The phenomenology of depression

The phenomenological method, characterized by the suspension of judgment (epoché), has helped analyzing the subjective experience of patients affected by mental disorders. Psychiatry, dealing with the human being itself in its complexity and unicity, is placed between the biological positivistic attempt, for which the symptoms of mental illness are a mere consequence of brain dysfunctions and the phenomenological-existential approach, inclined to consider the symptoms as meaningful phenomena of the person’s subjective experience. Eugène Minkowski, Ludwig Binswanger, Arthur Tatossian, Kimura Bin, Henri Maldiney and Hubertus Tellenbach are fundamental authors in the phenomenological psychopathology of depression; they described the alterations of the lived time, space, body and others experienced by the depressed. Starting from the main theoretical contributions of the authors, we will focus on the psychopathology and discuss the key themes of clinical depression: guilt, poverty and hypochondriasis. Finally we will focus on the typus melancholicus construct

The impact of early-life stress in the development and course of bipolar disorder: Mechanisms and implications

Traumatic events experienced throughout the different stages of childhood and adolescence are frequent circumstances with a detrimental impact on the physical and psychological health of the individual. A growing body of evidence shows the trauma-related effects on the hypothalamic-pituitary-adrenal axis, the sympathetic nervous system, the serotonin system, the immune system, on brain development, structure, and connectivity. Interestingly, a relation was found between early life stress and Bipolar Disorder: the patients who were exposed to childhood trauma showed a worsened course of the disorder with poor clinical and psychopathological factors. According to the kindling hypothesis, early environmental stressors interact with the genetic susceptibility through epigenetic mechanisms, making the subject more vulnerable to milder stressors, and lowering the threshold for the occurrence of subsequent mood episodes. Understanding these processes is crucial to the discovery of new targets of treatment to reduce or, possibly, revert the effect of early life stress on bipolar disorder

Personality Disorders

The present chapter aims at providing an overview of the current state of the art as to the conceptualization, diagnosis, epidemiology, etiological correlates, and treatment of personality disorders (PDs). The two DSM-5 models for PDs (i.e., the traditional categorical model listed in DSM-5 Section II and the Alternative Model of PD proposed in DSM-5 Section III) are reviewed and the scientific rationale for moving from a categorical model to an empirically based dimensional model of PDs are presented. Key aspects and basic principles of PD treatment are summarized. Finally, the chapter offers three clinical vignettes to help the reader familiarizing with the clinical presentation of PDs

Introduction

Psychiatry is the branch of medicine appointed to the diagnosis, treatment, and prevention of mental disorders. Throughout ages, the concept of mental illness had changed many times, and today, the biopsychosocial model tries to explain mental disorders as the result of the complex interaction between biological correlates, psychological factors, and the socio-cultural background. The psychiatric interview is the fundamental element for the evaluation of the subject with mental illness. It allows to have access to the patient’s psychic state, enabling to collect the information that will guide the professional in formulating a diagnosis and through the choice of therapy

Eating Disorders

Anorexia and bulimia are diseases known since ancient times, but in recent years their frequency has been continuously increasing in most industrialized countries. The etiology of these disorders can be traced back to the interaction between genetic predisposition, childhood experiences, and cultural pressures. As regards the course, a certain tendency to chronicity can be observed, and in extreme cases, they can cause death. According to the diagnostic classification of the DSM-5, eating disorders include anorexia nervosa, bulimia nervosa, binge eating disorder (which, compared to DSM-IV, becomes a diagnostic category in its own right), and other specified feeding and eating disorders (OSFED). Both anorexia and bulimia cause potentially serious medical complications. To maximize the chances of good outcomes a multidisciplinary intervention is necessary with staff including professionally heterogeneous figures: a psychiatrist, a psychologist, and a nutritionist. Therapeutic success for these patients is limited. Eating disorders require, among psychiatric disorders, the greatest possible collaboration between different professional figures with different specializations

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

Psychopharmacology

Psychopharmacology is the scientific study of the effects drugs have on mood, sensation, thinking, and behavior. Particularly it concerns the use of medications in the treatment of mental disorders. The goal of this chapter is to define the major classes of psychotropic drugs, introducing general pharmacological concepts, explaining the different mechanisms of action and the main clinical applications of the drugs used to treat psychiatric disorders. Psychotropic drugs are commonly categorized according to their major clinical applications: antidepressants, anxiolytics, antipsychotics, and mood stabilizers. However, almost every drug used in psychiatry has multiple therapeutic roles and many clinical applications. For example, SSRIs are considered the first-line pharmacological treatment for several disorders, such as depressive disorders, anxiety disorders, and OCD. Similarly, antipsychotics are indicated as first-choice drugs for psychotic disorders, but many guidelines recommend their use, in combination with mood stabilizers, also in the treatment of acute mania

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