Chiara De Panfilis

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

OBJECTIVES Most physiological indicators of bipolar disorder (BPD) reflect current acute illness, and rarely have proved to be state-independent. Activity rhythms are highly abnormal in acute phases of BPD; we compared circadian activity rhythms in BPD I patients during ill and recovered states to those of normal controls to test the hypothesis that some abnormalities may persist. METHODS We compared 36 adult DSM-IV BPD I patients during acute mania or mixed states, and during full and sustained clinical recovery, to 32 healthy controls of similar age and sex distribution, using wrist-worn, piezoelectric actigraphic monitoring for 72 h and computed cosinor analysis of circadian activity rhythms. RESULTS We verified expected major differences between manic or mixed-state BPD I patients and matched normal controls, including phase advances averaging 2.1 h in ill BPD I patients and 1.8 h in recovered patients. Moreover, recovered BPD patients differed highly significantly from controls in several measures, including acrophase advance, higher percentage of nocturnal sleep, and lower average daily activity (mesor). Actigraphic measures among recovered BPD patients were independent of ratings of mania (on the Young Mania Rating Scale), depression (on the Hamilton Depression Rating Scale), or rating-scale scored subjective distress, as well as the type and dose of concurrent psychotropic medication. CONCLUSIONS These findings suggest that abnormal activity rhythms, including sustained phase advances, may represent enduring (trait) characteristics of BPD patients even during clinical recovery. If verified, such indices may be useful in supporting diagnoses and as an objective phenotype for genetic or other biological studies.

The TAS-20 more likely measures negative affects rather than alexithymia itself in patients with major depression, panic disorder, eating disorders and substance use disorders

BACKGROUND This study evaluates whether the difference in Toronto Alexithymia Scale-20 item (TAS-20) between patients with major depression (MD), panic disorder (PD), eating disorders (ED), and substance use disorders (SUD) and healthy controls persisted after controlling for the severity of anxiety and depression. METHODS Thirty-eight patients with MD, 58 with PD, 52 with ED, and 30 with SUD and 78 healthy controls (C) completed the TAS-20, the Hamilton Rating Scale for Anxiety (Ham-A), the Hamilton Rating Scale for Depression (Ham-D). RESULTS The differences in TAS-20 scores observed between patient groups, regardless of the type of their disorders, and controls disappeared after controlling for the effect of anxiety and depression severity. In contrast, the differences in severity of anxiety and depression between patients and controls were still present, after excluding the effect of alexithymic levels. CONCLUSIONS Our data suggest that alexithymic levels, as measured by the TAS-20, are modulated by the severity of symptoms, supporting the view that alexithymia can represent a state phenomenon in patients with MD, PD, ED and SUD, because the TAS-20 seems overly sensitive to a general distress syndrome, and it is more likely to measure negative affects rather than alexithymia itself.

Personality disorders and response to medication treatment in panic disorder : A 1-year naturalistic study

OBJECTIVE In this naturalistic and prospective study, personality was assessed in patients with panic disorder (PD), in order to evaluate whether personality features negatively influence the outcome of pharmacological treatment. METHOD Before drug treatment, PD was diagnosed with the Structured Clinical Interview for DSM-IV disorders and personality was assessed with the Structured Interview for DSM-IV Personality Disorders. Moreover, all patients were evaluated with the SCL-90, the Ham-A and Ham-D. Then, patients were randomly treated with paroxetine (33.5+/-13.3 mg/day) or citalopram (34.7+/-15.2 mg/day) and were followed at monthly intervals for 1 year. Absence of full and limited-symptom attacks, anticipatory anxiety, phobic avoidance and depression for 3 months was used to establish remission. The effect of personality traits on each symptom domain was evaluated. RESULTS Seventy-one patients completed the study. Remission rate was 76% for panic attacks and 46% for complete remission. When the effects of age, gender, age of onset and duration of PD, baseline SCL-90 phobic anxiety, Ham-A and Ham-D scores, Axis I comorbidity and the SIDP traits on remission were analyzed in a logistic regression, only borderline traits negatively influenced remission of panic attacks (OR=0.69; 95% CI=0.49-0.96; p=0.03), whereas the number of traits of each personality Cluster and the total number of SIDP traits did not affect the outcome of treatment. CONCLUSIONS This study suggests that in PD patients, borderline features may negatively influence the response to monotherapy with SSRI drugs; therefore, other treatment strategies (i.e., combination of SSRI with psychotherapy) are needed to obtain remission in these patients.

Parsing the intrinsic networks underlying attention: a resting state study

The attention system functionally modulates brain activity to exert control over thoughts, feelings and actions. Three distinct but mutually interacting components of attention have been hypothesized: alerting, which mediates the maintenance of a state of vigilance toward an upcoming stimulus; orienting, which supports the selection of sensory information, and executive control that is involved in detecting and resolving cognitive conflicts. The performance of tasks probing these components engages fronto-parietal and thalamic regions. Also, general attention has been associated with the activity of resting-state networks (RSNs), which are sets of brain regions with synchronous temporal fluctuations. Importantly, the association between the intrinsic brain activity of RSNs and the efficiency and integration of the specific attentional components remains largely unexplored. For this aim, we recruited twenty healthy volunteers who performed the Attention Network Test-Revised (ANT-R), assessing the alerting, orienting and executive control components as well as their interactions, and underwent resting-state functional magnetic resonance imaging. For each participant RSNs were estimated using double regression. The RSNs spanning across areas previously implicated in attentional processing were correlated with ANT-R scores using multiple regressions. Significant brain behavior correlations emerged between ANT-R scores and RSNs comprising the regions relevant for attentional processing, i.e., left and right prefronto-parietal (PFC-PC), dorsal attentional (DAN), salience (SN), and default mode (DMN) networks. The activity of PFC-PC networks was correlated with alerting in parietal and frontal regions, and with location conflict in the frontal regions. The DAN connectivity was correlated with flanker, location conflict, and their interaction in parietal regions. SN was associated with flanker by location and flanker by orienting interactions in the inferior frontal regions. Finally, the activity of the DMN was associated with flanker conflict in midline structures such as precuneus and anterior cingulate cortex and also in right angular gyrus. These results suggest that the brain is endowed with an intrinsic functional organization to support attention, not only in its global function, but also in its distinct components.

Parental bonding and personality disorder: the mediating role of alexithymia.

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

Temperament and one-year outcome of gastric bypass for severe obesity.

BACKGROUND The role of temperament traits in shaping the outcome of gastric bypass for severe obesity has not been established yet. This study evaluated whether temperament traits influence weight loss 1 year after gastric bypass, controlling for the potential confounding effect of Axis I and II disorders. METHODS Forty-nine patients with severe obesity (body mass index = 46.4 ± 6.7) undergoing gastric bypass completed a thorough psychiatric evaluation before surgery, including structured interviews, rating scales, and questionnaire assessing the presence and severity of co-morbid Axis I and II disorders. Temperament was evaluated with the Temperament and Character Inventory (TCI). Weight loss 1 year after surgery was calculated as percent total weight loss (%TWL). Predictors of weight loss were investigated with multivariate linear hierarchical regression. RESULTS After accounting for psychiatric covariates, higher TCI persistence scores independently predicted 1-year outcome of gastric bypass and explained 40% of the variance in %TWL. Patients with low persistence scores showed a significantly lesser weight loss than patients with high scores. CONCLUSION Temperament traits denoting the ability to persevere in ones goals in spite of immediate frustration (persistence) are associated with greater weight loss 1 year after gastric bypass. These data suggest the utility of preoperatively assessing and reinforcing such capacity to optimize surgical outcome. Future research will clarify the behavioral mechanisms mediating this relationship as well as the influence of temperament on weight maintenance.

Effect of pharmacological treatment on temperament and character in panic disorder.

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

The clinical meaning of obsessive-compulsive symptoms in bipolar disorder and schizophrenia.

The rate of co-morbid obsessivecompulsive disorder (OCD) with both bipolar and schizophrenia spectrum disorders is high. The lifetime prevalence of bipolar disorder (BD) in OCD patients is up to 21.5% and almost 50% of OCD patients have cyclothimic traits (D’Ambriosio et al., 2010). Co-morbid OCD is diagnosed in 8–32% of patients with schizophrenia (SCZ) and in up to 35% of patients with schizotypal personality disorder (de Haan et al., 2013). On one hand, BD-OCD is associated with poorer functioning as compared to ‘pure’ BD or ‘pure’ OCD (Amerio et al., 2014). On the other hand the impact of OC symptoms (OCS) on functioning in SCZ might depend on their severity: OCS might have an improving effect while a fullblown OCD might have a worsening one (de Haan et al., 2013). In line with these findings, preliminary results of our recent study have showed a gradual transition from an improving effect (mild OCS) to a worsening one (moderate–severe OCS) on functioning in SCZ subjects. OC symptoms are mediated by fronto-striato-thalamic circuits which have a crucial role in the regulation of daily master routines and sub-routines. Since these circuits can also be involved in the pathogenesis of BD and SCZ, OCS may have different clinical meanings in these disorders:

The facets of identity: personality pathology assessment through the Inventory of Personality Organization.

This work aims to further validate the object-relations-based model of personality pathology assessment, evaluating the psychometric properties of the Italian version of the Inventory of Personality Organization (IPO), a self-report instrument for the assessment of personality organization according to O. Kernbergs model of personality pathology. Six hundred ninety-six nonclinical volunteers and 121 psychiatric patients completed a set of questionnaires including the IPO, the Severity Indices of Personality Problems, the Borderline Personality Disorder Checklist, the Response Evaluation Measure 71, and the Symptom Checklist 90-Revised. Confirmatory factor-analyses on the IPO items supported the 1-, 2-, 3-, and 4-factor solutions. The last (Instability of sense of self/others, Instability of goals, Instability of behaviors, Psychosis) resulted in relatively better fit indexes. Invariance across samples (nonclinical, clinical) and gender was confirmed. The 4 IPO subscales showed good levels of internal coherence and, in the nonclinical sample, good test-retest reliability. Associations with the convergent measures were in line with theoretical expectations and supported the benefit of adopting a 4-factor solution. The 4 factors showed the expected criterion relations: All the dimensions discriminated between clinical and nonclinical subjects, whereas only Instability of self/others and Instability of goals discriminated patients with borderline personality disorder from patients with other diagnoses. Our results suggest that the Italian version of the IPO is a reliable and valid tool for the assessment of personality organization according to Kernbergs model. Results are discussed in the context of the current directions in the evaluation of personality disorders proposed by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition.

The relationship between effortful control, current psychopathology and interpersonal difficulties in adulthood.

This study examined whether the relationship between low effortful control (EC), general psychopathology and interpersonal maladjustment previously reported among children extends to adulthood. Two hundred and forty undergraduate students were assessed using the EC scale of the Adult Temperament Questionnaire, the General Severity Index of the Brief Symptom Inventory (BSI-GSI) and the interpersonal distress index of the Inventory of Interpersonal Problems-Short Circumplex (IIP-distress). Both the BSI-GSI and the IIP-distress scores were related to low levels of EC. Furthermore, interpersonal distress mediated the association between low EC and greater psychopathology severity. These results suggest that deficits in regulatory temperament among adults may be associated with experiencing greater psychopathology distress, and that this relationship may be explained by an impairment in interpersonal adjustment. Such preliminary findings may constitute a useful starting point for investigating this hypothesis among clinical populations.