Lara Mangelli

Well-Being Therapy of Generalized Anxiety Disorder

Background: There is increasing awareness that the goal of treatment in generalized anxiety disorder (GAD) should not simply be a response, but restoration of normal function. The aim of this study was to apply a novel psychotherapeutic approach for increasing the level of remission in GAD. Methods: Twenty patients with DSM-IV GAD devoid of comorbid conditions were randomly assigned to 8 sessions of cognitive behavioral therapy (CBT) or the sequential administration of 4 sessions of CBT followed by other 4 sessions of well-being therapy (WBT). Assessment methods included the Anxiety and Depression Scales of Paykel’s Clinical Interview for Depression, Ryff’s Psychological Well-being Scales and Kellner’s Symptom Questionnaire. A one-year follow-up was undertaken. Results: Significant advantages of the CBT-WBT sequential combination over CBT only were observed with both observer and self-rated methods after treatment. Such gains were maintained at follow-up. Conclusions: These preliminary results suggest the feasibility and clinical advantages of adding WBT to the treatment of GAD. They lend support to a sequential use of treatment components for achieving a more sustained recovery.

Long-term outcome of panic disorder with agoraphobia treated by exposure

BACKGROUND There is a paucity of long-term outcome studies of panic disorder that exceed a 2-year follow-up. The aim of the study was to evaluate the long-term follow-up of patients with panic disorder with agoraphobia treated according to a standardized protocol. METHODS A consecutive series of 200 patients satisfying the DSM-IV criteria for panic disorder with agoraphobia was treated in an out-patient clinic with behavioural methods based on exposure homework. One hundred and thirty-six patients became panic free after 12 sessions of psychotherapy and 132 were available for follow-up. A 2- to 14-year (median = 8 years) follow-up was performed. Survival analysis was employed to characterize the clinical course of patients. RESULTS Thirty-one of the 132 patients (23%) had a relapse of panic disorder at some time during follow-up. The estimated cumulative percentage of patients remaining in remission was 93.1 after 2 years, 82.4 after 5 years, 78.8 after 7 years and 62.1 after 10 years. Such probabilities increased with younger age, and in the absence of a personality disorder, of high pre-treatment levels of depressed mood, of residual agoraphobic avoidance after exposure, and of concurrent use of benzodiazepines and antidepressant drugs. CONCLUSIONS The findings suggest that exposure treatment can provide lasting relief to the majority of patients with panic disorder and agoraphobia. Disappearance of residual and subclinical agoraphobic avoidance, and not simply of panic attacks, should be the aim of exposure therapy.

Assessment of Psychological Distress in the Setting of Medical Disease

The biopsychosocial model of disease has recently been depicted as the basis for a renewed emphasis on the multiaxial diagnostic system of the DSM-IV. The authors challenge this stance, underscoring the clinical inadequacies of the DSM-IV in the setting of medical disease, particularly the chapters concerned with somatoform disorders and psychological factors affecting medical conditions. Diagnostic criteria which are based on the clinical insights derived from psychosomatic research in the past decades may offer new opportunities to psychosomatic medicine and consultation-liaison psychiatry. The development of the Diagnostic Criteria for Psychosomatic Research (DCPR), encompassing alexithymia, type A behavior, irritable mood, demoralization, disease phobia, thanatophobia, health anxiety, illness denial, functional somatic symptoms secondary to a psychiatric disorder, persistent somatization, conversion symptoms and anniversary reaction, is described. Preliminary results obtained with the combination of DSM and DCPR criteria appear to be promising.

Psychological Assessment in Cardiac Rehabilitation

Background: While there has been an upsurge of interest in the psychiatric correlates of myocardial infarction, little is known about the presence of psychological distress in the setting of cardiac rehabilitation. Methods: A consecutive series of 61 patients with recent myocardial infarction who participated in a cardiac rehabilitation program was evaluated by means of both observer-rated (DSM and DCPR) and self-rated (Psychosocial Index) methods. A follow-up of this patient population was undertaken (median = 2 years). Survival analysis was used to characterize the clinical course of patients. Results: Twenty percent of patients had a DSM-IV diagnosis (in half of the cases minor depression). An additional 30% of patients presented with a DCPR cluster, such as type A behavior and irritable mood. Only high levels of self-perceived stressful life circumstances and psychological distress approached statistical significance as a psychological risk factor for cardiovascular events after myocardial infarction. Conclusions: Psychological evaluation of patients undergoing cardiac rehabilitation needs to incorporate both clinical (DSM) and subclinical (DCPR) methods of classification. Type A behavior was present in about a quarter of patients and can be studied in specific subgroups of cardiovascular patients defined by DCPR.

Psychological Evaluation after Cardiac Transplantation: The Integration of Different Criteria

Background: The psychological evaluation of patients undergoing cardiac transplantation is currently based on DSM-IV criteria. An alternative diagnostic and conceptual framework has been proposed by an international group of psychosomatic investigators. The aim of this study was to compare these new criteria (Diagnostic Criteria for Psychosomatic Research, DCPR) with DSM-IV in a population where a high prevalence of psychological problems is expected (heart-transplanted patients). Method: 129 consecutive patients who underwent heart transplant surgery were assessed according to DSM-IV and DCPR criteria. Results: The results showed a higher number of diagnoses made using the DCPR than with the use of the DSM-IV. At least one DCPR diagnosis was found in 85 (66%) patients, whereas at least one DSM diagnosis was present in 23 (18%) patients. The number of DCPR diagnoses was almost the triple of DSM criteria. While patients who were given a DSM diagnosis frequently had additional DCPR diagnoses, many patients with DCPR criteria did not fulfill any DSM criteria. Four DCPR syndromes appeared to be particularly frequent: demoralization, type A behavior, irritable mood and alexithymia. Conclusions: The joint use of DSM and DCPR criteria was found to improve the identification of psychological factors which could result in a worsening of quality of life in heart-transplanted patients.

Subclinical Symptoms of Panic Disorder: New Insights into Pathophysiology and Treatment

The aim of this review was to survey the available literature on prodromal and residual symptoms of panic disorder. Both a computerized (Medline) and a manual search of the literature were performed. In a substantial proportion of patients with panic disorder with agoraphobia a prodromal phase can be identified. Most patients report residual symptoms despite successful treatment. Residual symptoms upon remission have a prognostic value. There appears to be a relationship between residual and prodromal symptomatology (the rollback phenomenon). Appraisal of subclinical symptomatology in panic disorder has important implications as to the pathophysiological model of disease, its conceptualization and treatment.

The spectrum of anxiety disorders in the medically ill.

OBJECTIVE The purpose of this cross-sectional study was to assess the prevalence and characteristics of anxiety disorders in the medically ill. METHOD A sample of 1,660 medical patients was recruited from different medical settings in different periods from 1996 to 2007. All patients underwent detailed semistructured interviews with the Structured Clinical Interview for DSM-IV (SCID) and the Structured Interview for Diagnostic Criteria for Psychosomatic Research (DCPR). RESULTS Generalized anxiety disorder was the most frequent anxiety disturbance (10.3%) and was associated with DCPR somatization syndromes, Type A behavior, and irritable mood. Panic disorder with agoraphobia and agoraphobia without history of panic disorder had almost identical prevalence (about 4.5%), but differed in some patterns of somatization. Agoraphobia without panic attacks was related to illness denial, persistent somatization, anniversary reactions, and demoralization. Much lower prevalence rates were reported for social phobia and obsessive-compulsive disorder. CONCLUSIONS The findings indicate that anxiety disorders are common in the setting of medical disease and are associated with several types of psychosomatic presentations. The links between agoraphobia without history of panic disorder and illness denial may provide an explanation for some discrepancies that have occurred in the literature as to the prevalence of agoraphobia in clinical samples compared to epidemiologic studies.

A cluster analysis-derived classification of psychological distress and illness behavior in the medically ill.

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.

Irritable mood in Italian patients with medical disease

Irritability may be a mood state independent of other moods and anxiety disorders, even though it may be symptomatic of several psychiatric disorders, such as major depression. The aims of this exploratory study were to verify the presence of irritable mood in a group of medical outpatients with a variety of clinical conditions (functional gastrointestinal disorders, cardiovascular disorders, endocrine diseases and cancer) and to examine its relationship with major depression. A total of 609 consecutive outpatients recruited from different medical settings were assessed according to DSM-IV and Diagnostic Criteria for Psychosomatic Research using semistructured research interviews. Irritable mood was identified in 163 (27%) patients, while major depression was present in 113 (19%) patients. Even though there was a considerable overlap between the two diagnoses, 76 (67%) patients with major depression were not classified as irritable, and 126 (77%) patients with irritable mood did not satisfy the criteria for major depression. The findings suggest a high prevalence of irritability in the medically ill, which in most cases is independent of mood disorder. Further research may determine whether irritability, alone or in association with major depression, entails prognostic and clinical implications.

Assessing the Community Prevalence of Bipolar Spectrum Symptoms by the Mood Disorder Questionnaire

Background: The goal of this study was to assess the frequency and spectrum of symptoms related to bipolar disorders in a community sample by means of a self-rating questionnaire. Method: The Mood Disorder Questionnaire, a self-rating scale which evaluates DSM-IV manic/hypomanic symptoms, was administered to a community sample of 1,034 individuals recruited through advertisements. Symptom interrelationships were studied by factor analysis. Results: 275 individuals (26.6%) reported moderate or severe impairment due to the symptoms. Manic/hypomanic symptoms were present in a high proportion of individuals. Factor analysis found a two-factor structure of bipolar spectrum symptoms (an elevated mood overactivity factor, and an irritable behavior factor). Conclusion: The findings of this study highlight the need of complementing clinical investigations on the bipolar spectrum with community studies. Subclinical manic-hypomanic symptoms may be present also in allegedly unipolar patients and may have implications on the course of illness.