Lorenzo Tarsitani

Heterogeneity and symptom structure of schizophrenia

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.

Somatization in primary care : A comparative survey of immigrants from various ethnic groups in Rome, Italy

Objectives: Those responsible for interviewing immigrants in primary care settings often underestimate the importance of somatic symptoms arising from psychological distress. This study investigates the current prevalence of somatization in immigrants, and evaluates the comparative rates of somatic complaints in four ethnic groups (Caucasians, Asians, South/Center Americans, and Africans). Methods: We studied the 301 consecutive outpatients (aged between 16 and 70 years) attending the “Caritas” primary care unit for immigrants in Rome (Italy) from January to December 2003, all of whom completed the 21-item version of the Bradford Somatic Inventory (BSI-21). Patients scoring 14 or more on the BSI-21 were considered at risk for somatization. Results: The current prevalence of somatization was 35.2%; 62.3% of the somatizers were women. A multiple regression analysis adjusting for the possible confounding effects of sex, age, education, and months of stay in Italy showed that South/Central Americans had significantly higher somatization scores than the other three groups. Conclusions: These findings suggest a high probability of somatization syndromes in immigrant patients. South/Central Americans tend to somatize more than other ethnic groups. A psychosomatic approach may be useful for immigrants in primary care settings.

Attachment security and immunity in healthy women.

Background: 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. Methods: A random sample of 61 female nurses provided a blood sample and completed the Perceived Stress Scale, the Multidimensional Scale of Perceived Social Support, the 20-item Toronto Alexithymia Scale, and the Experiences in Close Relationships questionnaire. Immune measures included immunophenotypic analysis, lymphocyte proliferative response to Phytohemagglutinin, and NK cell cytotoxicity (NKCC). Statistical analysis focused on the relationship between attachment-related anxiety or avoidance and immune measures. Multiple regression was used to control for perceived stress and support, alexithymia, health-related behaviors possibly influencing immunity, and use of anti-inflammatory drugs, tobacco or alcohol. Results: Attachment-related anxiety was not associated with any immune parameter. Attachment-related avoidance was associated with lower NKCC. This association was independent from the number of circulating NK cells, which suggests a change in cell functionality. Perceived stress was also associated with lower NKCC. Conclusions: This study suggests a link between attachment security and immunity. While our findings should be interpreted with great caution and need replication, they are consistent with previous work suggesting that insecure attachment may be a risk factor for health and may relate to biological processes relevant to health. PSS = Perceived Stress Scale; MSPSS = Multidimensional Scale of Perceived Social Support; TAS-20 = 20-item Toronto Alexithymia Scale; ECR = Experiences in Close Relationships questionnaire; PHA = Phytohemagglutinin; NKCC = Natural Killer Cell Cytotoxicity; BMI = body mass index.

Combined pharmacological and short-term psychodynamic psychotherapy for probable medication overuse headache: a pilot study

We studied the effects of short-term psychodynamic psychotherapy (STPP) and pharmacological therapy in 26 consecutive patients with probable medication overuse headache (pMOH). Patients underwent a standard in-patient detoxification protocol, lasting a mean of 7 days. Eleven patients overused non-steroidal anti-inflammatory drugs (NSAIDs), five a combination of NSAIDs and triptans, four triptans, four a combination of NSAIDs, and three triptans and ergot derivates. Preventive therapy was initiated during detoxification. The STPP protocol comprised the Brief Psychodynamic Investigation (BPI) and psychoanalysis-inspired psychotherapy. All patients (groups A and B) underwent the BPI and pharmacological therapy. Half of the patients (group B) also not randomly underwent psychoanalysis-inspired psychotherapy. We found a significant interaction between time and group for headache frequency and medication intake. At 12-month follow-up, a statistically greater decrease in headache frequency and medication intake was observed in group B than in group A (P = 0.0108 and P = 0.0097, respectively). The relapse rate was much lower in group B patients at both 6 and 12 months [15.3%, odds ratio (OR) 0.11, P = 0.016, and 23%, OR 0.18, P = 0.047, respectively] than in group A. The risk of developing chronic migraine (CM) during follow-up was higher in group A than in group B at 6 (OR 2.0, P = 0.047) and 12 months (OR 2.75, P = 0.005). Our study suggests that STPP in conjunction with drug withdrawal and prophylactic pharmacotherapy relieves headache symptoms in pMOH, reducing both long-term relapses and the burden of CM.

What every psychiatrist should know about PANDAS: a review

The term Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus infections (PANDAS) was coined by Swedo et al. in 1998 to describe a subset of childhood obsessive-compulsive disorders (OCD) and tic disorders triggered by group-A beta-hemolytic Streptococcus pyogenes infection. Like adult OCD, PANDAS is associated with basal ganglia dysfunction. Other putative pathogenetic mechanisms of PANDAS include molecular mimicry and autoimmune-mediated altered neuronal signaling, involving calcium-calmodulin dependent protein (CaM) kinase II activity. Nonetheless the contrasting results from numerous studies provide no consensus on whether PANDAS should be considered as a specific nosological entity or simply a useful research framework. Herein we discuss available data that could provide insight into pathophysiology of adult OCD, or might explain cases of treatment-resistance. We also review the latest research findings on diagnostic and treatment.

Combining an SSRI with an anticonvulsant in depressed patients with dysphoric mood: an open study

BackgroundSeveral 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.MethodsThirty-five newly admitted outpatients with substantial anger, irritability, aggressiveness or hostility who were diagnosed a DSM-IV unipolar depressive disorder were rated on the Hamilton Depression Rating Scale (HDRS), the Clinical Global Improvement (CGI) scale, and a scale for the rapid dimensional assessment (SVARAD), were prescribed an SSRI and an anticonvulsant (usually valproate), and were followed up for 12 weeks. Repeated measures analysis of variance was used to test for within-subject changes in scale scores over time.ResultsThirty-two and 23 patients attended the follow-up visits 4 and 12 weeks later, respectively. Significant decreases (p < .001) were observed in HDRS total score, HDRS and SVARAD anxiety factors, HDRS and SVARAD core depression factors, and SVARAD anger/irritability factor. Adjusting for age or gender did not change the results. Most patients (82%) were rated as improved or much improved on the CGI.ConclusionAlthough our study has several limitations, we observed a remarkable improvement in most unipolar depressed outpatients with dysphoric mood treated with an SSRI and an anticonvulsant. The effectiveness of anticonvulsants might be linked to their action on symptoms of aggression and behavioural activation.

Acute psychiatric treatment and the use of physical restraint in first-generation immigrants in Italy: A prospective concurrent study

Background and Aims: Immigrants in Europe appear at higher risk of psychiatric coercive interventions. No studies have investigated this issue in Italy. The aim of this study is to investigate whether the use of physical restraint, compulsory admission and other treatment characteristics differ in immigrated and Italian-born patients admitted to a psychiatric intensive care unit. Methods: One hundred first-generation immigrant patients were compared to 100 age-, gender- and diagnosis-matched Italian-born patients. Subjects were diagnosed according to DSM-IV-TR and rated on the Clinical Global Impression – Severity Scale and the Global Assessment of Functioning. Clinical data and treatment characteristics were collected. Results: Immigrant patients were more likely to be physically restrained as compared to Italian-born patients (11% vs 3%; χ 2 = 4.92; p = 0.027; RR = 3.67; 95% CI = 1.05–12.7). No differences in the proportion of involuntary treatment were found. Immigrant patients did not receive higher doses of antipsychotics or benzodiazepines, but they had a longer stay in the hospital. Conclusions: The higher rate of physical restraint among migrants may reflect cultural, ethnic and language differences leading to communication problems between immigrant patients and mental health professionals. Since coercive interventions can be harmful, specific strategies to prevent this phenomenon in immigrants are needed.

Attachment style and immunity: A 1-year longitudinal study

Previous cross-sectional studies suggested an association between attachment-related avoidance and altered immune function. We aimed at testing this hypothesis with longitudinal data. A random sample of 65 female nurses provided a blood sample and completed measures of perceived stress, social support, alexithymia, and attachment style. Immune assays included lymphocyte proliferative response (LPR) to Phytohemagglutinin and NK cell cytotoxicity (NKCC). State measures (perceived stress and support) and immune measures were collected again after 4, 8, and 12 months. Linear mixed effects models were used to examine the relationship between attachment and immunity. While low to moderate levels of attachment-related avoidance were not associated with NKCC, there was a significant negative association (beta -.35; p=.005) between high levels of avoidance and NKCC. No association was observed between NKCC and attachment-related anxiety, and between LPR and both attachment dimensions. While our findings should be interpreted with caution due to study limitations such as the relatively small sample size and the inclusion of only female participants, they corroborate the notion that attachment is linked to physiology and health.

Development and validation of the Italian version of the 15-item Dispositional Resilience Scale

Studies have shown that psychological hardiness is an important stress resilience resource for individuals. The 15-items Dispositional Resilience Scale (DRS-15) is a short, reliable and valid self-report instrument to measure hardiness that is not available in Italian. The present study was undertaken to create an Italian version of the DRS-15, and evaluate its psychometric properties and validity in the Italian context. An Italian version was produced using multiple independent bilingual translators. This version was administered to a non-clinical sample of adults (N=150), along with measure o psychological well-being (PWB-18) and health. A sub-sample (N = 66) completed the DRS-15 again one month later. Results showed good reliability in terms of internal consistency and test-retest stability. With regard to the subscale, stability was high for all three subscales, whereas two subscales (Commitment and Control) showed marginal internal consistency. DRS-15 total and subscales scores showed a theoretically meaningful pattern of correlations with PWB-18 subscales, supporting the validity of the Italian DRS. Also, multiple regression analysis revealed a correlation between DRS-15 scores and self-rated general health, even after controlling for age and sex. The new Italian DRS-15 provides a valid, reliable and easy to use tool fr assessing stress resilience in clinical and research settings.

Treatment with β-Blockers and Incidence of Post-Traumatic Stress Disorder After Cardiac Surgery: A Prospective Observational Study

OBJECTIVE The aim was to investigate perioperative factors associated with the development of post-traumatic stress disorder (PTSD) in patients who underwent cardiac surgery. DESIGN Prospective observational study. SETTING Single academic center. PARTICIPANTS One hundred twenty-eight consecutive patients scheduled for elective cardiac surgery with cardiopulmonary bypass. INTERVENTIONS Patients were interviewed within the surgical unit 1 to 3 days before cardiac surgery. MEASUREMENTS AND MAIN RESULTS Six months after surgery, participants were mailed the modified version of the Posttraumatic Stress Symptom Inventory 10. Of the 71 patients who completed the questionnaire and mailed it back at follow-up, 14 (19.7%) received a diagnosis of PTSD. Seven of 13 female patients who were not treated with β-blockers received a diagnosis of PTSD compared with 0 of 12 who were treated with β-blockers (p = 0.005, Fisher exact test). In a general linear model, including sex and β-blocker treatment as predictors, the Posttraumatic Stress Symptom Inventory 10 score was significantly predicted by β-blockade (F = 4.74, p = 0.033), with a significant interaction between sex and β-blockade (F = 9.72, p = 0.003). CONCLUSIONS These findings suggest that the use of β-blockers might be protective against the development of PTSD in women after cardiac surgery.