Psychiatric Emergencies

Psychiatric emergencies are conditions of acute disturbance of thought, behaviour, affect or psychomotor activity, demanding urgent interventions. They mostly include attempted suicide, severe depression, psychosis, substance abuse, violence or other rapid changes in behaviour. The initial assessment should include a thorough history collection and a general physical examination with a lab screening, to rule out any underlying medical cause, as well as providing a secure environment for both the patient and healthcare workers

Quantitative Comparison of Hand Kinematics Measured with a Markerless Commercial Head-Mounted Display and a Marker-Based Motion Capture System in Stroke Survivors

Upper-limb paresis is common after stroke. An important tool to assess motor recovery is to use marker-based motion capture systems to measure the kinematic characteristics of patients’ movements in ecological scenarios. These systems are, however, very expensive and not readily available for many rehabilitation units. Here, we explored whether the markerless hand motion capabilities of the cost-effective Oculus Quest head-mounted display could be used to provide clinically meaningful measures. A total of 14 stroke patients executed ecologically relevant upper-limb tasks in an immersive virtual environment. During task execution, we recorded their hand movements simultaneously by means of the Oculus Quest’s and a marker-based motion capture system. Our results showed that the markerless estimates of the hand position and peak velocity provided by the Oculus Quest were in very close agreement with those provided by a marker-based commercial system with their regression line having a slope close to 1 (maximum distance: mean slope = 0.94 ± 0.1; peak velocity: mean slope = 1.06 ± 0.12). Furthermore, the Oculus Quest had virtually the same sensitivity as that of a commercial system in distinguishing healthy from pathological kinematic measures. The Oculus Quest was as accurate as a commercial marker-based system in measuring clinically meaningful upper-limb kinematic parameters in stroke patients

Construct Validity and Responsiveness of the COVID-19 Yorkshire Rehabilitation Scale (C19-YRS) in a Cohort of Italian Hospitalized COVID-19 Patients

Post-COVID Syndrome (PCS) is characterized by physical, psychological and cognitive symptoms with a negative impact on daily activities. This study tested the responsiveness and construct validity of the original version of the COVID-19 Yorkshire Rehabilitation Scale (C19-YRS) in a cohort of Italian hospitalized COVID-19 patients. This longitudinal study involved 79 hospitalized COVID-19 patients with rehabilitation needs, assessed after 12 and 26 weeks post-infection. Functional and patient-reported outcome measures were correlated with 10 items of the C19-YRS to test the construct validity, whereas distribution-based methods were used for the responsiveness over time. After 12 weeks since infection, 88.5% of patients reported fatigue, 83.3% breathlessness, 69.4% anxiety, 55.6% depression, and 44.9% pain. Moreover, 84.6% experienced reduced mobility, 75.7% had difficulties with usual activities, and 47.4% with personal care. Single items for each symptom had significant correlation (rho 0.25–0.60) with well-established scales for these symptoms. At 26 weeks, except for anxiety, all the PCS symptoms were still present but significantly reduced. The C19-YRS had moderate responsiveness for the most represented deficit reported. The C19-YRS was a valuable patient-reported outcome for screening, assessing severity, and monitoring the persistence of symptoms after 12 and 26 weeks from SARS-CoV2 infection in a cohort of Italian hospitalized patients

Anxiety-Related Disorders

Anxiety is a common experience, a physiologic mechanism that lets us cope with a stressor, but if it occurs without a stimulus or it is exaggerated and general functioning is impaired, it becomes pathological. Treating anxiety disorders requires pharmacotherapy to lower anxiety levels and psychological therapies to learn to cope with stressors adaptively. Obsessive-compulsive disorder (OCD) has been considered as part of the Anxiety Disorders chapter up to the fourth edition of the DSM (DSM IV-TR), while from the fifth edition (DSM-5) it is placed in a separate chapter. The nosographic autonomy of this disorder depends on the fact that the anxious manifestations, even if present, would be secondary and dependent on the obsessive contents. A group of conditions related to OCD from a clinical, epidemiological, and sometimes aetiopathological perspective is included in the DSM chapter about “obsessive-compulsive and related disorders”. After a traumatic experience, one person physiologically develops a limited-in-time reaction. In some cases, more pronounced depressive, anxious, intrusive, and/or dissociative symptoms occur. The biological basis for trauma-related disorders is not fully understood, but insights so far have let us choose pharmacological treatments alongside with psychotherapy in order to control symptoms and elaborate the traumatic experience

Non-Pharmacological Treatments

In clinical psychiatry, we dispose of different non-pharmacological approaches, such as somatic treatments, chronobiological treatments, cognitive remediation, and psychotherapy. Somatic treatments include transcranial direct current stimulation (tDCS), transcranial magnetic stimulation (TMS), and electroconvulsive therapy (ECT). These techniques, which exert their function through the modulation of cortical excitability, find an application in many psychiatric disorders, but mainly in resistant depression. Chronotherapies, a group of non-pharmacological therapeutic approaches to mood disorder treatment, are rooted in the hypothesis of chronobiology aetiopathogenesis of psychiatric disorders (mainly mood disorders). Chrono-biological treatments include light therapy (LT), sleep deprivation (SD), and dark therapy (DT). While LT and SD are mainly used in depression, DT finds a clinical application in mania. Cognitive remediation (CR) is a set of interventions based on behavioural training whose goal is to enhance neurocognitive abilities. This technique finds its main application in schizophrenia. Psychotherapy approaches have a proved effectiveness for the treatment of various psychiatric conditions when combined to psychopharmacological treatment. The two main approaches are cognitive-behavioural therapy and psychodynamic therapy

Fatigue can influence the development of late-onset pain in post-COVID-19 syndrome: An observational study

Background: Late-onset pain is frequent following COVID-19, and many pathogenetic mechanisms have been proposed. Identifying the main features of patients may help in designing tailored rehabilitative interventions.Methods: We enrolled post-COVID-19 patients with an increase in pain intensity of two points on the COVID-19 Yorkshire Rehabilitation Scale (C19-YRS) at 52 weeks compared to the pre-COVID-19 condition. All subjects were retrospectively monitored at 12, 26, and 52 weeks. A specific pain assessment was performed to determine the characteristics and mechanisms of pain. Catastrophizing, kinesiophobia, and other psychological symptoms were evaluated. The pressure pain threshold (PPT) and temporal summation (TS) were measured and compared in age- and sex-matched healthy controls to analyse pain characteristics.Results: A total of 67 patients were recruited, with 20 of them presenting an increase in pain at 52 weeks. Subjects of the two subgroups were similar in demographic and clinical characteristics at baseline; significant differences in fatigue, anxiety, mobility, ability to perform daily activities, and general health perception were recorded at 26 weeks. Fatigue significantly predicted pain onset (beta = 0.54, p = 0.002). Sixteen different body regions were identified as painful, with a pain intensity of 6.0 +/- 1.9. Most of the samples did not show neuropathic or nociplastic mechanisms. No differences in PPT and TS were recorded between patients and healthy controls.Conclusions: Almost one out of three patients hospitalized for COVID-19 developed pain 1 year later, and fatigue seems responsible for chronicity. An overlapping of conditions may explain late-onset post-COVID-19 pain, and a comprehensive approach must be considered for patient management.Significance: Late-onset pain is frequent in post-COVID-19 syndrome and an overlapping of different mechanisms seems to be responsible for its development. Among many predisposing factors, fatigue in the months before seems to be one of the primary causes of pain one year following infection and its management may help to identify new strategies for prevention and treatment of late-onset pain

Substance-Related Disorders

Addiction is a chronic-relapsing brain disorder characterized by cognitive, behavioral, and physiological symptoms including compulsion to take the drug, loss of control over use, and persistent consumption despite substance-related problems. Individual susceptibility is influenced by genetic, psychological, and environmental factors; age of first exposure; substance characteristics; and pattern of use. Substances of abuse act on several brain’s systems leading to persistent changes, which can trigger relapse even after prolonged abstinence. Addiction is a major public health concern. About 35.6 million people worldwide suffer from substance use disorders (SUDs), whose prevalence is expected to continue to grow. SUDs are associated with psychiatric conditions, adverse health consequences, and social disadvantage. Despite their high prevalence and their impact in terms of mortality, morbidity, and societal costs, health-care providers report inadequate preparedness in recognizing and supporting patients with SUDs. Awareness of risk factors, knowledge of the underlying neurobiological mechanisms and identification of early signs make it possible to implement prevention and treatment strategies for SUDs. Therefore, this chapter aims to discuss the identification, management, and treatment of substance-related disorders, providing health-care professionals with fundamental tools to face one of the most challenging public health threats to our society

A novel immersive virtual reality environment for the motor rehabilitation of stroke patients: A feasibility study

We designed and implemented an immersive virtual reality (VR) environment for upper limb rehabilitation, which possesses several notable features. First, by exploiting modern computer graphics its can present a variety of scenarios that make the rehabilitation routines challenging yet enjoyable for patients, thus enhancing their adherence to the therapy. Second, immersion in a virtual 3D space allows the patients to execute tasks that are closely related to everyday gestures, thus enhancing the transfer of the acquired motor skills to real-life routines. Third, in addition to the VR environment, we also developed a client app running on a PC that allows to monitor in real-time and remotely the patients’ routines thus paving the way for telerehabilitation scenarios. Here, we report the results of a feasibility study in a cohort of 16 stroke patients. All our patients showed a high degree of comfort in our immersive VR system and they reported very high scores of ownership and agency in embodiment and satisfaction questionnaires. Furthermore, and notably, we found that behavioral performances in our VR tasks correlated with the patients’ clinical scores (Fugl-Meyer scale) and they could thus be used to assess improvements during the rehabilitation program. While further studies are needed, our results clearly support the feasibility and effectiveness of VR-based motor rehabilitation processes

Video game therapy on mobility and dual tasking in multiple sclerosis: Study protocol for a randomised controlled trial

Introduction Multiple sclerosis (MS) is one of the major causes of disability in young adults and affects mobility, compromising daily living activities and participation in social life. Cognitive domain is also frequently impaired in people with MS (PwMS), particularly the capacity to perform dual-task activities. Impaired cognitive processing abilities need to be treated, and motor and cognitive aspects need to be considered together. Recently, video game therapy (VGT) has been used in rehabilitation to improve motor outcomes and cognitive processing speed. The aim of this study is to test the efficacy of commercially available VGT on mobility and dual tasking in PwMS compared with standardised balance platform training (BPT). Methods and analysis This will be a parallel-assignment, double-blinded, randomised control trial. Forty-eight (24 per arm) PwMS with Expanded Disability Status Scale 4-5.5 will be randomly assigned to receive 1 hour training session over 4 weeks (three sessions/week) of either: (1) VGT on commercial video game console to train balance and mobility-related activities or (2) BPT to perform balance, postural stability and weight-shifting exercises with and without visual feedback. The same assessor will evaluate outcome measures at points: before and after the 12 training sessions and at 3 months of follow-up. The primary outcome will be functional mobility, assessed by the Timed Up and Go test. We will also evaluate gait, risk of fall, fatigue and health-related quality of life as well as cognitive and psychological aspects (depression, anxiety and attentional performance) and stability through posturographic evaluation. Dual-tasking assessment will be performed combining posturographic and neuropsychological tests. Data analysis will be performed to compare the efficacy of the two treatments. Ethics and dissemination Ethical approval have been granted from the local Ethics Committee. Study results will be communicated through high-quality journals and national and international conferences. Trial registration number NCT0335397