I disturbi del sonno.

Sul piano della classificazione, i disturbi del sonno vengono classificati in maniera diversa dal DSM-IV-TR, dall’ICD-10 e dall’International Classification of Sleep Disorders (ICSD) dell’American Sleep Disorders Association, benché i quadri descritti siano ovviamente sul piano clinico i medesimi. In oncologia non sono numerosi gli studi che hanno approfondito quest’argomento, benché sia stata riportata la necessità di una maggior precisione nel definire, all’interno delle complicanze neuropsichiatriche secondarie al cancro, anche i disturbi del sonno. Il capitolo prende in esame i principali distrubi del sonno in oncologia e il loro trattamento

Gli strumenti testali.

Un’area significativa dell’attività di Psichiatria di C-L è rappresentata dall’impiego di strumenti testistici, intesi come ausilio diagnostico a quanto, all’interno del colloquio psichiatrico. Il loro utilizzo, ferma restando la consapevolezza dell'irriducibilità dell'esperienza umana e della molteplicità dei fattori che influenzano le risposte soggettive agli eventi di vita mira fondamentalmente a cogliere e definire in parametri precisi alcuni fenomeni psichici e comportamentali, dalle caratteristiche di personalità, ai sintomi di sofferenza psicopatologica, dalle modalità di risposta emozionale alla malattia alle funzioni cognitive. In Psichiatria di C-L l’importanza della misurazione di diversi parametri psichici e comportamentali assume certamente un ruolo significativo. Nell’ambito degli strumenti a disposizione della clinica, è solitamente operata una distinzione tra strumenti a carattere proiettivo e strumenti a carattere obiettivo (rating scales e strumenti self-report). In questo capitolo, vengono presi in esame in particolare gli strumenti a carattere obiettivo, fornendo alcuni concetti generali relativamente alle caratteristiche e ai criteri psiconmetrici che costituiscono la base per la costruzione e l’impiego degli strumenti stessi. Verranno inoltre descritti alcuni tra gli strumenti più usati in ambito consulenziale, in particolare quelli impiegati per la valutazione della personalità, dei sintomi psicopatologici, degli stili di reazione e di comportamento verso la malattia e delle funzioni cognitive

Psychosocial aspects of cancer in movies. A survey oriented to medical didactics

INRODUCTION: The need for training cancer care professionals on psychosocial issues in oncology has been reported as a relevant area. The use of movies has been repeatedly showed to be a powerful didactic instrument in psychiatry. The aim of this study was to examine the use of movies dealing with cancer subjects as a possible further tool in training cancer care professionals. METHODS: The study, as a part of a more general one concerning cancer and the media, examined the most important movies produced over the last 50 years which explicitly contained cancer themes. The Morandini Movie Dictionary, the web sites (e.g. Cinema and Disabilities), with the addition of movie reviews from specialized magazines, were employed for the survey. RESULTS: 137 titles were selected and classified according to time of production . A full descriptive analysis of the story was performed in order to classify the movies by main themes (e.g., doctor-patient relationship, family issues, death and dying) and the main psychosocial implication (e.g. emotional reactions and coping, social support, spirituality). A series of short video-clips were created to be used in Psychosocial Aspects of Cancer Care workshops for cancer care professionals. DISCUSSION: The study showed that significant didactic material deriving from cancer movies can be easily and flexibly inserted in different formats of psycho-oncology workshops in order to favour awareness, introspection and discussion (in small and in large groups) of participants

Gabapentin treatment of impulsive-aggressive behaviour

Gabapentin is a relatively new antiepileptic agent structurally similar to gamma-aminobutyric acid (GABA), with unclear mechanisms of action and a good safety profile. It has been used in psychiatric practice, with promising results, for the treatment of several disorders (e.g. bipolar disorder, schizoaffective disorder, obsessive-compulsive disorder, social phobia, behavioral agitation in dementia). With regard to aggressive behavior, a few studies have reported significant improvement in symptoms among demented patients , while in one study it has been indicated a decrease in frequency and intensity of violent episodes in a young patient affected by intermittent explosive disorder, attention deficit hyperactivity disorder, organic mood disorder secondary to a closed head injury, simple partial seizure disorder after treatment with gabapentin (1200mg/day). We report a case of successful treatment of chronic impulsive aggressive behavior by using gababentin in a patient with severe borderline personality disorder

Dalla comunit\ue0 terapeutica al trattamento residenziale intensivo: esperienza di un processo trasformativo

Dalla comunit\ue0 terapeutica al trattamento residenziale intensivo: esperienza di un processo trasformativ

Factor structure of the Brief Psychiatric Rating Scale in unipolar depression

Background: In clinical practice patients with unipolar depression present with a variety of symptom clusters that may combine together in many different ways. However, only few factor analytic studies used general psychopathology scales to investigate the symptom structure of unipolar depression. Methods: The study included 163 consecutive inpatients with an ICD-10 diagnosis of depressive disorder (ICD-10 codes F32 to F33). All patients were assessed with the 18-item version of the Brief Psychiatric Rating Scale (BPRS) within 3 days from admission. Exploratory factor analysis with Varimax rotation was performed on BPRS items. Results: Four factors were extracted, explaining 52% of total variance. They were interpreted as Apathy, Dysphoria, Depression and Psychoticism. The distribution of factor scores was approximately normal for Apathy, while it displayed a slight negative skewness for Depression, a slight positive skewness for Dysphoria, and a marked positive skewness for Psychoticism. Patient sex, family history of depression, lifetime history of suicide attempt, and recent serious family conflict were not associated with any factor. Occupational status, age, and age at onset displayed a positive correlation with Apathy. Duration of illness and number of previous admissions were positively correlated with Dysphoria. Limitations: Patients were not administered a structured diagnostic interview, and no detailed assessment of personality disorders was performed; also, patients were recruited only at a single site, which reduces the generalizability of the results. Conclusions: Our findings suggest that in depressive disorders there are psychopathological dimensions other than depressed mood that are worthy of greater clinical attention and research. Dimensions such as apathy and dysphoria may play an important part in the clinical phenomenology of unipolar depression and deserve systematic and careful assessment in order to provide patients with the best possible treatment and improve clinical outcomes

Use of the diagnostic criteria for psychosomatic research in oncology

BACKGROUND: Psycho-oncology literature has shown that 30-50% of cancer patients meet the criteria for a psychiatric diagnosis, according to the usual nosographic classification (e.g. DSM). The Diagnostic Criteria for Psychosomatic Research (DCPR) have been shown to be useful in identifying psychological constellations in patients with medical illness. The aims of the study were to compare the DSM-IV and the DCPR in their application to cancer patients. METHOD: One hundred and forty-six patients with cancer underwent semistructured interviews to assess psychiatric morbidity and psychosocial syndromes according to the DSM-IV and the DCPR, respectively. The Brief Symptom Inventory (BSI) was also used to assess psychological stress symptoms. RESULTS: Sixty-five subjects (44.5%) met the criteria for a DSM-IV diagnosis (DSM cases), while 104 patients (71.2%) presented symptoms meeting the criteria for at least one DCPR syndrome. Three DCPR dimensions were more frequent than others, specifically Health Anxiety (37.7%), Demoralization (28.8%) and Alexithymia (26%). Among the subjects with no formal DSM-IV diagnosis (n = 81), 58% had at least one DCPR syndrome. DSM-IV cases had higher scores on several BSI subscales in comparison with patients with only one DCPR syndrome, while no difference was found in patients with more than one DCPR diagnosis. CONCLUSIONS: The DCPR system was found to be useful in oncology in investigating psychological conditions which are not identified by the DSM-IV alone. Assessment of more specific constructs, other than intensity of general stress symptoms, may give more specific information and help in tailoring psychological intervention for patients with cancer

Psychological factors affecting oncology conditions.

The area of psychological factors affecting cancer has been the object of research starting from the early 1950s and consolidating from the 1970s with the development of psychooncology. A series of problems in the DSM and ICD nosological systems, such as the difficult application of the criteria for psychiatric diagnoses (i.e. major depression, adjustment disorders) and the scarce space dedicated to the rubric of psychosocial implications of medical illness (i.e. Psychological Factors Affecting a Medical Condition under 'Other Conditions That May Be a Focus of Clinical Attention' in the DSM-IV) represent a major challenge in psycho-oncology. The application of the Diagnostic Criteria for Psychosomatic Research (DCPR) has been shown to be useful in a more precise identification of several psychological domains in patients with cancer. The DCPR dimensions of health anxiety, demoralization and alexithymia have been shown to be quite frequent in cancer patient (37.7, 28.8 and 26%, respectively). The overlap between a formal DSM-IV diagnosis and the DCPR is low, with 58% of patients being categorized as non-cases on the DSM-IV having at least one DCPR syndrome. The specific quality of the DCPR in characterizing psychosocial aspects secondary to cancer is also confirmed by the fact that some dimensions of coping (e.g. Mini-Mental Adjustment to Cancer subscale hopelessness) correlate with the DCPR dimension of demoralization, while a quantitative approach on symptom assessment (e.g. stress symptoms on the Brief Symptom Inventory) is not useful in discriminating the patients with and without DCPR syndromes. More research is needed in order to understand the relationship between DCPR constructs (e.g. alexithymia) and psychosocial factors which have been shown to be significant in oncology (e.g. emotional repression and avoidance). The role of specific DCPR constructs in influencing the course of illness is also an area that should be investigated

Efficacy of a Short-term Psychoeducational Intervention for Persistent Nonorganic Insomnia in Severely Mentally ill Patients. A pilot study.

Insomnia in psychiatric patients is frequently underestimated in clinical practice. Usually drugs are prescribed for the treatment of this disorder but non-pharmacological intervention can be successfully used. The present study aimed at evaluating the efficacy of a two-session psychoeducational intervention in improving persistent non-organic insomnia and reducing the administration of PRN therapy in severely mentally ill patients. A pre-post study was performed on 36 psychiatric patients admitted to a residential psychiatric unit. The Nocturnal Sleep Onset Scale (NSOS) and Daytime Sleepiness Scale (DSS), the sleep onset latency, the time awake after sleep onset and the numbers of awakenings were gathered 2 weeks before the intervention (T0), immediately prior the intervention (T1), 2 weeks after the last session of the intervention (T2) and a 3-month follow-up (T3). The total number of administrations of PRN therapy from T0 to T1 and from T1 to T2 were also examined. A significant reduction was shown on the NSOS, the sleep onset latency and in the time awake after sleep onset from T1 to T2 and from T1 to T3, while no significant difference was found between T0 and T1. A significant decrease on the mean number of administrations of PRN therapy was also found between 15 days before the intervention (T0-T1) and 15 days after intervention (T1-T2). The initial results of this study seems to suggest the possible efficacy of a short-term psychoeducational intervention on improving persistent non-organic insomnia in severely mentally ill patients. Further control studies are necessary to confirm these findings

Determinants of antipsychotic polypharmacy in psychiatric inpatients: a prospective study

A recent survey of clinicians' opinions suggested that antipsychotic polypharmacy is reserved for particularly severe cases, and that it is intended to avoid high doses of a single drug. In the present study, we tested these clinicians' reasons for antipsychotic polypharmacy in a sample of Italian psychiatric inpatients. During a 6-year recruitment period, all psychiatric patients receiving antipsychotic therapy at discharge from an inpatient facility were included. Sociodemographic and clinical data were collected, and the 18-item version of the Brief Psychiatric Rating Scale was administered on admission and before discharge. At discharge, data on length of inpatient stay, psychotropic drug therapy and treatment adherence were collected. Prescribed daily doses were converted into multiples of the defined daily doses. A total of 354 inpatients receiving antipsychotic treatment at discharge were included. Of these, 100 (28%) were discharged with two or more antipsychotic drugs. After background group differences were controlled for, positive symptoms, manic/hostility symptoms and polypharmacy on admission were predictors of polypharmacy at discharge. The risk of high-dose antipsychotics in patients receiving polypharmacy at discharge was 10-fold higher than that in patients receiving one antipsychotic (odds ratio 10.70, 95% confidence interval 4.78-23.97, P<0.001). The perception of clinicians is to reserve antipsychotic polypharmacy for severe, persistent and difficult-to-treat cases, and this was confirmed by the finding that patients discharged on two or more antipsychotic agents were more severely ill on admission. Conversely, the theoretical advantage of avoiding a high dose of a single drug is counterbalanced by the documented disadvantage of administering high total doses