Italian National Institute of health Centre of Epidemiology, Surveillance, and Health Promotion Mental Health Unit
angelo.picardi@iss.it
Angelo Picardi, born and living in Rome.
Present position Senior Researcher, Mental Health Unit, Centre for Epidemiology, Surveillance, and Health Promotion, Italian National Institute of Health, Rome, Italy.
Professional training - Degree in Medicine and Surgery; - Specialisation Degree in Psychiatry; - 4-year Training in Cognitive Psychotherapy (trainer/supervisor: Dr. Vittorio Guidano); - Basic and Intermediate Clinical Epidemiology Courses (teacher: Dr. Moyses Szklo).
Research - Co-investigator in the project ‘Pathogenic studies in families with twins or siblings discordant for systemic rheumatic disorders’ of the National Institute of Environmental Health Sciences, National Institutes of Health, Bethesda, MD, USA (2003-present). - Principal Investigator, research projects ‘Screening and management of depression in general practice: a randomized controlled trial’ funded by the Italian Ministry of Health in the framework of the ‘Ricerca Finalizzata 2006’ (2007-2010), ‘Development of process and outcome indicators for psychiatric residential facilities and acute inpatient facilities’ funded by the Italian Ministry of Health in the framework of the ‘SIVeAS Program’ (2008-2011), ‘An epidemiological approach to autism spectrum disorders’ funded by the Italian Ministry of Health in the framework of the ‘Ricerca Finalizzata Strategica 2007’ (2008-2011).
Main areas of research: - Psychiatric epidemiology; - Mental health services research; - Assessment instruments in psychiatry; - Early recognition and treatment of mental disorders; - Integrated treatment with psychotherapy and medication; - Clinical psychopathology; - Psychiatric and psychosocial aspects of medical disease (e.g., epilepsy, skin disease, HIV infection); - Personality and emotion regulation (e.g., adult attachment style, alexithymia); - Psychoneuroimmunology and psychoneuroendocrinology.
Teaching - Guest Lecturer for the resident course “Psyche and Skin”, Karolinska University Hospital, Stockholm, Sweden (2005). - Adjunct Professor in research methodology, Graduate School in Clinical Psychology, Catholic University of Rome, Italy (2004-2007). - Adjunct Professor in research methodology, Graduate School in Clinical Psychology, University of Siena, Italy (2006-2009). - Adjunct Professor in Psychiatry, School of Nursing, Sapienza University of Rome, Italy (2006-present). - Adjunct Professor in Epidemiology, Graduate School in Psychiatry, Sapienza University of Rome, Italy (2011-present).
Services - Member of the Editorial Board of the peer-reviewed journals “Clinical Practice and Epidemiology in Mental Health” and “Rivista di Psichiatria”, both indexed in Medline/PubMed and other bibliographic databases. - Reviewer of submitted papers for many international peer-reviewed journals, including Schizophrenia Bulletin, Psychological Medicine, Journal of Affective Disorders, Psychiatry Research, Psychotherapy and Psychosomatics, Journal of Psychosomatic Research, Psychosomatics, General Hospital Psychiatry, Biological Psychology, Journal of Personality Assessment, Personality and Individual Differences, Journal of Neurology Neurosurgery and Psychiatry, Epilepsy Research, Archives of Dermatology, Pediatrics.
Scientific Publications - Author of 105 papers published in international peer-reviewed journals; - Author of 43 papers published in peer-reviewed national journals indexed in MEDLINE, EMBASE or PsycInfo. - Citation Report (ISI Web of Science, June 28, 2012; databases=SCI-Expanded, CCR-Expanded, A&HCI, SSCI): Sum of the times cited: 1,834; H-index: 25 - Author or Editor of 6 books, and author of 21 book chapters for publishers such as Karger, International Universities Press, Schattauer, Masson.
Abstract: To evaluate the efficiency and safety of pre-surgical video-EEG monitoring with a slow anti-epileptic drug (AED) taper and a rescue benzodiazepine protocol.
Abstract: OBJECTIVE: To assess the prognostic value of postoperative EEG in patients surgically treated for drug-resistant extra-temporal lobe (ET) epilepsy. METHODS: We studied 63 consecutive patients with ET epilepsy who underwent epilepsy surgery and were followed up for at least 2years (mean duration of follow-up 6.2±2.3years, range 2-12). Follow-up evaluations were performed 2, 12, and 24months after surgery, and included standard EEG (at 2months) and long-term video-EEG monitoring during both wakefulness and sleep (at 12 and 24months). Seizure outcome was determined at each follow-up evaluation, and then at yearly intervals. Patients who were in Engel Class I at the last contact were classified as having a good outcome. RESULTS: Seizure outcome was good in 39 patients (62%). The presence of interictal epileptiform discharges (IED) in postoperative EEG at each time point was found to be associated with poor outcome. The strength of this association was greater for awake plus sleep recording as compared with awake recording alone. In a multiple regression model including all pre- and post-operative factors identified as predictors of outcome in univariate analysis, the presence of early (2months after surgery) EEG epileptiform abnormalities was found to be independently associated with poor seizure outcome. CONCLUSIONS: Postoperative IED may predict long-term outcome in patients undergoing resective surgery for ET epilepsy. SIGNIFICANCE: The increase in risk of unfavourable outcome associated with EEG epileptiform abnormalities detected as early as two months after surgery may have substantial practical importance. Serial postoperative EEGs including sleep recording may add further predictive power and help making decision about antiepileptic drug discontinuation.
Abstract: Background. The classification of psychological distress and illness behavior in the setting of medical disease is still controversial. Current psychiatric nosology does not seem to cover the spectrum of disturbances. The aim of this investigation was to assess whether the joint use of DSM-IV categories and the Diagnostic Criteria for Psychosomatic Research (DCPR), that provide identification of syndromes related to somatization, abnormal illness behavior, irritable mood, type A behavior, demoralization and alexithymia, could yield subtyping of psychosocial variables in the medically ill. Method. A cross-sectional assessment using both DSM-IV and the DCPR was conducted in eight medical centers in the Italian Health System. Data were submitted to cluster analysis. Participants were consecutive medical out-patients and in-patients for whom a psychiatric consultation was requested. A total of 1700 subjects met eligibility criteria and 1560 agreed to participate. Results. Three clusters were identified : non-specific psychological distress, irritability and affective disturbances with somatization. Conclusions. Two-step cluster analysis revealed clusters that were found to occur across clinical settings. The findings indicate the need of expanding clinical assessment in the medically ill to include the various manifestations of somatization, illness behavior and subclinical distress encompassed by the DCPR. Received 14 December 2010; Revised 14 June 2011; Accepted 14 June 2011; First published online 18 July 2011
Abstract: The aim was to investigate perioperative factors associated with the development of post-traumatic stress disorder (PTSD) in patients who underwent cardiac surgery.
Abstract: The prevalence of depressive disorders is high among patients with skin disease. The PC-SAD is a 37-item self-administered depression screening questionnaire that has been validated in dermatological patients.
Abstract: The influence of severe psychopathology on alexithymic features has been poorly studied. This study aimed at investigating whether alexithymia is affected by the presence of psychosis and the severity of psychopathology.
Abstract: Video-EEG monitoring with intracranial subdural electrodes is a useful assessment tool for the localization of the epileptogenic zone in patients with drug-resistant focal epilepsy. We aimed at assessing the morbidity related to electrode implantation and the surgical outcome in patients who underwent epilepsy surgery after intracranial EEG monitoring. All patients (Nâ=â58) admitted to our Epilepsy Surgery Centre for drug-resistant focal epilepsy who underwent resective surgery after intracranial monitoring with subdural electrodes and were followed up for at least 2Â years were included in the study. Their mean age was 30.4Â years (range 8-60Â years), 25 (43Â %) were female, and 44 (76Â %) had a preoperatively detected structural lesion. The mean duration of invasive recording was 2.3Â days (range 1-14Â days). Extraoperative ECoG allowed the identification of the epileptogenic focus in all cases. The temporal lobe was involved in 21 (36Â %) patients, whereas extratemporal foci were identified in 24 (41Â %) patients. Thirteen patients (23Â %) had multilobar involvement. Functional brain mapping was performed in 15 (26Â %) patients. Transient complications related to electrode implantation occurred in three patients. Among patients with evidence of lesion on preoperative MRI, lesionectomy alone was performed in 12 cases (27Â %), while it was combined with tailored cortical resection in the remaining cases. Tailored cortical resection was also performed in patients without evidence of lesion on MRI. After resective surgery, transient neurological deficits occurred in five cases, while another patient experienced permanent lateral homonymous hemianopia. At the last follow-up observation, 34 (57Â %) patients were seizure-free (Engel class I). This study suggests that invasive EEG recording with subdural electrodes may be useful and fairly safe for many candidates for epilepsy surgery.
Abstract: Previous studies failed to identify a consistent factor structure of the BPRS-24 in schizophrenia. Our aims were to examine the fit of all previously published factor models and then to explore unobserved population heterogeneity and identify salient latent classes. Two hundred thirty-nine patients with ICD-10 schizophrenia admitted to a random sample of all Italian public and private acute inpatient units during an index period were administered the BPRS-24. Confirmatory factor analysis (CFA) was used to test all factor models derived in previous studies. Then, factor mixture analysis (FMA) with heteroscedastic components was carried out to explore unobserved population heterogeneity. No previously reported factor solution showed adequate fit in CFA. FMA indicated the presence of three heterogeneous groups and yielded a 5-factor solution (Depression, Positive Symptoms, Disorganization, Negative Symptoms, Activation). Group 1 was characterized by higher Disorganization, lower Activation, lower psychosocial functioning, greater lifetime number of admissions, more frequent history of compulsory admission. Group 2 displayed lower Disorganization. Group 3 showed higher Activation and more frequent history of recent self-harming behavior. Our finding that a reliable factor structure for the BPRS-24 could be obtained only after assuming population heterogeneity suggests that the difficulty in identifying a consistent factor structure may be ascribed to the clinical heterogeneity of schizophrenia. As compared with clinical subtypes, the psychopathological dimensions displayed much greater discriminatory power between groups identified by FMA. Though preliminary, our findings corroborate that a dimensional approach to psychopathology can facilitate the assessment of the clinical heterogeneity of schizophrenia.
Abstract: Mental health is recognized worldwide as a major public health priority for the twenty-first century. Different actions are needed, including developing or strengthening national mental health information systems, based on standardized indicators that allow national and international monitoring. In 2008, the national Centre for Disease prevention and Control of the Italian Ministry of Health and the Mental Health Unit of the Italian National Institute of Health (INIH) jointly launched a mental health information system named SEME (an Italian acronym meaning 'mental health epidemiological surveillance') based upon data collected from trained psychiatrists working in 22 selected sentinel community mental health centers distributed across Italy and covering a total population of 1,941,853 inhabitants, in order to collect and report site-level information on first-contact patients suffering from specific severe mental disorders (schizophrenia, schizophreniform disorder, schizoaffective disorder, delusional disorder, bipolar I disorder, anorexia nervosa, major depressive episode with psychotic symptoms or suicide attempt). Strengths of the system are the high reliability of diagnoses and the use of a web-based technique for data collection with data entry forms designed for ease of completion. During the first year of implementation of this system, a total of 343 first-contact patients met criteria for one of the severe mental disorders under surveillance. As the system includes standardized instruments to measure psychiatric symptoms and psychosocial functioning, it may facilitate health services research based on longitudinal measurements aimed at evaluating the continuity of psychiatric care and the effectiveness of innovative therapeutic and rehabilitative programs.
Abstract: The relative contribution of genetic and environmental influences to individual differences in attachment security is still incompletely understood. We assessed attachment style with the Experiences in Close Relationships questionnaire in a volunteer sample of 677 twins (43% male) ages 23-24 years drawn from the population-based Italian Twin Register, who belonged to 244 complete pairs (46% monozygotic) and 189 unmatched pairs. Genetic structural equation modeling was performed with the Mx program. Genetic effects accounted for 45% and 36% of individual differences in attachment-related anxiety and avoidance, respectively. Furthermore, the covariation between anxiety and avoidance was found to be mainly due to genetic factors, with heritability of the latent attachment security phenotype estimated at 62%. Unshared environmental factors explained the remaining proportion of variance. Although our findings are best regarded as preliminary given some study limitations, they suggest that both nature and nurture contribute to individual differences in adult attachment.
Abstract: To analyze factors associated with a patient's probability of being a Heavy User (HU) of inpatient psychiatric services and to compare the HU inpatient population with Non-Heavy Users (NHUs).
Abstract: To describe 5-year changes in the provision of Residential Facilities (RFs) in a large Italian Region and in the characteristics of their staffing and patients. 2000 census data of all RFs with >4 residential beds in the Emilia-Romagna Region were compared with 2005 census data. The number of residential beds increased from 3.1 per 10,000 inhabitants in 2000 to 4.1 per 10,000 inhabitants in 2005. The RFs operated by private non-profit associations increased at a greater rate than the number of NHS-operated facilities, and the percentage of non-qualified staff has also risen at a greater rate than that observed for qualified staff. The number of individuals with comorbid substance abuse increased from 2.1% in 2000 to 5.7% in 2005. Patient turnover rates were low in both 5-year periods. A process of new institutionalization might be taking place. Mental health care policy-makers should take these findings into account to enhance the planning of effective services, including RFs granting a satisfactory quality of life to patients with severe disorders requiring long-term, eventually unlimited care.
Abstract: A robust psychopathological and psychotherapeutic tradition underscores the importance of the clinician's feelings in the assessment and therapeutic process. Our aim is to develop an instrument to evaluate psychiatrist' experience induced by each patient. This paper describes the development and preliminary validation of this instrument.
Abstract: Little is known about whether severe psychopathology influences the assessment of self-reported attachment style. Fifty-eight randomly selected adult psychiatric inpatients completed the Experiences in Close Relationship questionnaire (ECR; Brennan, Clark, & Shaver, 1998) and were administered the 24-item Brief Psychiatric Rating Scale (BPRS; Ventura et al., 1993) and the Hamilton Depression Rating Scale (HDRS; Hamilton, 1960) at both admission and discharge. The Structured Clinical Interview for DSM-IV (SCID-I; First, Spitzer, Gibbon, & Williams, 1996) was used to establish Axis I diagnoses. The ECR scales showed good internal consistency and absolute stability both in patients with (n = 24) and without (n = 34) a psychotic disorder. Relative stability was only fair among patients with psychotic disorders but good among patients without psychotic disorders. Neither higher BPRS or HDRS scores, nor the presence of a psychotic disorder, significantly reduced the retest reliability of the ECR scales. These findings suggest that self-report measures might provide a reliable assessment of attachment style in patients with severe psychopathology, except for the most severely impaired patients.
Abstract: The factors involved in the etiology of alexithymia are still unclear. While a few studies suggested substantial genetic influences on alexithymia, it remains to be determined if these influences are independent of genetic influences on other mental health variables correlated with alexithymia, such as depression. This study is aimed at confirming previous findings of a genetic contribution to alexithymia, examining whether there are genetic or environmental influences common to alexithymia facets, and investigating whether genetic influences on alexithymia are independent of genetic influences on depression.
Abstract: The present study investigated: (i) the rate of prescription of antipsychotic (AP) polypharmacy (APP) in a large, representative sample of psychiatric inpatients; and (ii) the relationship between APP prescription and the characteristics of patients and facilities.
Abstract: There is increasing awareness of the need of subtyping major depressive disorder, particularly in the setting of medical disease. The aim of this investigation was to use both DSM-IV comorbidity and the Diagnostic Criteria for Psychosomatic Research (DCPR) for characterizing depression in the medically ill.
Abstract: This study provides: a) rates of hospitalization for anorexia nervosa (AN) in Italy in 2004-2005 period; b) an estimate of the incidence of moderate to severe hospitalized AN in the same period among persons aged 10-19 years.
Abstract: In clinical practice patients with unipolar depression present with a variety of symptom clusters that may combine together in many different ways. However, only few factor analytic studies used general psychopathology scales to investigate the symptom structure of unipolar depression.
Abstract: The aim of this study was to describe the sociodemographic, clinical and treatment-related characteristics of patients admitted to any acute psychiatric inpatient facilities in Italy for the first time in their life, and to identify reasons contributing to admission. Data from the PROGRES-Acute Project, a national survey on facilities admitting acute psychiatric patients in Italy, were used. A cluster analysis was carried out in order to identify patients' groups sharing similar sociodemographic and clinical characteristics. Among patients admitted during the index period, 337 were at their first-ever admission. Median age at admission was 40, and about 46% of patients were not receiving any treatment in the month prior to admission. Social/work functioning problems, social withdrawal and conflict with family members were the most common reasons contributing to admission. Cluster analysis yielded four patient groups: two groups of younger subjects, differentiating each other for frequency of antisocial behaviors, compulsory admissions, treatment at time of admission and family support; two groups of older subjects, with high rates of affective disorders, who showed remarkable differences with regard to their living situation and family support. Our study shows that first-ever admitted patients represent a highly heterogeneous group. Early intervention research should take this sociodemographic and clinical diversity into account, in order to better allocate resources and develop special intervention programs.
Abstract: Bipolar disorder is a complex clinical entity that presents with pleomorphic signs and symptoms varying from depression to hypomania, full-blown mania, mixed states, and psychosis. Therefore, the assessment of patients with bipolar disorder poses a difficult challenge to clinicians, who may find themselves puzzled when having to choose among the many instruments available. This paper aims at briefly reviewing these instruments.
Abstract: It is well known that theta rhythms (3-8 Hz) are the fingerprint of hippocampus, and that neural activity accompanying encoding of words differs according to whether the items are later remembered or forgotten ["subsequent memory effect" (SME)]. Here, we tested the hypothesis that temporal synchronization of theta rhythms among hippocampus, amygdala, and neocortex is related to immediate memorization of repeated words. To address this issue, intracerebral electroencephalographic (EEG) activity was recorded in five subjects with drug-resistant temporal lobe epilepsy (TLE), under presurgical monitoring routine. During the recording of the intracerebral EEG activity, the subjects performed a computerized version of Rey auditory verbal learning test (RAVLT), a popular test for the clinical evaluation of the immediate and delayed memory. They heard the same list of 15 common words for five times. Each time, immediately after listening the list, the subjects were required to repeat as many words as they could recall. Spectral coherence of the intracerebral EEG activity was computed in order to assess the temporal synchronization of the theta (about 3-8 Hz) rhythms among hippocampus, amygdala, and temporal-occipital neocortex. We found that theta coherence values between amygdala and hippocampus, and between hippocampus and occipital-temporal cortex, were higher in amplitude during successful than unsuccessful immediate recall. A control analysis showed that this was true also for a gamma band (40-45 Hz). Furthermore, these theta and gamma effects were not observed in an additional (control) subject with drug-resistant TLE and a wide lesion to hippocampus. In conclusion, a successful immediate recall to the RAVLT was associated to the enhancement of temporal synchronization of the theta (gamma) rhythms within a cerebral network including hippocampus, amygdala, and temporal-occipital neocortex.
Abstract: A proper understanding of patterns of care represents a crucial step in improving clinical decision making and enhancing service provision. Only a few studies, however, have explored global patterns of psychiatric admissions nationwide, and none have been undertaken in Italy.
Abstract: To analyze the characteristics of patients scheduled for discharge from acute psychiatric inpatient facilities in Italy, and their pattern of care.
Abstract: Memory decline is often observed after anterior temporal lobectomy (ATL), particularly in patients with dominant hemisphere resections. However, the follow-up length has been 1 year or less in most studies. Our aims were to examine postoperative memory changes over a longer period and to identify baseline demographic and clinical predictors of memory outcome.
Abstract: Adherence to highly active antiretroviral treatment (HAART) is critical to long-term treatment success in patients infected with human immunodeficiency virus (HIV). However, the relationship between psychological variables and medication adherence is still poorly understood. The aim of this study was to investigate how anger dimensions in subjects with HIV affect adherence to antiretroviral drugs.
Abstract: People seeking for psychotherapeutic help present with a variety of conditions including stress, depression, anxiety, and maladaptive individual difference factors. This paper reviews the studies investigating the link between these conditions and immunity.
Abstract: Many patients drop-out from treatment after a single contact; however, characteristics have only rarely been investigated. We aimed at estimating the frequency of early drop-out and identifying possible risk factors.
Abstract: The aim of the present study was to further test criterion validity and factorial validity of the McGIll Quality Of Life (MQOL) questionnaire, and to assess its reliability and sensitivity to clinical change in outpatients with HIV infection.
Abstract: The aim of the present study was to assess the characteristics of long-stay inpatients in public and private Italian acute inpatient facilities, to identify risk factors and correlates of the long duration of hospital stay in these patients, and to identify possible barriers to alternative placements.
Abstract: A survey of oncologists was conducted in Italy to evaluate the potential problems of physician-patient discussion about hormonal switch in the adjuvant therapy of breast cancer. Materials and methods: A questionnaire, including both closed and open-ended questions, was administered to 70 oncologists. Fifty-one of them returned completely filled questionnaires.
Abstract: Despite increasing interest in dimensional psychopathology and the use of symptom clusters in clinical research, factor analytic studies of mania are rare. Most studies included not only manic patients, but also patients with a mixed episode or other severe mental disorders. We aimed at further elucidating the symptom structure of manic states.
Abstract: Despite the undeniable impact of systemic sclerosis (SS) on quality of life, only a few studies so far have focused on its psychiatric or psychological aspects. We aimed at assessing psychiatric symptoms and self-image in inpatients with SS and comparing them with patients with either a very mild skin condition or a serious skin condition.
Abstract: Discharge from a psychiatric forensic institution is a critical moment for patients with severe mental disorders; often it leads to relocation to a non-forensic residential facility (RF) where treatment and support needs can be met. The present study used data from the Italian PROGRES project (aimed at studying the countryâs residential mental health care system) to investigate the characteristics of a large sample of patients formerly admitted to forensic mental hospitals (FMH) living in a psychiatric RF, and to compare them with RF patients never admitted to FMH. Structured interviews were conducted with the managers and staff of a representative sample of Italian RFs (n = 265); residents were also evaluated using standardized rating instruments. Among 2,962 surveyed residents, a total of 193 patients (6.5%) had previously been admitted to a FMH. The majority had a diagnosis of schizophrenia or a related disorder (n = 149, 78.0% of FMH patient vs. 1830, 66.8% of non-FMH patients). Overall, the symptom profile did not differentiate former forensic patients from residents who had never been admitted to an FMH. The rate of violent behaviour reported during stay in current residence was low and limited to a very small group of former FMH patients. The present studyâs main conclusion is that patients discharged from FMHs and selected as suitable for relocation to ordinary RFs are able to remain in this type of accommodation without posing a significant danger in terms of violent behaviour or threats.
Abstract: Psoriasis is a chronic inflammatory skin disease in which several Th1 cytokines such as interleukin-1 beta (IL-beta) have been shown to play a pivotal role. Psychological stress has also been implicated in triggering or exacerbating the disease.
Abstract: The Health of the Nation Outcomes Scales (HoNOS) was developed as an inclusive and comprehensive instrument to assess patient outcomes in 4 main domains: behaviour, cognitive and physical impairment, symptoms and social functioning/context. Concerns about the reliability and validity of the HoNOS have been raised. The aim of this study was to further investigate the discriminatory ability of the HoNOS; criterion validity was also examined.
Abstract: After legislative changes in 1978, Italian psychiatry underwent a thorough overhaul, with the gradual closure of all Mental Hospitals. A nation-wide network of Departments of Mental Health now deliver outpatient and inpatient care, but also run semi-residential and residential facilities (the latter with 2.9 beds per 10,000 inhabitants). Hospital care is delivered through small psychiatric units (with no more than 15 beds). There are also many private inpatient facilities operating in Italy, and the number of private inpatient beds per 10,000 inhabitants exceeds the number of public beds; overall there are 1.7 acute beds per 10,000 inhabitants - one of Europe's currently lowest numbers. There is marked quanti- and qualitative variation in the provision of out- and inpatient care throughout the country, and service utilization patterns are similarly uneven. Studies examining quality of life report a fairly high degree of patient satisfaction, whereas patients' families frequently bear a heavy burden. In conclusion, the Italian reform law led to the establishment of a broad network of facilities to meet diverse care needs. Further efforts are required to improve quality of care and to develop a more effectively integrated system. Greater attention must be paid to topics such as quality of care and outcomes, public and private sector balance, and the coordination of various resources and agencies.
Abstract: Introduction. It is debated whether the prevalence of psychiatric disorders, particularly depression and anxiety, has greatly increased recently. Methods. A specifically developed questionnaire inquiring about perceived changes in the frequency and the magnitude of any change of occurrence of several disorders over the previous 10 years was sent to 253 Italian psychiatrists. Risultati. A total of 110 (44%) psychiatrists (63% males, mean clinical experience 20.8 years) completed and returned the questionnaire. The frequency of schizophrenia, obsessive-compulsive disorder, and somatoform disorders was perceived as stable or only slightly changed. The frequency of panic disorder, social anxiety disorder, adjustment disorders, eating disorders, and of depressive disorders, especially disorders other than major depression, was perceived as substantially increased in the last 10 years. The interviewees indicated women, adolescents and the elderly as the age groups in which these disorders occurred with increased frequency. Discussion. This study suggests that the number of individuals who seek psychiatric help in Italy has increased considerably, although it is not possible to establish whether this is due to an actual increase in the prevalence of mental disorders or to changes in referral patterns and health services utilization.
Abstract: In the latest years, mental hospitals have gradually been replaced by a community-based network of facilities, including non-hospital residential facilities (RFs). Little information is still available about their costs. Our aims were to estimate the costs of Italian RFs and to evaluate which factors affect the cost of RFs and their patients.
Abstract: The relationship between alexithymia and psychosocial functioning has been investigated in a few studies using indirect measures of adaptation. We aimed at directly evaluating the relationship between alexithymia and global psychosocial functioning, as measured by a standardised scale.
Abstract: Legislation in 1978 led to the gradual replacement of mental hospitals in Italy with a full range of community-based services, including facilities for acute in-patient care.
Abstract: A link between the mind and the skin has long been hypothesized. Indeed, some studies suggested that psychosocial factors may play a role in the pathogenesis and course of several skin diseases. Conversely, other studies suggested that psychiatric disorders and psychosocial difficulties may result as a complication of a primary skin disease. Epidemiological studies indeed found a high prevalence of psychiatric disorders among dermatological patients. This is a source of concern, because psychiatric morbidity is associated with emotional suffering, disability, lower quality of life, poorer adherence to dermatological treatment, and increased risk of self-harm. Conditions such as demoralization, health anxiety, irritable mood, type A behavior, and alexithymia were also found to be frequent in dermatological patients, and to be independently associated with greater psychological distress, lower quality of life, and poorer psychosocial functioning. Several studies also raised concerns about under-recognition and undertreatment of psychiatric disorders. This large body of findings suggests that psychosocial issues deserve more attention in everyday dermatological practice, and highlights the need for a biopsychosocial approach to the management of patients with skin disease. To this purpose, the development of efficient consultation-liaison services enabling an effective collaboration between dermatologists and mental health professionals is mandatory.
Abstract: Attachment security is associated with health and possibly autonomic and endocrine reactivity to stress, however the relationship between attachment style and immune function has not yet been investigated.
Abstract: The differential diagnosis between panic disorder and focal epilepsy may sometimes pose a serious challenge. We report the case of a 32-year-old woman who complained of paroxysmal episodes of acute anxiety that evaded diagnosis for 8 years. Standard EEGs and brain CT scan showed no clear pathologic findings. Antidepressants, support psychotherapy and several courses of antiepileptic drugs were not beneficial. She was referred to our centre for a comprehensive diagnostic assessment. Clinical and standardized personality assessment did not reveal the personality organization typically associated with proneness to develop phobic anxiety disorders. Also, agoraphobic avoidance was absent, and the patient's main worries during the episodes involved negative social judgments rather than health. A brain MRI revealed a slightly increased signal at FLAIR images in the right amygdala. Video-EEG monitoring was decisive in establishing the diagnosis of drug-resistant right mesial temporal lobe epilepsy. Anteromesial temporal lobectomy was offered and successfully performed. Pathological examination of removed brain tissue revealed amygdalar sclerosis and mild hippocampal neuronal loss. At a 6-month follow-up visit, the paroxysmal episodes had completely disappeared. Depression, anxiety and quality of life were markedly improved. This case suggests that focal epilepsy should be considered in patients with paroxysmal episodes of anxiety, especially if dissociative symptoms and atypical clinical features for panic disorder are present, and if there is no satisfactory response to adequate trials of medication and psychotherapy within one year. A careful psychopathological analysis rather than a descriptive enumeration of symptoms is needed to bring these features to light. In such cases, even if routine EEGs or MRI are inconclusive and there is no response to antiepileptic drugs, it would be advisable to perform video-EEG monitoring to rule out partial seizures.
Abstract: Several patients with unipolar depression present with prominent dysphoric mood. We aimed at examining the effectiveness of the combination of an SSRI with an anticonvulsant in such patients.
Abstract: Psychological distress has been frequently reported in the setting of skin disorders. The Diagnostic Criteria for Psychosomatic Research (DCPR) have been found to yield valuable integrative information, in addition to DSM-IV nosology, in a variety of medical diseases. The aim of this study was to verify whether this integration could also be helpful in dermatology. A consecutive series of 539 inpatients with various skin conditions was evaluated by means of structured interviews for DSM-IV and DCPR diagnoses. The prevalence of DSM-IV conditions was 38% (mostly depressive disorders and anxiety disorders), whereas that of DCPR clusters (mostly demoralization and somatization secondary to psychopathology) was 48%. Overall, DCPR diagnoses were significantly more frequent than DSM-IV categories, regardless of the presence or absence of a psychiatric disorder. Psychological assessment of patients with skin diseases needs to incorporate both clinical (DSM-IV) and subclinical (DCPR) methods of classification. The health status of these patients can be improved if their psychological problems are appropriately assessed and recognized.
Abstract: Our aim in this observational study was to evaluate the feasibility of a multiphasic screening project for the detection and treatment of mood and anxiety disorders among cancer patients in a natural setting. One hundred sixty-five patients with cancer, consecutively admitted to the Oncology Division of San Camillo-Forlanini Hospital, were recruited to the study. All patients had solid tumors; the majority of them were colon, breast, and lung cancers. All patients completed the Hospital Anxiety and Depression Scale (HADS). Patients screened as positive were administered the following instruments by a psychiatrist: the Structured Clinical Interview for DSM-IV (SCID-I), the Beck Depression Inventory (BDI), the Hamilton Anxiety Rating Scale (HARS), and a validated scale for the rapid dimensional assessment of psychopathology (SVARAD). The BDI, HARS, and SVARAD were administered again at 4 and 10 weeks to all treated patients. Out of 45 patients administered the SCID-I, 37 had a mood or anxiety disorder. Adjustment disorders were identified in 20 patients, depressive disorders in 14, and anxiety disorders in three patients. Most patients were prescribed psychotropic medications: mirtazapine was prescribed to 15 patients, citalopram to 13 patients, and escitalopram to four patients. A significant improvement in symptoms of depression and anxiety was observed on all measures (P<.001). Although the design of the study prevents any firm conclusions about effectiveness, this study suggests that including psychiatric expertise in an oncology division is feasible and may lead to improved detection and treatment of psychiatric disorders among cancer patients. Further randomized trials are needed to elaborate on our findings.
Abstract: Supratentorial cavernous angiomas may be associated with drug-resistant focal epilepsy. Surgical removal of the malformation may result in seizure control in a number of patients, although in most studies a long history and high frequency of attacks have been recognized as indicators of unfavorable seizure outcome. In the literature, there are no clear indications regarding the optimal diagnostic presurgical workup and the surgical strategy for this particular subgroup of patients with symptomatic epilepsy. In this paper the authors focus on the preoperative workup and the surgical management of the disease in eight consecutive patients undergoing surgery for drug-resistant temporal lobe epilepsy (TLE) due to cavernous malformations (CMs), and the relevant literature on this issue is also reviewed.
Abstract: A defective response of psoriatic skin to beta-adrenergic stimulation has been implicated in the pathophysiology of psoriasis. A psychophysiological study was planned to investigate whether the beta-adrenergic receptor hyporesponsiveness found in psoriatic skin can also be detected in other systems. Twenty-five psoriatic patients and 50 healthy controls were submitted to a standardized stressful procedure (mental arithmetic and the Stroop Colour-Word Naming Test) to trigger the activation of the sympathetic nervous system, and their haemodynamic responses were compared. While there were no differences between groups in perceived stress, a blunted increase in heart rate and a sharper increase in diastolic blood pressure was observed in psoriasis patients compared with controls. The psychophysiological reaction pattern observed in psoriatic patients might be explained by lower reactivity of heart beta1-adrenergic receptors and arteriolar walls beta2-adrenergic receptors. While this study suggests that beta-adrenergic receptor hyporesponsiveness might have a systemic expression in psoriatic patients, it needs support from future studies exploring beta-adrenergic function in psoriatic patients more directly.
Abstract: We aimed at further elucidating the association between quality of life (QOL) and sociodemographic factors, clinical seizure factors, depression and anxiety in drug-resistant temporal lobe epilepsy (TLE).
Abstract: A comprehensive neuropsychological assessment was performed on a 38-year-old woman with drug-resistant right temporal lobe epilepsy before temporal lobectomy, during a 2-year follow-up period, and approximately 3 years after surgery when she developed a malignant glioma in the left medial temporal lobe (MTL). Both before and after epilepsy surgery, memory function was normal. When the tumour was discovered, the patient suffered from severe retrograde and anterograde amnesia, whereas working memory and the other cognitive abilities were preserved. Compared with other cases of bilateral temporal lesion, this case is peculiar because the damage occurred on two distinct occasions. It suggests that only one MTL can allow normal memory function, or can take over the function normally subserved by a dysfunctional contralateral MTL when the dysfunction is marked and prolonged, such as in chronic epilepsy.
Abstract: Our aim was to test the lateralizing value of a neuropsychological battery including several memory tests on a large sample of consecutive patients with drug-resistant temporal lobe epilepsy (TLE) evaluated for epilepsy surgery. We studied 73 right-handed patients (56% males, mean age 35.3 +/- 11.2 years, 49% left TLE) aged 16 years or older with normal IQ who underwent a preoperative neuropsychological assessment including several memory tests and were seizure-free after at least 1 year of follow-up. Forty-seven had TLE due to hippocampal sclerosis, whilst 26 had TLE secondary to tumors or other lesions. Receiver Operating Characteristic (ROC) analysis and discriminant function analysis were used to evaluate the lateralization value of selected tests and of the battery as a whole, respectively. In patients with TLE secondary to tumors or other lesions, no test showed significant lateralizing value. In patients with TLE due to hippocampal sclerosis, the immediate (P < 0.01) and delayed (P < 0.001) Rey Auditory Verbal Learning Test (RAVLT) displayed substantial discriminatory ability. The battery as a whole correctly classified 82% of patients with respect to side of epileptogenesis. Our findings suggest that a non-invasive, relatively short and unexpensive neuropsychological battery based on memory tests may profitably complement other well-established diagnostic procedures such as video-EEG or magnetic resonance imaging (MRI), at least in patients with drug-resistant TLE due to hippocampal sclerosis.
Abstract: We administered structured interviews to managers and staff of a random sample of 265 Italian psychiatric Residential Facilities (RFs). Most are independent buildings, located in urban and suburban areas. The median number of residents is 10. The few RFs (5.7%) with more than 20 beds have a higher rate of drop-outs and escapes. The average indoor space per resident is 36 square meters, there is often a garden, and residents generally live in two-bed rooms. Most facilities are located within walking distance of shopping centers or recreational facilities. Three-quarters have 24-hour staff coverage. On average, each facility has about 10 full-time equivalent workers, with a staff:resident ratio of 0.92. Most of the professional input is provided by nurses and auxiliary staff. Critical issues to be considered in planning facilities include the physical environment, the size, and the staffing patterns.
Abstract: Quality of Life (QOL) is an outcome measure particularly useful to assess the effects of deinstitutionalization policies. To date no large-scale study has been conducted in residential facilities (RFs). Participants included 1492 subjects living in 174 RFs (20% of the total) randomly sampled in 15 Italian regions. Assessment instruments included the WHOQOL-Bref, the GAF, and the Physical Health Index (PHI). WHOQOL scores of residents were compared with those of healthy subjects (N = 65) and outpatients with schizophrenia (N = 162). Multivariate analyses were used to examine the relationship between selected patients' characteristics and WHOQOL scores. Mean WHOQOL scores of residents were similar to those of outpatients with schizophrenia, and substantially lower than those of healthy controls. Lower scores on WHOQOL domains were associated with schizophrenia and non-affective psychoses, unipolar depression, anxiety or somatoform disorders, shorter duration of illness, positive, negative or mood symptoms, lower GAF scores, no participation in internal activities, and PHI score. Our findings are consistent with previous studies. The present study highlights a marked difference between patients in RFs and healthy controls in the social domain. This suggests the need of well-designed rehabilitation plans, tailored to patients' needs, to foster the development of their independence and, ultimately, improve their QOL.
Abstract: In Italy, Residential Facilities (RFs) have completely replaced Mental Hospitals (MHs) for the residential care of mentally ill patients. We studied all patients resident in 265 randomly sampled Italian RFs (20% of the total).
Abstract: Despite the high prevalence of bipolar spectrum disorders, most instruments currently available for the assessment of depression do not explore symptoms of 'activation' such as anger, irritability, aggressiveness, hostility, and psychomotor activation.
Abstract: To investigate in a representative national sample (N=2,962) of patients living in Residential Facilities (RFs) patterns of polypharmacy as well as related variables, association between diagnoses and therapeutic patterns, and the rate of adverse events.
Abstract: Both medication and psychotherapy are effective in obsessive-compulsive disorder (OCD). However, they both have disadvantages. We aimed at studying the long-term effectiveness of integrated treatment compared with medication alone.
Abstract: Controversy still exists concerning the stability of the alexithymia construct. Also, although alexithymia has been found to be related in a theoretically meaningful way to other personality constructs such as the 'Big Five' factors, few studies have investigated its relationship with influential constructs such as temperament and character, and attachment security.
Abstract: Psychiatric disorders are frequent in dermatology patients, and many studies pointed out complex, mutual relationships between psyche and skin. Our aim was to provide a systematic psychosocial evaluation of a large and heterogeneous population of patients with skin diseases, including assessments of quality of life, psychiatric status according to the DSM-IV and psychological conditions with psychosomatic relevance according to established criteria (Diagnostic Criteria for Psychosomatic Research, DCPR).
Abstract: The stability of attachment-related anxiety and avoidance and their relationship with influential personality models are issues worth further investigation. Studying discriminant validity with respect to aspects of personality deemed as prevalently heritable, such as temperament, is particularly important. Our aims were to examine the stability of attachment dimensions and to study their relationship with psychological distress, the Big Five factors, and temperament and character dimensions.
Abstract: To evaluate the effect of patient satisfaction on health-related quality of life among dermatological outpatients, independently of patients' sociodemographic, and clinical characteristics.
Abstract: Although residential facilities (RFs) have largely replaced mental hospitals (MHs) in most developed countries for the long-term residential care of severely impaired patients, the process of care in RFs has not been well studied. The aim of this paper is to investigate the process of care in 265 RFs, representing 19.3% of all RFs in Italy, and to devise a classification of RFs based on process characteristics.
Abstract: The Dermatology Life Quality Index (DLQI) is one of the most frequently used questionnaires to evaluate the impact of dermatological diseases on patients' lives. This study aimed to assess the reliability and validity of the instrument and to test its unidimensionality in a large sample of patients with psoriasis (n=976) hospitalized at IDI-IRCCS, Rome, Italy. Nine hundred patients completed the DLQI, the Psoriasis Disability Index (PDI) and the Skindex-29 (response rate 92%). The internal consistency of the DLQI was high (Cronbach's alpha=0.83). Evidence of convergent validity was provided by high (r=0.64-0.81) correlations between the DLQI, the PDI, and the functioning and emotions scales of Skindex-29. Exploratory factor analysis indicated the presence of four different principal common factors. Confirmatory factor analysis showed a clear second-order factor structure, with a homogeneous second-order factor underlying the four primary-surface factors. This study confirms that the DLQI is a reliable and valid instrument to assess patient-perceived impact of skin disease. Also, it supports the unidimensionality of the DLQI and hence corroborates the common practice of using the total score.
Abstract: The authors' aim was to investigate the role of stressful events, perceived social support, attachment security, and alexithymia in triggering exacerbations of diffuse plaque psoriasis. Inpatients experiencing a recent exacerbation of diffuse plaque psoriasis (N=33) were compared with inpatients with skin conditions believed to have a negligible psychosomatic component (N=73). Stressful events during the last year were assessed with Paykel's Interview for Recent Life Events. Attachment style, alexithymia, and perceived social support were assessed with the Experiences in Close Relationships questionnaire, the Toronto Alexithymia Scale, and the Multidimensional Scale of Perceived Social Support, respectively. Multiple logistic regression analysis was used to control for age, gender, education, marital status, and alcohol consumption. In relation to comparison subjects, the patients with psoriasis had lower perceived social support and higher attachment-related avoidance. Also, they were more likely to have high alexithymic characteristics. There were no differences between the patients with psoriasis and the comparison subjects in scores on the Experiences in Close Relationships anxiety scale, the total number of stressful events, and the number of undesirable, uncontrollable, or major events. Although caution should be applied in generalizing these findings to outpatients, this study suggests that alexithymia, attachment-related avoidance, and poor social support might increase susceptibility to exacerbations of diffuse plaque psoriasis, possibly through impaired emotional regulation. Several physiological mechanisms involving the neuroendocrine and the immune system might mediate the interplay between stress, personality, and diffuse plaque psoriasis.
Abstract: Despite being common, depression often goes undetected in patients with skin diseases. Our aim was to examine and compare the performance of three depression screeners. We studied dermatological inpatients aged 18-65 years. They completed the questionnaires Primary Care Screener for Affective Disorders (PC-SAD), Patient Health Questionnaire (PHQ) and General Health Questionnaire (GHQ-12) and were administered a standardized psychiatric interview (SCID-I) by a mental health professional, who was unaware of the questionnaire answers. The analysis was performed on 141 patients with complete data (79% of all eligible patients, 89% of all patients who agreed to participate). The prevalence of the main forms of depression, major depressive disorder and dysthymic disorder, was 8.4% and 6.3%, respectively. For major depressive disorder, the sensitivity and specificity of the questionnaires were as follows: PC-SAD, 73% and 88%; PHQ, 55% and 91%; GHQ-12, 73% and 78%. For dysthymic disorder, the sensitivity and specificity were as follows: PC-SAD, 56% and 95%; PHQ, 44% and 90%; GHQ-12, 56% and 76%. The small sample size suggests caution in drawing conclusions about the relative merits of these screeners. Although both the GHQ and the PHQ are short and easily hand scored, the first is a generic screener for psychiatric morbidity that is not specific for depression, while the second displayed modest sensitivity. The PC-SAD, with short average administration time, acceptable sensitivity and high specificity, might be particularly useful in settings where the technology for computer automated scoring is available. Although screening programmes might be useful, they should be supplemented by quality improvement programmes and by the development of consultation-liaison services.
Abstract: Although mental disorders are frequent among dermatological patients, little is known about their recognition by dermatologists. This study aimed to assess dermatologists' ability to recognize depressive and anxiety disorders. All adult outpatients who visited four dermatologists on predetermined days (n=317) completed the 12-item General Health Questionnaire (GHQ-12) and the section on depressive and anxiety disorders of the Patient Health Questionnaire (PHQ). Dermatologists, masked to GHQ-12 and PHQ scores, rated patients' mental health status. The analysis was performed on 277 patients (87%) with complete data. With the PHQ as criterion standard, the dermatologists' assessment sensitivity was 33%, while specificity was 76%. In most cases of disagreement between the dermatologists and the PHQ, the GHQ-12 corroborated the PHQ classification. Anxiety disorders tended to be recognized better than depressive disorders. Among patients with a PHQ diagnosis, male gender tended to be associated with misclassification by dermatologists. Although limitations inherent in self-report psychiatric assessment should be considered, this study suggests that mental disorders often go unrecognized in dermatological patients. This issue might be addressed by implementing specific training programmes, using validated screening questionnaires for depression and anxiety, and developing rational consultation-liaison services.
Abstract: Current psychiatric classification systems underestimate the part played by anger and aggressiveness in unipolar depression. This study was designed to assess the relevance of anger, irritability, aggressiveness, hostility, and psychomotor activation in major depressive disorder.
Abstract: The aims of this study are: (1) to estimate patients' costs in Italian non hospital Residential Facilities (RF); (2) to analyse the relationship between the costs of care received by residents and patients' or facilities characteristics.
Abstract: Although psychiatric disorders are frequent among dermatological patients, no study has formally assessed the performance of any psychiatric screening questionnaire in dermatological practice. This study tested the ability of the 12-item General Health Questionnaire (GHQ-12) to identify psychiatric morbidity in dermatological patients.
Abstract: Measuring patient satisfaction is regarded as one of the principal methods for obtaining patients' evaluation of services they receive. During the last decades more interest has been devoted to inpatients' preferences and needs. Surveys on patient satisfaction may provide information to hospitals about areas where improvement is needed. In this survey, 648 questionnaires were completed by dermatological inpatients and were analyzed for overall satisfaction and seven satisfaction determinants. Background factors and clinical parameters were considered. Emotional support was recognized as a critical area. "Coordination of care" and "information and education" were identified as the most relevant determinants for overall patient satisfaction. The Hospital Management, taking into account the results, planned training in order to improve personnel's communication skills. This study confirms that patient satisfaction analysis is a useful instrument also among dermatological inpatients, and satisfaction is a valid measure of quality of health care.
Abstract: Many short-term trials suggested that the combination of psychotherapy with medication might be more effective than either treatment alone. However, only few studies examined the long-term effectiveness of this combination.
Abstract: Although various surveys on job satisfaction have been performed in mental health care settings, no studies have investigated in-depth the level of satisfaction with the various aspects of work in Italian mental health services. In the present study, all clinical mental health staff working in a large psychiatric catchment area in Rome were invited to anonymously complete a previously validated questionnaire designed to measure job satisfaction among mental health professionals. Of the total 236 health professionals, 196 (83%) agreed to participate. Most participants were not completely satisfied with many aspects of their job, and many were not even moderately satisfied. The level of satisfaction increased with age, and it was significantly lower among hospital-ward staff compared to the staff of outpatient clinics or residential facilities, even after adjusting for age, gender, profession, work setting, and time in current job, using a multiple logistic regression model. Our findings suggest that interventions aimed at increasing job satisfaction among Italian mental health professionals might be warranted, particularly among hospital-ward staff.
Abstract: Quality of life is increasingly recognized as an important outcome measure in dermatology. The Dermatology Life Quality Index (DLQI) is a self-administered questionnaire designed to measure the impact of skin diseases on patients' quality of life.
Abstract: Epidemiological studies have shown that the prevalence of psychiatric disorders among dermatological patients is high. We aimed at estimating the short-term incidence of psychiatric disorders among patients with skin disease.
Abstract: Although the onset of alopecia areata has often been anecdotally linked with emotional stress, findings from the few controlled studies have not been univocal. The authors compared outpatients experiencing a recent onset of alopecia areata (N=21) with outpatients affected by skin conditions commonly believed as having a low psychosomatic component (N=102). Participants were administered Paykel's Interview for Recent Life Events, the Experiences in Close Relationships scale, the 20-item Toronto Alexithymia Scale, and the Multidimensional Scale of Perceived Social Support. Multiple logistic regression was used to control for age and gender. The total number of recent life events (last 12 months) was not different between the alopecia patients and the comparison subjects. Also, the alopecia patients and the comparison subjects did not differ in terms of the number of undesirable or major events. The comparison subjects even experienced a greater number of uncontrollable events. Alopecia areata tended to be associated with high avoidance in attachment relationships, high alexithymic characteristics, and poor social support. The results suggest that personality characteristics might modulate individual susceptibility to alopecia areata.
Abstract: It has often been suggested that stress might trigger vitiligo. However, only one study supported this hypothesis, and no study explored the role of other personality or social factors.
Abstract: Research data suggest that the detection of psychiatric disorders by dermatologists is not completely satisfactory, and that patients and dermatologists often assess patients' quality of life differently. Given that expectations influence perception and cognitia, these discrepancies might at least in part descend from conceptual models of skin disease that are prevalent among dermatologists.
Abstract: Quality of life is increasingly recognized as an important measure in dermatology. The Skindex-29 is a self-administered questionnaire recently developed to measure comprehensively the complex effects of skin diseases on patients' quality of life.
Abstract: In Italy, where all mental hospitals have been gradually phased out since 1978, psychiatric patients requiring long-term care are being treated in non-hospital residential facilities (NHRFs). However, detailed data on these facilities are sparse.
Abstract: To assess the effectiveness of a behavioural group intervention for smoking cessation, which included as its most original feature the recommendation to participate with a relative or close friend.
Abstract: To assess the satisfaction of patients and their relatives with psychiatric care and to identify variables associated with any dissatisfaction.
Abstract: To test the hypothesis that not only intrafamiliar childhood abuses inflicted to the patient, but also major losses or other severe life events suffered by the mother within 2 years of patient's birth, are risk factors for the development of dissociative disorders (DDs).
Abstract: Agreement on the factor structure of the Hamilton Depression Rating Scale (HDRS) has not been consistent among studies, and some investigators argued that the scale's factor structure is not reliable. This study aimed at shedding more light on this debated issue.
Abstract: It has been shown that poor patient satisfaction can lead to poor adherence to treatment with consequently poor health outcomes. In order to improve the quality of care perceived by the patient and thus the health outcome, it is important to understand which are the main factors influencing patient satisfaction.
Abstract: Psychiatric disorders are frequent among patients with skin diseases. We aimed at identifying factors associated with psychiatric morbidity in dermatological outpatients. All adults attending the outpatient clinics of a dermatological hospital on predetermined days were given the 12-item General Health Questionnaire. The dermatologists indicated the diagnosis and location of skin lesions and rated the disease severity. A total of 1389 patients were asked to take part in the study. Of the 722 who accepted, 389 had a complete set of data and were included in the analysis. To verify the representativeness of our sample, we used the administrative registries to compare participants with the total population of patients who attended the clinics during the same period, and we examined the distribution of missing data. There was a tendency towards a younger age in the sample studied, but no evidence of substantial selection bias. The prevalence of psychiatric morbidity was 20.6%. We found higher probability of psychiatric disorders in women, controlling for age, clinical severity and localization of lesions. In women, but not in men, the prevalence of psychiatric morbidity was higher in patients with lesions on the face or hands. Given that the identification and appropriate management of psychiatric morbidity are important, it seems that the dermatologist should be particularly alert to the possibility of a concurrent psychiatric disorder in women with lesions on the face or hands.
Abstract: The possibility of a causal influence of emotional stress, especially of stressful life events, on the course of various skin diseases has long been postulated. Clinical wisdom and experience, as well as many anecdotal observations and uncontrolled case series, support this opinion. We reviewed the available evidence on the role of stressful life events in triggering or exacerbating skin diseases. The role of stressful events in vitiligo, lichen planus, acne, pemphigus and seborrhoeic dermatitis was either controversial or insufficiently explored. The role of stressful events in psoriasis, alopecia areata, atopic dermatitis and urticaria was apparently clearer. However, only a few studies met acceptable methodological standards for stress measurement. Also, few studies considered common potential confounding factors (e.g. age, duration of illness, familial factors), and no study controlled adequately for the influence of other crucial factors (e.g. discontinuation of treatment, seasonal effects). Adding that the large majority of studies were retrospective, it seems wise to conclude that only preliminary evidence has been published so far on the role of stressful life events in bringing on or worsening any dermatological disease. Further research is mandatory, either in the form of prospective studies or, more feasibly, of well-designed case-control studies with adequate statistical power. Future studies should also pay more attention to protective as well as vulnerability factors in stressful events. Further, it would be important to investigate other sources of psychological stress, such as chronic stress and everyday stress. Measuring stress appraisal, although difficult, would also be important.
Abstract: Our aim was to deepen the understanding of the psychosomatic aspects of temporomandibular joint (TMJ) pain dysfunction syndrome. Patients affected by this syndrome were compared with both healthy subjects and psychiatric patients, using both self-report and physician-scored psychological measures.
Abstract: This paper reviews experimental contributions published in the last two decades and exploring the effect of emotional stress on neuroendocrine function in healthy humans. Laboratory studies allow standardization of the stressor and better control for known confounding factors. Commonly used stressors are mental arithmetics, speech tasks, the Stroop test, videogame playing, films or videotapes and interviews. Little is known about the generalizability of laboratory results, with some studies suggesting great caution in extrapolating data to real-life stress conditions. Another strategy is studying the psychoendocrine reaction to real-life stressors, such as bereavement or anticipated loss, academic examinations, everyday work and parachute jumping. The effects of different stressors on neuroendocrine axes are reviewed, as well as the influence of gender, age, personality, coping style, social support, biological and nonbiological interventions. The subjective perception of the situation is probably a main determinant of the psychoendocrine response pattern. In fact, marked variability in individual responses to a variety of stressors has frequently been observed. Evidently, the 'objective' characteristics of a given event are not the only determinants of reaction to the event itself. According to a constructivistic perspective, every given stressor has a strictly personal and idiosyncratic meaning and loses its 'objective' characteristics. Of course, biological factors may also play a part. In any case, it is mandatory to overcome a rigid dichotomy between psychological and biological processes. Dualistic conceptions which imply a determination of the physical by the psychological or vice versa should give place to a systemic conception, which implies mutual, circular interactions.
Abstract: Loss and bereavement can be regarded as risk factors for the development of psychiatric and medical illness. Vulnerability to physical illness and mortality are increased during the first 2 years of bereavement, with men at higher risk than women. Symptoms of anxiety and a frank depressive syndrome are common during the first months of bereavement and, although depressive symptoms are usually transient and self-limited, bereaved individuals not rarely go on to develop major depression. In our perspective, loss perceived as irreparable, and persistence of perceived loss may favour the development of complicated grief and depression. Factors such as unexpectedness, absence of social support, concurrent loss or illness, and grief proneness may predict poor adjustment after bereavement. Complicated bereavement should be distinguished from uncomplicated bereavement, because patients with the latter need no treatment. In humans, there is evidence of increased adrenocortical activity and altered immune function following bereavement, whereas in non-human primates, biogenic amine systems appear to be involved in the response to maternal or social separation. According to a 'psychosomatic view of the brain', critical life events can both affect brain neurotransmitters and contribute to psychological and somatic symptoms of depression. Emotional events may be transduced into long-lasting brain changes, involving neurotransmitters, neuropeptides and receptors. Although only very limited evidence exists, long-term consequences could involve changes at the gene expression level.
Abstract: Growth hormone (GH) and prolactin (PRL) responses to the acute administration of clonidine (150 micrograms) and apomorphine (0.5 mg) were investigated in parallel in 20 drug-free subchronic and chronic schizophrenic patients and in nine control subjects. Neither basal levels of the two hormones nor their mean responses to both stimuli differed significantly between the two groups. However, eight patients had blunted GH responses to clonidine and seven to apomorphine; only two patients showed blunted GH responses to both stimuli. The blunted GH response to apomorphine correlated with the chronicity of the disorder. A greater than normal GH response to clonidine stimulation was observed in paranoid patients. Significant correlations were observed between negative symptoms and GH responses to clonidine (negative), between negative symptoms and PRL responses to apomorphine (positive), and between positive symptoms and PRL responses to apomorphine (negative).
Abstract: It is common opinion that temporomandibular joint pain-dysfunction (TMJPD) syndrome and bruxism have a major psychosomatic component. In this paper, we try to review these entities in an integrated manner, taking into account both medical and psychological aspects. Two etiological models have been developed: the structural model emphasizes the role played by malocclusion or alterations of the maxillomandibular relationship, while the functional model underscores the role of stress, emotional tension, and personality characteristics. In TMJPD and bruxist patients a careful physical and psychological examination has to be performed. The classical dental treatment is based on equilibration procedures, prostheses and drugs. Treatment strategy can also be based on psychotherapeutic and relaxation treatments; in this respect, the use of EMG biofeedback training has been subjected to intense study.
