Towards a specific psychopathology of Substance-Related and Addictive Disorders. Comparison between Heroin Use Disorder and Gambling Disorder patients

This dissertation aims, in its first part, to define Gambling Disorder on the basis of the terminology history, aetiology, clinical aspects, medical and psychiatric comorbidity and treatment options. In the second part comparison between psychopathology of Heroin Use Disorder and GD patients has been made. Gambling, defined as placing something of value at risk in the hope of gaining something of greater value, has been observed across cultures for millennia. Gambling is a harmless form of entertainment for most consumers, but it has the capacity to become dysfunctional in a minority. The negative consequences could be severe, and include financial debt, bankruptcy, family dissolution, and criminal behaviour. In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), Pathological Gambling become Gambling Disorder (GD) and it moved from “Impulse Control Disorder” to the chapter of “Substance-Related and Addictive Disorders”. DSM-5 in this way is the first diagnostic system to recognize a behavioural addiction. As in addiction to substances, there are similar elements in term of clinical expression (e.g., craving, tolerance, withdrawal symptoms) and diagnostic criteria, comorbidity, neurobiological profile, heritability, natural history, treatment, and treatment outcome. Actually, 0.12-5.8% of the world’s population meets criteria for GD and in Italy, the prevalence estimated is between 0,5 and 2,2%. Neurobiological studies underline involvement of Serotoninergic, Dopaminergic, GABAergic, Glutamatergic and Noradrenergic systems both in GD and in Substance Use Disorder and GD’s heritability is similar to heritability rates of other Addictions. Indeed, several neuropsychological differences have been found between subjects with GD and control subjects and that have been linked to brain regions such as ventral striatum, ventromedial prefrontal cortex, orbitofrontal cortex, dopaminergic midbrain and insula, fundamental structures in the reward system and decision processes. GD is more frequent in males than females, in younger than in older people; 96% of individuals with lifetime GD also meet criteria for at least one other lifetime psychiatric disorder. High rates of co-occurrence between SUDs and GD are present in both directions. Similarities between GD and SUD are: (1) Euphoric state/ excitement or arousal-state; euphoric state such as ‘‘high’’. (2) Loss of control/ impaired control. (3) Craving/failure to resist an impulse, drive, or temptation to perform an act. (4) Recidivism/exacerbations and remissions. (5) Alteration in global functioning/impaired control. Currently, three main pharmacological approaches exist for GD derived from the psychopathological and phenomenological perspectives of the disorder itself: considering GD as a behavioural addiction, as belonging to the obsessive- compulsive disorder spectrum, or as the result of an emotional deregulation related to mood disorders. Opioid antagonist, SSRIs antidepressant and Mood Stabilizers are generally used. Cognitive Behavioural Therapy has been used to reduce gambling behaviour. In the experimental study, the aim was to investigate psychopathology and to test if the specific psychopathology already found in HUD patients could be likewise detected in GD patients. The five psychopathological dimensions found, by our research group, in Substance-Related Disorders were applied to a Non-Substance-Related Disorder, comparing a sample of Heroin Use Disorder (HUD) with Gambling Disorder (GD) patients at univariate and multivariate level. At univariate level the number of psychopathological symptoms were more severe in HUD patients and all the five psychopathological dimensions were significantly more severe in HUD patients. Psychopathological subtypes were not the most important discriminant factor to differentiate HUD from GD patients. Psychopathological subtypes characterized by ‘Somatic Symptoms’ and ‘Violence- Suicide’ symptomatology were more frequent in HUD patients, whereas ‘Panic Anxiety’ symptomatology were more frequent in GD individuals. At multivariate level, prominentcharacteristic of PG individuals was only the absence of ‘Somatic Symptoms’ psychopathological subtype membership. The SCL-90-defined structure of opioid addiction seems to represent a trait-dependent, rather than a state-dependent psychopathology also in non-substance-related disorders of addictive disorders, further supporting the existence of a specific psychopathology of addiction

L’impulsività in un campione di pazienti obesi affetti da Binge Eating Disorder con e senza disturbo bipolare

Scopo dello studio: negli ultimi anni numerosi studi stanno evidenziando la validità diagnostica del Binge eating disorder (BED) che ha mostrato stabilità nel tempo come un Disturbo psichiatrico definito e caratteristiche proprie dei Disturbi della Condotta Alimentare (DCA) come l’eccessivo valore attribuito al peso e all’aspetto fisico che influenza, in maniera patologica, l’autostima. Un deficit del concetto di sé e una sopravvalutazione dell’importanza del peso e dell’aspetto fisico sembrano costituire aspetti fondamentali del disturbo (Masheb e Grilo, 2003; Ramacciotti, Coli e coll., 2008). Nei soggetti obesi la presenza del BED è associata a caratteristiche peculiari come, appunto, l’inappropriato ruolo dell’insoddisfazione corporea nel determinare l’autostima, una maggiore compromissione del funzionamento globale a causa della condizione di sovrappeso, una maggiore insicurezza sociale, disagio nelle relazioni interpersonali e maggiore stress psicologico (Ramacciotti, Coli e coll., 2008), l’alta comorbidità con Disturbi dell’Umore, Disturbi del Controllo degli Impulsi e Disturbi di Personalità. Tali caratteristiche influenzano la prognosi di queste persone. Con l’obiettivo di approfondire la conoscenza di questo Disturbo e del suo nucleo psicopatologico, abbiamo ricercato la presenza di eventuali tratti impulsivi, visto che l’Impulsività è un tratto comune agli altri DCA. Il senso comune del termine “Impulsività” si riferisce a comportamenti che includono una componente di avventatezza, perdita di previsione o pianificazione o comportamenti che si verificano senza considerazione riguardo le conseguenze del comportamento stesso. L’impulsività coinvolge comportamenti che sono inappropriati per il contesto, poco pianificati e che frequentemente risultano in conseguenze avverse, riflettendo l’incapacità di valutare e rispondere, per ottenere un determinato obiettivo, a una situazione mutevole. L’abbuffata può essere considerata una manifestazione di discontrollo degli impulsi e, alla luce del fatto che questo si associa spesso ai cambiamenti dell’umore, ci è sembrato utile approfondire la relazione tra BED e Disturbo Bipolare (BD). Alcuni studi, infatti, hanno evidenziato la presenza di una maggior impulsività anche nei soggetti con BD (Swann e coll., 2001). Materiali e metodi: 40 pazienti affetti da BED afferenti all’Ambulatorio per i Disturbi della Condotta Alimentare della Unità Operativa 2a della Clinica Psichiatrica dell’Università di Pisa sono stati reclutati nello studio. All’interno di questo campione 16 persone presentavano comorbidità con Disturbo Bipolare (I o II). Per il confronto è stato selezionato un gruppo di controllo, senza una storia di disturbi psichiatrici, costituito da 20 persone della popolazione generale. I soggetti sono stati sottoposti a tre tipi di test: la Structured Clinical Interview for DSM-IV Axis I disorders (SCID I), l’Eating Disorder Inventory (EDI-2) e la Barratt Impulsiveness Scale (BIS-11). Risultati: i soggetti affetti da BED, rispetto ai controlli, hanno presentato un maggior BMI (34,8±8,1 vs. 21,1±1,6 kg/m2, p<0,01), maggiori livelli d’impulsività statisticamente significativi sia nel totale della BIS-11 (p<0,01) sia nei fattori di II ordine della stessa scala: Impulsività Attentiva, Motoria e da non pianificazione (p<0,01). L’impulsività ha mostrato una correlazione positiva con alcuni domini della EDI-2 (p<0,01). Nel gruppo BED il totale della BIS-11 non è correlato al BMI. Dopo aver effettuato una Regressione Logistica Multipla abbiamo trovato un incremento del 33% di rischio di BED per un punto di differenza nella scala di Impulsività da non pianificazione (p<0,02). Nel gruppo di pazienti affetti da BED, 16 soddisfacevano i criteri diagnostici per Disturbo Bipolare Tipo I o II; i soggetti con BED e BD non hanno mostrato differenze significative in nessuna delle variabili rispetto ai soggetti con BED senza BD (Kruskas – Wallis test, Test POST-HOC di Dunn). Conclusioni: i dati ottenuti dalla presente ricerca sono in accordo con i pochi studi esistenti in letteratura che supportano maggiori livelli d’impulsività nei DCA e nel BED. Sorprendentemente, questa dimensione sembra non collegata a una sottostante diatesi bipolare che era ben rappresentata nel nostro campione come diagnosi d’Asse I. Abbiamo riscontrato le correlazioni che ci attendevamo con la sottoscala Regolazione degli Impulsi della EDI-2, confermando la validità di questa scala addizionale. L’assenza di peculiarità legata alla comorbidità con il Disturbo Bipolare potrebbe indicare che alcuni aspetti impulsivi rilevabili nel BED quali il non riuscire a non iniziare e a non smettere di mangiare, il mangiare in risposta agli stati emotivi e l’impulsività da non pianificazione, intesa come il preferire una gratificazione immediata ad un vantaggio futuro, appartengono al nucleo del disturbo alimentare più che all’instabilità emotiva legata al disturbo dell’umore

Psychopathology of addiction: Can the SCL90-based five-dimensional structure differentiate Heroin Use Disorder from a non-substance-related addictive disorder such as Gambling Disorder?

Abstract Background In the Gambling Disorder (GD), there is no exogenous drug administration that acts as the central core of the traditional meaning of addiction. A specific psychopathology of Substance Use Disorders has been proposed recently. In a sample of Heroin Use Disorder (HUD) patients entering opioid agonist treatment, it became possible to identify a group of 5 mutually exclusive psychiatric dimensions: Worthlessness-Being trapped (W-BT), Somatic Symptoms (SS), Sensitivity-Psychoticism (SP), Panic Anxiety (PA) and Violence-Suicide (VS). The specificity of these dimensions was suggested by the absence of their correlations with treatment choice, active substance use, psychiatric comorbidity and the principal substance of abuse and by the opportunity, through their use, of fully discriminating HUD from Major Depression patients and, partially, from obese non-psychiatric patients. To further support this specificity in the present study, we tested the feasibility of discriminating HUD patients from those affected by a non-substance-related addictive behaviour, such as GD. In this way, we also investigated the psychopathological peculiarities of GD patients. Methods We compared the severity and frequency of each of the five aspects found by us, in 972 (83.5% males; mean age 30.12 ± 6.6) HUD and 110 (50% males; average age 30.12 ± 6.6) GD patients at univariate (T test; Chi square) and multivariate (discriminant analysis and logistic regression) level. Results HUD patients showed higher general psychopathology indexes than GD patients. The severity of all five psychopathological dimensions was significantly greater in HUD patients. Discriminant analysis revealed that SS and VS severity were able to discriminate between HUD (higher severity) and GD patients (lower severity), whereas PA and SP could not. W-BT severity was negatively correlated with SS and VS; GD patients were distinguished by low scores for SS and VS low scores associated with high ones for W-BT. Psychopathological subtypes characterized by SS and VS symptomatology were better represented in HUD patients, whereas PA symptomatology was more frequent in GD individuals. No differences were observed regarding the W-BT and SP dimensions. At multivariate level, the one prominent characteristic of HUD patients was the presence of SS (OR = 5.43) as a prominent qualification for psychopathological status. Conclusions Apart from the lower severity of all psychopathological dimensions, only the lower frequency of SS typology seems to be the prominent factor in GD patients. The SCL90-defined structure of opioid addiction seems to be useful even in non-substance-related addictive disorders, as in the case of GD patients, further supporting the possible existence of a psychopathology specific to addiction

Opposed effects of hyperthymic and cyclothymic temperament in substance use disorder (heroin- or alcohol-dependent patients)

Introduction In the last decade, the comprehension of affective temperaments has helped us to outline the boundaries of mood disorders, and to expand our knowledge of nosographic areas other than those of affectivity, even if affectivity is closely related to them. In the field of substance use disorders, the temperamental profile of heroin addicts and alcoholics has been discussed elsewhere, but no comparison has yet been made between these two patient populations. Such a comparison would help to shed light on the pathogenetic mechanisms that link temperament with substance abuse. Methods 63 Heroin Use Disorder (HUD) and 94 Alcohol Use Disorder (AUD) patients were compared with 130 healthy controls, with the aim of outlining affective temperament quantity and typology according to the formulation of Akiskal and Mallya. Results Cyclothymic temperamental quantity differentiated - both at the univariate and multivariate levels - between patients who had various different types of Substance Use Disorder, largely irrespective of the principal substance of abuse (heroin or alcohol); irritable temperament quantity differentiated HUD patients from AUD patients. Hyperthymic temperament typology seemed to be more frequent in healthy controls at both univariate and multivariate levels. Limitation Cross-sectional study. Conclusions Our analyses suggest that cyclothymic temperament quantity could best correspond to the temperamental profile of Substance Use Disorder patients independently of principal substance of abuse (alcohol or heroin), and that irritable temperament quantity may differentiate HUD from AUD patients. Hyperthymic temperament typology seemed to be highly protective for HUD and, though a bit less, for AUD patients, and was a typical feature of healthy controls

Six-Month Outcome in Bipolar Spectrum Alcoholics Treated with Acamprosate after Detoxification: A Retrospective Study

Background: Glutamate system is modified by ethanol and contributes both to the euphoric and the dysphoric consequences of intoxication, but there is now growing evidence that the glutamatergic system also plays a central role in the neurobiology and treatment of mood disorders, including major depressive disorders and bipolar disorders. We speculate that, using acamprosate, patients with bipolar depression (BIP-A) can take advantage of the anti-glutamate effect of acamprosate to “survive” in treatment longer than peers suffering from non-bipolar depression (NBIP-A) after detoxification. Method: We retrospectively evaluated the efficacy of a long-term (six-month) acamprosate treatment, after alcohol detoxification, in 41 patients (19 males and 22 females), who could be classified as depressed alcoholics, while taking into account the presence/absence of bipolarity. Results: During the period of observation most NBIP-A patients relapsed, whereas a majority of BIP-A patients were still in treatment at the end of their period of observation. The cumulative proportion of ‘surviving’ patients was significantly higher in BIP-A patients, but this finding was not related to gender or to other demographic or clinically investigated characteristics. The treatment time effect was significant in both subgroups. The treatment time-group effect was significant (and significantly better) for bipolar patients on account of changes in the severity of their illness. Limitations: Retrospective methodology and the lack of DSM criteria in diagnosing bipolarity. Conclusions: Bipolarity seems to be correlated with the efficacy of acamprosate treatment in inducing patients to refrain from alcohol use after detoxification (while avoiding relapses) in depressed alcoholics. Placebo-controlled clinical trials are now warranted to check the validity of this hypothesis

Differentiating between the course of illness in bipolar 1 and chronic-psychotic heroin-dependent patients at their first agonist Opioid treatment

In an effort to inquiry the "self-medication hypothesis" in heroin-dependent patients suffering from chronic psychosis and bipolar disorder, a naturalistic comparative cohort study was designed with the aim of comparing, according to the presence of dual diagnosis, the clinical characteristics of heroin-dependent patients presenting for their first agonist opioid treatment. The main finding was that addictive (heroin) illness was more severe in bipolar 1 patients and less severe in chronic psychotic patients when compared with heroin-dependent patients without dual diagnoses. In the case of chronic psychotic patients, these differences do not allow us to exclude a therapeutic heroin use, at least at the beginning of their toxicomanic career, with limited progression of their addictive disease. This occurrence seems to be excluded for bipolar 1 heroin-dependent patients, who come to their first agonist opioid treatment with a more severe addictive disease

Chronology of illness in dual diagnosis heroin addicts: The role of mood disorders

Background Recent celebrity deaths have been widely reported in the media and turned the public attention to the coexistence of mood, psychiatric and substance-abuse disorders. These tragic and untimely deaths motivated us to examine the scientific and clinical data, including our own work in this area. The self-medication hypothesis states that individuals with psychiatric illness tend to use heroin to alleviate their symptoms. This study examined the correlations between heroin use, mood and psychiatric disorders, and their chronology in the context of dual diagnosis. Methods Out of 506 dual diagnosed heroin addicts, 362 patients were implicated in heroin abuse with an onset of at least one year prior to the associated mental disorder (HER-PR), and 144 patients were diagnosed of mental illness at least one year prior to the associated onset of heroin use disorder (MI-PR). The retrospective cross-sectional analysis of the two groups compared their demographic, clinical and diagnostic characteristics at univariate and multivariate levels. Results Dual diagnosis heroin addicts whose heroin dependences existed one year prior to their diagnoses (HER-PR) reported more frequent somatic comorbidity (p < 0.001), less major problems at work (p=0.003), more legal problems (p=0.004) and more failed treatment for their heroin dependence (p<0.001) in the past. More than 2/3 reached the third stage of heroin addiction (p= < 0.001). Their length of dependence was longer (p=0.004). HER-PR patients were diagnosed more frequently as affected by mood disorders and less frequently as affected by psychosis (p=0.004). At the multivariate level, HER-PR patients were characterized by having reached stage 3 of heroin dependence (OR=2.45), diagnosis of mood disorder (OR=2.25), unsuccessful treatment (OR=2.07) and low education (OR=1.79). Limitations: The main limitation is its retrospective nature. Nonetheless, it does shed light on what needs to be done from a clinical and public health perspective and especially prevention. Conclusions The data emerging from this study, does not allow us to determine a causal relation between heroin use and mental illness onset. However, this data, even if requiring longitudinal studies, suggest that self-medication theory, in these patients, can be applied only for chronic psychoses, but should not be applied to patients with mood disorders using heroin

Towards a specific psychopathology of heroin addiction. Comparison between heroin use disorder and major depression patients

It is our conviction that mood, anxiety and impulse-control dysregulation, lie at the psychopathological core of the Addictions. In this vision, we are confident that Heroin Use Disorder (HUD) has a specific psychopathology when compared with other mental disorders. Methods: We compared 972 HUD patients with 504 Major Depression (MD) patients on the basis of five SCL-90 dimensions that had previously been identified in HUD patients, with the purpose of estimating the magnitude of the differences, in terms of psychopathological symptoms. Results: Prominent psychopathological domains are more frequent in HUD patients, in particular, "worthlessness and being trapped", "somatic-symptoms" and "sensitivity psychoticism". The "violence-suicide" dimension is more frequent in MD patients, while the "panic anxiety" dimension fails to differentiate between the two groups. The prominent psychopathological groups are the most important factor in significantly differentiating between the two groups, when drawing comparisons on the basis of age, male gender and the severity of psychopathological symptoms. Conclusions: Our results suggest that the five found psychopathological dimensions seem to confirm the trait, instead of the state, nature of our proposed psychopathology of heroin addiction. In any case, the psychopathological symptoms of HUD and MD patients seem to differ quantitatively and qualitativel