Carlo Faravelli

Epidemiology of somatoform disorders: a community survey in Florence

Since the exclusion of somatic causes is necessary for somatoform disorders (SMD) to be diagnosed, there is little information on the prevalence of such disorders in the community. As the method we have previously developed [general practitioners (GPs) with psychiatric training who interview samples representative of the general population] seemed to be appropriate to deal with the problem, we carried out a community survey focused on somatoform disorders. The prevalence rates of DSM-III-R somatoform disorders were studied in two wards of the city of Florence. In order to be representative of the general population, 673 subjects randomly selected were interviewed by their own GP. Four GPs, all with specific training in psychiatry, participated in the interviewing process. The 1-year prevalence figures were as follows: 0.7% body dysmorphic disorder; 4.5% hypochondriasis; 0.6% somatoform pain disorder; 0.3% conversion disorder; 0.7% somatization disorder; 13.8% undifferentiated somatoform disorder. No specific comorbidity was found between somatoform disorders and mood or anxiety disorders. Although the sample investigated was small, this study may be seen as one of the first in an area where knowledge is still scant. The prevalence rates of somatoform disorders were generally found to be slightly lower than expected.

The epidemiology of panic disorder and agoraphobia in Europe

A literature search, in addition to expert survey, was performed to estimate the size and burden of panic disorder in the European Union (EU). Epidemiologic data from EU countries were critically reviewed to determine the consistency of prevalence estimates across studies and to identify the most pressing questions for future research. A comprehensive literature search focusing on epidemiological studies in community and clinical settings in European countries since 1980 was conducted (Medline, Web of Science, Psychinfo). Only studies using established diagnostic instruments on the basis of DSM-III-R or DSM-IV, or ICD-10 were considered. Thirteen studies from a total of 14 countries were identified. Epidemiological findings are relatively consistent across the EU. The 12-month prevalence of panic disorder and agoraphobia without history of panic were estimated to be 1.8% (0.7-2.2) and 1.3% (0.7-2.0) respectively across studies. Rates are twice as high in females and age of first onset for both disorders is in adolescence or early adulthood. In addition to comorbidity with agoraphobia, panic disorder is strongly associated with other anxiety disorders, and a wide range of somatoform, affective and substance use disorders. Even subclinical forms of panic disorder (i.e., panic attacks) are associated with substantial distress, psychiatric comorbidity and functional impairment. In general health primary care settings, there appears to be substantial underdiagnosis and undertreatment of panic disorder. Moreover, panic disorder and agoraphobia are poorly recognized and rarely treated in mental health settings, despite high health care utilization rates and substantial long-term disability.

Stress, hypothalamic-pituitary-adrenal axis and eating disorders.

The etiopathogenesis of eating disorders (ED) is complex and poorly understood. Biological, psychological and environmental factors have all been considered to be involved in the onset and the persistence of these syndromes, often with conflicting results. The recent literature focused on the possible role of hormonal pathways, in particular the hypothalamic-pituitary-adrenal (HPA) axis, as a relevant factor capable of influencing the onset and the course of ED. Other studies have suggested that the onset of ED is often preceded by severe life events, and that chronic stress is associated with the persistence of these disorders. As the biological response to stress is the activation of the HPA axis, the available literature considering the relationships between stress, HPA axis functioning and anorexia nervosa, bulimia nervosa and binge eating disorder is reviewed by the present article.

Psychopathological and clinical features of outpatients with an eating disorder not otherwise specified

In order to investigate similarities and differences between Eating Disorder Not Otherwise Specified (EDNOS) and Anorexia Nervosa (AN) and Bulimia Nervosa (BN), we studied a consecutive series of 189 female outpatients attending two Eating Disorder Units. The data were collected by means of interviews (Eating Disorder Examination, EDE 12.0D), the Structured Diagnostic Interview for DSM III-R, (SCID), and self-reported questionnaires (Beck Depression Inventory, BDI, and State and Trait Anxiety Inventory, STAI 1–2). The diagnosis of EDNOS was as frequent as that of AN and BN (43.8% versus 43.2%). There were no significant differences between EDNOS and AN/BN patients in terms of their general and specific psychopathological features, but significant differences were observed between bulimic-like and anorectic-like EDNOS patìents, as well as between those with AN and BN. In conclusion, in our clinical setting, the patients with EDNOS and those with typical eating disorders have similar psychopathological features, thus suggesting that EDNOS patients should be further divided into two groups, anorectic-like (similar to AN) and bulimic-like (similar to BN) patients.

Brain perfusion abnormalities in drug-naive, lactate-sensitive panic patients: A SPECT study

Using single photon emission computed tomography (SPECT) and 99mTc-hexamethylpropyleneamine oxime (HM-PAO), we assessed brain perfusion in seven patients with panic disorder (PD) and in five age-matched normal subjects at rest. No patient had ever received drug treatment for panic. All patients were sensitive to lactate-induced panic. Computed tomography (CT) scans did not reveal any morphological abnormalities of the brain in any of the PD patients. Two indices of cerebral perfusion were calculated; these demonstrated alterations of brain perfusion in the PD group. Significant right-left asymmetry was found in the inferior frontal cortex of the PD patients. We also observed a significant blood flow increase in the left occipital cortex and a significant decrease in the hippocampal regions bilaterally. Although the changes seen in the inferior frontal cortex and occipital cortex may be related to anxiety experienced by the patients during the study, the pattern of hippocampal hypoperfusion appears to be characteristic of panic disorder. This suggests that the hippocampal structures may play an important role in the pathophysiology of panic disorder.

Epidemiology of anxiety disorders in Florence

ABSTRACT– A structured interview designed to diagnose anxiety disorders according to DSM‐III (plus infrequent panic attacks and generalized anxiety disorder using DSM‐III‐R criteria) was given to 1110 people registered with 6 general practitioners (CPs), whether they consulted the doctor or not. As each citizen in Italy has to be registered with a GP, the sample was representative of the population. The interviews were carried out by the GPs, who were also third‐ or fourth‐year trainees in psychiatry. The lifetime prevalence and point prevalence were: 0.36% and 0.27% for agoraphobia; 0.90% and 0.72% for agoraphobia with panic; 1.35% and 0.27% for panic disorder; 0.63% and 0.45% for simple phobia; 0.49% and 45% for social phobia, 5.41% and 2.79% for generalized anxiety disorder; and 0.72% and 0.63% for obsessive‐compulsive disorder. These figures are lower than those reported in other surveys; possible explanations may be the use of a hierarchical diagnostic model and the fact that diagnosticians were psychiatrists instead of lay interviewers as in most studies in the United States. On the whole, 62% of anxiety cases consult a GP, 50% consult a psychiatrist and 7% are hospitalized.

Life events preceding the onset of panic disorder

The life events experienced in the 12 months prior to the first panic attack were studied in 23 patients with a DSM-III diagnosis of panic disorder as well as in 23 healthy subjects matched for age, sex, social and educational level. Patients showed significant excess of life events compared to controls, however life events were assessed. Panic patients in fact scored higher on the number of events, the weighted scores (according to Paykels scale) and the number of subjects who underwent a major life event (death or severe illness, either personal or of a cohabiting relative) in the two months preceding the onset of symptoms.

Diagnostic crossover and outcome predictors in eating disorders according to DSM-IV and DSM-V proposed criteria: a 6-year follow-up study.

Objective: To evaluate in a 6-year follow-up study the course of a large clinical sample of patients with eating disorders (EDs) who were treated with individual cognitive behavior therapy. The diagnostic crossover, recovery, and relapses were assessed, applying both Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and the DSM-V proposed criteria. Patients with EDs move in and out of illness states over time, display frequent relapses, show a relevant lifetime psychiatric comorbidity, and migrate between different diagnoses. Method: A total of 793 patients (including anorexia nervosa, bulimia nervosa, binge eating disorder, and EDs not otherwise specified) were evaluated on the first day of admission, at the end of treatment, 3 years after the end of treatment, and 3 years after the first follow-up. Clinical data were collected through a face-to-face interview; diagnosis was performed by means of the Structured Clinical Interview for DSM-IV and the Eating Disorder Examination Questionnaire was applied. Results: A consistent rate of relapse and crossover between the different diagnoses over time was observed. Mood disorders comorbidity has been found to be an important determinant of diagnostic instability, whereas the severity of shape concern represented a relevant outcome modifier. Using the DSM-V proposed criteria, most patients of EDs not otherwise specified were reclassified, so that the large majority of ED patients seeking treatment would be included in full-blown diagnoses. Conclusions: Among EDs, there are different subgroups of patients displaying various courses and outcomes. The diagnostic instability involves the large majority of patients. An integration of categorical and dimensional approaches could improve the psychopathological investigation and the treatment choices. AN = anorexia nervosa; BED = binge eating disorder; BMI = body mass index; BN = bulimia nervosa; CBT = cognitive behavior therapy; DSM = Diagnostic and Statistical Manual of Mental Disorders; EDs = eating disorders; EDE 12.0D = Eating Disorder Examination Interview; EDNOS = eating disorders not otherwise specified; EDNOS-A = eating disorders not otherwise specified Anorectic type; EDNOS-B = eating disorders not otherwise specified Bulimic type; OBEs = objective binge episodes; SBEs = subjective binge episodes; s-BED = subthreshold BED.

ORIGINAL RESEARCH–EPIDEMIOLOGY: Selective Serotonin Reuptake Inhibitor-Induced Sexual Dysfunction

INTRODUCTION Sexual dysfunctions are often present in subjects with mood disturbances; however. antidepressants can induce per se sexual dysfunctions. AIM To explore the relationship between the use of selective serotonin reuptake inhibitors (SSRIs), non-SSRIs antidepressants and benzodiazepines (BDZ), hormonal parameters, and reported sexual dysfunction (as assessed by the Structured Interview on Erectile Dysfunction [SIEDY]) in male subjects with comparable psychopathological symptoms (as assessed by the Middlesex Hospital Questionnaire [MHQ] a self-reported test for the screening of mental disorders in a non-psychiatric setting). METHODS A consecutive series of 2,040 (mean age 51 +/- 13 years) male patients with sexual dysfunction was studied. MAIN OUTCOME MEASURES Several hormonal and biochemical parameters were investigated, along with SIEDY and the MHQ. RESULTS Higher prolactin was observed only in patients using SSRIs, whereas no other hormonal difference was found after adjustment for confounders. Use of SSRIs was associated with a twofold risk for patient hypoactive sexual desire and with a higher impairment of reported erectile function. However, no difference in penile blood flow was observed. A very high risk (sevenfold) for delayed ejaculation (DE) was observed in SSRI users. Interestingly, the association with the mild, but not severe, form of DE was observed also in subjects using non-SSRI antidepressants (3.35 [1.48-7.59]; P < 0.005). Different life stressors and relational parameters were also associated with SSRI use. SSRI users reported less enjoyment with masturbation and decreased partner desire and climax. Conversely, a lack of significant association was observed among BDZ or non-SSRI antidepressant users and all the aforementioned life-stressors and relational parameters. CONCLUSIONS SSRIs can negatively affect all the steps of the male sexual response cycle (desire-arousal-excitement-orgasm). SSRI-associated sexual dysfunction has a deleterious effect on both auto- and couple-erotic performances. Conversely, other antidepressants and BDZ are less often associated with sexual impairment.

Epidemiology of mood disorders : a community survey in Florence

A structured interview designed to detect affective disorders and to produce both DSM-III and DSM-III-R diagnoses was administered to a community sample of 1000 people living in Florence. The interviews were carried out by physician-psychiatrists (qualified psychiatrists or 3rd-4th-year trainees) trained in the use of operational diagnoses. The 1-year prevalence and point prevalence were, respectively: 1.7% and 0.6% for bipolar disorder; 0.4% and 0.4% for cyclothymia; 6.2% and 2.8% for major depression; 2.6% and 0.8% for dysthymia; 5.2% and 1.8% for depressive disorder not otherwise specified. Most of the cases affected by mood disorder sought medical help, primarily through their GP. The large majority of them were specifically treated for it and, in almost 60% of the cases with a major form, were referred to a psychiatrist.