009/11,275) and increased with aging, whereas psychiatric drugs reached the plateau in the fifth decade. The cohort effect was remarkable for psychiatric drugs usage in patients born after 1950 compared to those born before (odds ratio: 1.47), whereas it was absent for antianxiety drugs. Conditions significantly associated with psychotropic drugs usage were assumption of more than 2 nonpsychotropic drugs, aging, female gender, smoking, marriage, widowhood, divorce, and socioeconomic status. In contrast, place of residence did not increase the consumption of psychotropic drugs. The influence of marriage and widowhood disappeared after adjusting for all covariates.Our study confirmed the frequent use of psychotropic medications with uninvestigated dyspepsia. However, the pattern of consumption was different for antianxiety and psychiatric drugs.

[Suicidal contagion and collusion between therapist and patient]

The purpose of the present study is to point out suicidal contagion and suicidal collusion describing clinical cases, to improve professional skills in suicidal risk evaluation and management. In suicide contagion we described three typologies of contagion between therapist and patient: 1) suicide contagion of the environment on the therapist and on the patient; 2) suicide contagion of the therapist on the patient; 3) suicide contagion of the patient on the therapist. We described also four typologies of suicidal collusion with specific kind of patients: 1) with patient suffering of physical illness; 2) with patient suffering of a serious mental illness; 3) with manipulative patients; 4) with patient who is aggressive toward himself and toward other people. In conclusion we pointed out the importance of an adequate recognizement and management of suicidal contagion and collusion to decrease patient suicidal risk.

[Psychiatrist's professional liability for generic, brand, and off-label drug prescription]

At present, drug prescription is a hot topic in terms of professional responsibility. Psychiatric-forensic criteria are provided for appropriate drug prescription, focusing on off-label and generic drug prescription. Off-label prescription should be made in accordance with current regulations, in particular with the regulatory requirements related to patient consent. Generic drug prescription is affected by several critical issues, such as drug excipients, equivalence to original drug, correspondence of therapeutic indications. The different spheres of responsibility of physicians and apothecaries in prescribing and distributing drugs, respectively, are discussed. The knowledge of these issues can be helpful for physicians in their clinical practice, allowing preservation of professional autonomy and compliance with current regulations. The explanation of the most common mistakes about drug prescription that are examined in law courts can be the starting point of an interdisciplinary debate involving all interested parties that are called upon to judge psychiatrist responsibility in drug prescription.

[Psychopathology and risk of homicide committed by a patient with schizophrenia]

We describe, thirteen psychopathologic dynamics based on defense mechanism and primary process thinking, that could determined an homicide committed by a patient with schizophrenia. The purpose of this study is to allow: a) to improve diagnosis of the homicidal act; b) to emphasize psychopathological elements which can be treated by specific forensic psychotherapy; c) to prevent an homicidal recidivism through evaluation of risk passing to the homicidal act.

[Therapist's reactions on the treatment of suicidal patients]

In the present study, we describe fourteen therapists' reactions (Avoidance, Rejection, Suicidal collusion, Over-involvement, Overprotection, Loss of patients' responsibilities, Loss of therapists' responsibilities, Reaction to the feeling of being exploited, Creation of dependency, Manipolatory acting out, Feeling of undergoing an iniquity, Patients psychopathology inflation, Therapists' psychopathology inflation, Suicidal Burnout Syndrome), based on emotions, behaviors and cognitivity, toward patients with suicidal risk. These responses can interfere with a correct assessment and management of suicidal risk in psychiatric patients. The purpose of the present clinical study was to improve therapist's professional skills through the recognition and management of his own responses to suicidal patients.

[The countertransference of the therapist towards the patient with mental disorder and violent behavior]

We described thirteen typologies of the therapist countertransference toward the patient with mental disorder and violent behavior. The purpose of this study is to improve: a) the ability of the therapist to mentalize emotions without any passing to the act; b) the recognition of the patient transference; c) the recognition of the countertransference related to mental disorder and violent behavior.

Validity and reliability of the Structured Clinical Interview for the Trauma and Loss Spectrum (SCI-TALS)

Background

DSM-IV identifies three stress response disorders (acute stress (ASD), post-traumatic stress (PTSD) and adjustment disorders (AD)) that derive from specific life events. An additional condition of complicated grief (CG), well described in the literature, is triggered by bereavement.

Methods

This paper reports on the reliability and validity of the Structured Clinical Interview for Trauma and Loss Spectrum (SCI-TALS) developed to assess the spectrum of stress response. The instrument is based on a spectrum model that emphasizes soft signs, low-grade symptoms, subthreshold syndromes, as well as temperamental and personality traits comprising clinical and subsyndromal manifestations. Study participants, enrolled at 6 Italian Departments of Psychiatry, included consecutive patients with PTSD (N = 48), CG (N = 44), and controls (N = 48).

Results

We showed good reliability and validity of the SCI-TALS. Domain scores were significantly higher in participants with PTSD or CG compared to controls. There were high correlations between specific SCI-TALS domains and corresponding scores on established measures of similar constructs. Participants endorsing grief and loss events reported similar scores on all instruments, except those with CG who scored significantly higher on the domain of grief reactions.

Conclusion

These results support the existence of a specific grief-related condition and the proposal that different forms of stress response have similar manifestations.

Post-mastectomy reconstruction: a comparative analysis on psychosocial and psychopathological outcomes

Although multiple benefits have been reported from post-mastectomy reconstruction and particularly from an immediate procedure, limited psychiatric evaluation has been published. The present study was planned to evaluate the psychosocial and psychopathological outcome in patients who had undergone post-mastectomy breast reconstruction. We also investigated if any psychopathological condition could significantly affect the benefits of the reconstructive procedure. We compared 33 breast-reconstructed patients with 33 patients with mastectomy alone and 33 healthy women. All women underwent a psychiatric interview with four questionnaire-based scales (SASS, QL-index, HAM-A, HAM-D) to assess social adaptation, quality of life, anxiety and depression. A 4-point scale evaluated reconstructed patients' satisfaction. After a year, there was no statistical difference in social, sexual relationships and quality of life among reconstructed patients and healthy women. Regarding anxiety, no statistical difference was found between reconstructed and mastectomy groups. Statistically different lower depression levels in the healthy group and higher levels in the mastectomy group were found. Depression in the reconstructed group decreased compared to the mastectomy group. Differences between timing and reconstructive techniques were not statistically validated. Eight patients were dissatisfied (24.2%). Immediate reconstructed patients who had pre-existing major depressive disorder were dissatisfied. Breast-reconstructed patients' quality of life, social and sexual relationships are not significantly different to those of healthy women. Anxiety does not decrease. Timing and techniques do not seem to influence, significantly, outcome and satisfaction. Pre-existing diagnosis of major depressive disorder may be a contraindication to immediate breast reconstruction.

Lymphocytes in schizophrenic patients under therapy: serological, morphological and cell subset findings

There is a growing body of opinions affirming schizophrenia is a spectrum disease covering several conditions of different aethiology. Various studies have recently shown immunological changes in schizophrenia, and an immune pathogenetic hypothesis has gained acceptance. In the present study, we analyse with a relatively wide approach the immunological dysfunction in schizophrenia, focusing in particular on lymphocytes morphology and subset distribution. We performed in peripheral blood samples of 24 schizophrenic patients: 1) haemochromocytometric evaluation; 2) in serum C-Reactive Protein (CRP) quantitative assay; 3) analysis of lymphocytes subset by flow cytometry with specific monoclonal antibodies (MoAb); 4) morphological evaluation with light microscopy (LM), transmission electron microscopy (TEM) and scanning electron microscopy (SEM). All patients were under treatment and were divided in group 1 with good, and group 2 with low response to treatment. Five healty voluteers were enrolled in the study as control group. The present study showed: a) increased serum CRP concentration (mg/ml); b) higher CD4+ / CD8+ ratio (P < 0.003) than healty controls; c) decrease CD8+ percentage (P = 0.006); d) P type compatible atypical lymphocytes (13.7% in LM) with irregularly shaped nucleus, often showing a lobulation or deep indentation and cytoplasmic basophilia. TEM analysis showed, for the first time in schizophrenic patients, fine morphological features of 6 different types of lymphocytes, and the prevalent type presented a cytoplasm rich in free ribosomes and polisomes. Surface morfology observed by SEM presented different characteristics if compared with lymphocytes from control group. Some cellular immune parameters are realted to the therapeutic outcome.