Carlotta Belaise

Childhood abuse and later medical disorders in women. An epidemiological study.

Background: There have been many studies documenting adverse psychiatric consequences for people who have experienced childhood and adult sexual and physical abuse. These include posttraumatic stress disorder, anxiety, depression, substance abuse, eating disorders and probably some personality disorders or trait abnormalities. Much less is known about the links between abuse and physical/psychosomatic conditions in adult life. Hints of causal links are evident in the literature discussing headache, lower back pain, pelvic pain and irritable bowel syndrome. These studies are not definitive as they use clinic-based samples. Methods: This study used interview data with a random community sample of New Zealand women, half of whom reported childhood sexual abuse and half who did not. Details about childhood physical abuse and adult abuse were also collected in a two-phase study. Results: Complex relationships were found, as abuses tended to co-occur. Seven of 18 potentially relevant medical conditions emerged as significantly increased in women with one or more types of abuse. These were chronic fatigue, bladder problems, headache including migraine, asthma, diabetes and heart problems. Several of these associations with abuse are previously unreported. Conclusions: In this random community sample, a number of chronic physical conditions were found more often in women who reported different types of sexual and physical abuse, both in childhood and in adult life. The causal relationships cannot be studied in a cross-sectional retrospective design, but immature coping strategies and increased rates of dissociation appeared important only in chronic fatigue and headache, suggesting that these are not part of the causal pathway between abuse experiences and the other later physical health problems. This finding and the low co-occurrence of the identified physical conditions suggest relative specificity rather than a general vulnerability to psychosomatic conditions in women who have suffered abuses. Each condition may require separate further study.

The concept of recovery in major depression

BACKGROUND There is increasing literature on the unsatisfactory degree of remission that current therapeutic strategies yield in unipolar depression. The aims of this review were to survey the available literature on residual symptoms of depression, to introduce new targets for therapy and to outline a more stringent definition of recovery. METHOD Studies were identified by using MEDLINE (English language articles published from 1967 to June 2006; keywords: recovery, remission, residual symptoms, sequential treatment, drugs and psychotherapy, related to depressive disorder and depression) and a manual search of the literature and Index Medicus for the years 1960-2006. RESULTS Most patients report residual symptoms despite apparently successful treatment. Residual symptoms upon remission have a strong prognostic value. There appears to be a relationship between residual and prodromal symptomatology. The concept of recovery should involve psychological well-being. CONCLUSIONS Appraisal of subclinical symptomatology in depression has important implications for pathophysiological models of disease and relapse prevention. New therapeutic strategies for improving the level of remission, such as treatment on residual symptoms that progress to become prodromes of relapse, may yield more lasting benefits.

Well-Being Therapy in School Settings: A Pilot Study

Background: There is increasing interest in the psychobiological mechanisms of resilience and psychological well-being. It is conceivable that activation of such mechanisms in the school setting may entail long-term benefits, both in terms of the developmental process and of prevention of distress. This study wants to apply and test the efficacy of a school-based intervention protocol derived from well-being therapy (WBT) compared to cognitive-behavioral strategies. Methods: School interventions were performed in a population of 111 students randomly assigned to: (a) a protocol using theories and techniques derived from cognitive-behavioral therapy; (b) a protocol derived from WBT. Assessment before and after interventions was performed using two self-rating scales: Kellner’s Symptom Questionnaire and Ryff’s Psychological Well-Being Scales. Results: Both school-based interventions resulted in a comparable improvement in symptoms and psychological well-being. Conclusions: This new well-being-enhancing strategy could play an important role in the prevention of psychological distress in school settings and in promoting optimal human functioning among children.

School intervention for promoting psychological well-being in adolescence

OBJECTIVE to test the efficacy of a new school program for the promotion of psychological well-being. In this study a school program for promoting psychological well-being has been compared to an attention-placebo intervention in a high school setting. METHODS Nine classes (227 students) were randomly assigned to: a) Well-Being intervention (5 classes); b)attention-placebo (4 classes). Assessment was performed at pre and post-intervention, and after six months using: 1) Symptom Questionnaire (SQ); 2) Psychological Well-Being Scales (PWB); 3) Revised Childrens Manifest Anxiety Scale (RCMAS). RESULTS A significant effect of WB school intervention in improving Personal Growth (PWB), and in decreasing distress (Somatization (SQ), Physical Well-being (SQ), Anxiety (SQ), and RCMAS Physiological Anxiety) emerged. CONCLUSIONS A school intervention based on promoting positive emotions and well-being was effective not only in increasing psychological well-being among adolescents, but also in decreasing distress, in particular anxiety and somatization.

Alternatives to Debriefing and Modifications to Cognitive Behavior Therapy for Posttraumatic Stress Disorder

Background: Psychological debriefing uses brief unsystematic exposure, and is ineffective for posttraumatic stress symptoms and disorder. Systematic exposure alone and cognitive restructuring alone are each effective. Other approaches too may be useful. Methods: The treatment of 3 posttraumatic stress disorder (PTSD) patients is detailed in which there was no exposure to the main traumatic event.There was exposure to related cues in case 1, exposure to related and other cues followed by well-being therapy (WBT) in case 2 and WBT in case 3. Results: The 3 patients improved enduringly, confirming earlier findings that exposure to the main trauma is not essential for PTSD to improve. Conclusions: A study is needed of therapeutic mechanisms in PTSD and of the value of WBT in a randomized controlled trial.

Differential effects of well-being promoting and anxiety-management strategies in a non-clinical school setting

The aim of the present study was to examine the differential effects of strategies for promotion of psychological well-being (Well-Being Therapy, WBT) and removal of distress (Anxiety Management, AM) in a non-clinical school setting.162 students attending middle schools in Northern Italy were randomly assigned to: (a) a protocol derived from WBT; (b) an anxiety-management protocol (AM). The students were assessed immediately before and after the interventions, and after 6 months using: Psychological Well-Being Scales (PWB), Symptom Questionnaire (SQ) and the Revised Childrens Manifest Anxiety Scale (RCMAS). In school children, well-being and symptom focused interventions produced slightly different effects on psychological dimensions. WBT, by facilitating progression toward positive and optimal functioning, may integrate symptom-centered strategies.

Promoting resilience and psychological well-being in vulnerable life stages.

vices, even in high-income countries [16] ; t he majority of young people with mental health problems are still not getting the help they need. A major reason for this is the worldwide gaps in child and adolescent mental health policy and services well identified by the World Health Organization through its Atlas project [17] . T he degree of coverage and quality of mental health services for the youths are generally worse compared with the ones pro-vided for adults [18] . Little information is now available about health and social investment into child and ad-olescent mental well-being. However, as denounced in the Florence Declaration – developed during the 13thEuropean Society for Child and Adolescent Psychiatry (ESCAP) Congress and signed by WHO and by EACAP (European Academy for Child and Adolescent Psychia-try) – as regards Europe, all indicators strongly suggest that child and adolescent mental health in most countries is receiving a relatively small proportion of funding, with, in turn, a typically low investment for general health, on average only 5.6% (see appendix). The median percentage of governments’ health budget earmarked for mental health is as little as 1% in low income countries [19] T . he gap is not limited to the quantity, as the quality of ser-vices is often extremely poor, even in high income coun-tries [19] . Nevertheless, the mental well-being of children still remains a major public health priority and a prominent area of international debate. Scientists and researchers from all over the world are focusing on how to improve Mental health and emotional and psychological well-being are fundamental for all children, enabling them to meet their potential, to experience life as meaningful and to be active citizens. Unfortunately, current estimates indicate that at least one out of every four to five young people in the general population will suffer from at least one mental disorder in any given year [1] . Similar data have been previously reported by WHO, showing that worldwide up to 20% of children and adolescents suffer from a mental illness with at least mild functional impairment: one adolescent in five has behavioural, cognitive and emotional difficul-ties and one adolescent in eight suffers from a mental dis-order [2]. C omorbidity is very common and can occur at three levels: with other mental disorders, with substance abuse and with chronic diseases [1] . Developmental psychiatric disorders rarely have a spontaneous remission and may cause difficulties in so-cial adaptation or mental disorders in adult life [3–12] . There is evidence that adult mental disorders usually be-gin during youth [13, 14] , although they are often first detected later in life [1] . Besides personal suffering, stigma and discrimina-tion, mental disorders may have a high social impact, in terms of treatment and support costs, reduced or lost pro-ductivity, and the expenditure of criminal justice (e.g. conduct and behavioural disorders) [15] . De spite these data, only a minority of vulnerable chil-dren and adolescents have access to mental health ser-

Psychosomatic medicine is a comprehensive field, not a synonym for consultation liaison psychiatry.

There is controversy surrounding the term psychosomatic. If it is used as an equivalent of consultation liaison psychiatry, there is little justification for retaining it. Psychosomatic medicine, however, may be defined as a comprehensive interdisciplinary framework for the assessment of psychosocial factors affecting individual vulnerability, course, and outcome of any type of disease; holistic consideration of patient care in clinical practice; and integration of psychological therapies in the prevention, treatment, and rehabilitation of medical disease. Psychosomatic medicine has developed several clinimetric tools for assessing psychosocial variables in the setting of medical disease and has raised the need for specific evaluations in medical assessment. The term psychosomatic medicine today seems to be more timely than ever and provides a home for innovative and integrative thinking at the interface of behavioral and medical sciences.

Patient Online Report of Selective Serotonin Reuptake Inhibitor-Induced Persistent Postwithdrawal Anxiety and Mood Disorders

In general, most studies have looked only at minor new symptoms of the CNS depressant withdrawal type [6] , but there are some exceptions which examined SSRI postwithdrawal emergent persistent disorders [7–9] . In the present study, we looked at both new SSRI withdrawal symptoms [6] and postwithdrawal persistent symptoms. Between February 2010 and September 2010, qualitative Google searches of 8 websites including Paxilprogress.org, ehealthforum.com, depressionforums.org, about.com, medhelp. org, drugLib.com, topix.com and survigingantidepressant.org were carried out in English, using keywords as ‘SSRIs withdrawal syndrome’, ‘Paxil withdrawal’, ‘SSRIs forums’. Links from the above websites/forums and other related material were also followed. In table 1 , we list selected online patient self-reporting of physical and psychiatric withdrawal symptoms for each of the 6 SSRIs: paroxetine (n = 3), sertraline (n = 2), citalopram (n = 2), fluoxetine (n = 1), fluvoxamine (n = 1) and escitalopram (n = 3), which we thought reflected best patient self-reporting of SSRI withdrawal symptoms. From online information available, gender is known for 4 patients (2 men and 2 women), the mean length of SSRI treatment (n = 9) was 5.13 years, range 0.25–15 years, median 4.5, and the mean duration of withdrawal symptoms (n = 7) was 2.5 years, range 0.125–6 years, median 2.1 years. As can be seen in table 1 , 58% of patients (7 out of 12) reported persistent postwithdrawal symptoms: 3 of 3 paroxetine patients, 2 of 2 citalopram, 1 of 1 fluvoxamine, 1 of 3 escitalopram and none of both sertraline and fluoxetine patients. We note in table 1 , persistent postwithdrawal disorders, which occur after 6 weeks of drug withdrawal, rarely disappear spontaneously, and are sufficiently severe and disabling to have patients returned to previous drug treatment. When their drug treatment is not restarted, postwithdrawal disorders may last several months to years. Significant persistent postwithdrawal emergent symptoms noted consist of anxiety disorders, including generalized anxiety and panic attacks, tardive insomnia, and depressive disorders including major depression and bipolar illness. Anxiety, disturbed mood, depression, mood swings, emotional liability, persistent insomnia, irritability, poor stress tolerance, impaired concentration and impaired memory are the more frequent postwithdrawal symptoms reported online. In the Fava et al. [8] gradual SSRI discontinuation controlled study on panic disorders, 9 of 20 patients (45%) had new withdrawal symptoms and 3 of the 9 (33%) paroxetinetreated patients had persistent emergent postwithdrawal disorders, consisting of bipolar spectrum disorder (n = 2) and major depressive disorder (n = 1) during a 1-year postwithdrawal fol low-up. Recently, Schifano et al. [1] analyzed online self-reporting of misuse of pregabalin, and found psychedelic dissociative effects induced by pregabalin in this selected population of drug abusers, information that apparently can only be obtained at least initially through online self-reporting studies [1] . In the present study, we analyze online self-reporting from a variety of websites visited by patients who had discontinued selective serotonin reuptake inhibitor (SSRI) antidepressants and were reporting, spontaneously on those internet forums, significant withdrawal symptoms and postwithdrawal psychopathology, that they attributed to discontinuation of their SSRI antidepressants. SSRI withdrawal, like for other classes of CNS depressant type (alcohol, benzodiazepine, barbituric, narcotic, antipsychotic, antidepressant), needs to be divided into two phases: the immediate withdrawal phase consisting of new and rebound symptoms, occurring up to 6 weeks after drug withdrawal, depending on the drug elimination half-life [2, 3] , and the postwithdrawal phase, consisting of tardive receptor supersensitivity disorders, occurring after 6 weeks of drug withdrawal [4] . One example of self-reporting new withdrawal symptoms of the CNS depressant type is the publication by Shoenberger [5] , which described new withdrawal symptoms (headaches, agitation, irritability, nausea, insomnia) as listed in controlled studies [6, 7] . Shoenberger self-reporting does not mention postwithdrawal disorders following withdrawal of paroxetine (taken for 3 years) [5] , but reports disturbing feelings of ‘zaps’, electric zapping sensations described as ‘washing over his entire body’ or ‘riding on a rollercoaster’ [5] , a withdrawal symptom of the CNS depressant type, which lasted into the fourth week of withdrawal. Zajecka et al. [6] had already listed ‘electric sensations’ as one of new withdrawal symptoms included in four published case reports. Received: January 19, 2012 Accepted after revision: June 5, 2012 Published online: September 6, 2012

[The post-traumatic embitterment disorder: clinical features].

BACKGROUND In the last decade, post-traumatic embitterment disorder (PTED) has been internationally recognised as a specific form of adjustment disorder which arises after severe and negative, but not life threatening, life events (conflicts at work, unemployment, death of a relative, divorce, severe illness). More recent research on its specific symptomatologic features, its chronic course, and the difficulties of treatment, have lead to the definition of distinct diagnostic criteria for PTED. The aim of this paper is to describe its main clinical features for both diagnostic and therapeutic purposes. METHODS The literature that is available allows to define specific psychopathological symptoms and etiology, and to distinguish PTED from post-traumatic stress, adjustment disorders and irritable mood. RESULTS AND CONCLUSIONS PTED is a disorder with a specific psychopathological framework. The introduction of PTED in the diagnostic manuals of mental disorders would be of help to better diagnose the spectrum of disorders following negative life events.