Characteristics of psychiatric comorbidities in emergency medicine setting and impact on length of hospitalization: A retrospective study

This study aims to evaluate clinical correlates of psychiatric comorbidity and length of hospitalization in patients admitted in a general hospital emergency medicine setting. Overall, 160 patients hospitalized for different acute medical pathologies were selected consecutively over 12 months. All subjects were evaluated with proper forms to collect data on medical and psychiatric diagnoses. Levels of C-reactive protein were also measured in all patients. Statistical analyses were conducted with univariate, logistic, and multiple linear regressions. Patients with psychiatric comorbidity had significantly longer hospitalization than did patients with no psychiatric diagnoses (days 10.9±9.5 vs. 6.9±4.5, p<0.005). Agitation and delirium were more frequent in the psychiatry comorbidity study group (p<0.05), as was cognitive impairment (p=0.001). These variables predicted longer hospitalisation (respectively: t=-3.27, p=0.002; t=-2.64, p=0.009; t=-2.85, p=0.006). Psychiatric comorbidity acts as an adjunct factor in determining clinical severity and predicting a more difficult recovery in patients hospitalized in an emergency medicine setting

Spettro Autistico, Spettro Post-Traumatico da Stress e Ruminazioni in un campione di pazienti affetti da Disturbo Borderline di Personalità

Introduzione: il rapporto tra Disturbo Borderline di Personalità (DBP) e Spettro Autistico è scarsamente indagato in letteratura. È invece oggetto di numerosi studi il legame tra DBP e Disturbo Post-Traumatico da Stress (DPTS). Obiettivi: analizzare la relazione fra lo Spettro Autistico e il DBP, con e senza comorbidità con DPTS, e di valutare se le diverse dimensioni afferenti allo spettro autistico siano predittive del DBP. Valutare inoltre il carattere predittivo dello spettro post-traumatico da stress in relazione alla componente ruminativa nel DBP. Metodo: 119 soggetti, di cui 50 con diagnosi di DBP e 69 senza disturbi psichiatrici (CTL), sono stati valutati per mezzo dell’Intervista Clinica Strutturata per il DSM-5 (SCID-5 RV), l’Adult Autism Subthreshold Spectrum (AdAS-SR), e la Ruminative Response Scale (RRS). Risultati: i pazienti con DBP rispettivamente senza (DBP-noDPTS) e con (DBP-DPTS) comorbidità con DPTS e il gruppo CTL differivano significativamente sia per il punteggio totale dell’AdAS Spectrum che per i punteggi riportati a ciascuno dei domini (tutte p < .001). I confronti post-hoc, mostravano che sia il punteggio totale dell’AdAS Spectrum che i punteggi riportati a ciascuno dei domini erano significativamente più alti nel gruppo DBP-DPTS rispetto al gruppo DBP-noDPTS e nel gruppo DBP-noDPTS rispetto al gruppo CTL. I domini Interessi ristretti e ruminazione (p = .040) e Iper-iporeattività agli stimoli (p = .035) hanno mostrato di predire in maniera significativa la diagnosi DBP-DPTS. Il dominio Interessi ristretti e ruminazioni ha mostrato di predire in maniera significativa la diagnosi di DBP-noDPTS (p = .007). Il dominio Routinarietà e Inflessibilità è risultato un predittore negativo di questa diagnosi (p = .025). Nei pazienti con DBP sono significativamente predittivi i domini Routinarietà e Inflessibilità (p = .030) e Interessi ristretti e ruminazioni (p = .005) dell’AdAS con effetto protettivo della Routinarietà e Inflessibilità. Ogni singolo criterio per il DPTS aumenta la probabilità di avere il DBP di quasi 3 volte (p < .001). Altro dato di rilievo è il ruolo che le Ruminazioni hanno nel predire la diagnosi di DBP. I punteggi dei domini Ruminazione (p = .019) e Depressione (p = .017) della RRS e i criteri DSM-5 del DPTS (p < .001) predicevano significativamente e in maniera positiva la diagnosi di DBP. I punteggi del dominio Riflessione (p = .047) della RRS prediceva significativamente ma con segno negativo la diagnosi di DBP. Discussione e conclusioni: il nostro studio mostra che i pazienti con DBP presentano una dimensione autistica sotto-soglia significativamente più alta che nel campione di controllo. I pazienti con DBP che presentano una comorbidità con DPTS hanno i valori più alti di tratti autistici, superiori ai controlli sani, ma anche ai soggetti DBP senza DPTS. Una possibile interpretazione è che i tratti autistici rappresentino un elemento di vulnerabilità per l’innesco di un effetto psicopatologico a seguito di un trauma, determinando una sintomatologia DPTS. La sintomatologia DPTS, a sua volta, sovrapponendosi ai tratti autistici, potrebbe determinare un fenotipo clinico sovrapponibile a quello osservabile nel DBP. Ulteriori studi longitudinali sono necessari per corroborare i dati ottenuti e confermare questa ipotesi

Electroconvulsive therapy for acute mania: predictors of response and outcome in a drug-resistant sample

Introduction: Manic episodes are associated with high morbidity and mortality and represent severe clinical conditions that need urgent interventions. The first choice treatments are mood-stabilizers and antipsychotics. Electroconvulsive therapy (ECT) is indicated in case of refractory mania and, despite historical and recent evidence of efficacy, is heavily underutilized. ECT has been shown to be particularly useful, with response rates ranging from 75% to over 90%, for severe and delirious mania, often associated with life-threatening physical exhaustion, rapid cycling, and drug resistance,. Aim of the study: The short-term outcome of a sample of severe and drug resistant manic patients treated with ECT was evaluated in order to explore possible demographic and clinical predictors of non-response. Method: This naturalistic and observational study was conducted in a cohort of 24 treatment-resistant manic patients who underwent bilateral ECT between January 2006 and December 2021. All patients were evaluated prior and after the ECT course using the Brief Psychiatric Rating Scale (BPRS), the Young Mania Rating Scale (YMRS) and the Clinical Global Impression scale (CGI). All patients showed a particularly severe manic symptomatology nonresponsive to multiple treatment trials with a combination of mood stabilizers, antipsychotics and benzodiazepines. Results: Overall, 75% of the sample responded to ECT. Chronicity of the episode, intended as a duration > 6 months and, generally, its duration emerged as significantly different between responder and non-responders and acted as predictors of non-response (p<0.10). Responders showed higher rates of delirious mania (p<0.10), which was characterized by shorter episodes with higher severity on YMRS scoring, and it resulted to be associated with response to ECT (OR 10.65, p<0.10). Conclusions: Overall, 75% of our severe drug resistant manic patients responded to ECT. In our sample, the duration of the manic episode and the chronicity of manic symptoms (> 6 months) are associated with non-response to ECT. This result is consistent with previous observation on depression and mixed states. The high response rate of the entire sample and the high rate of remission of delirious mania are in line with the results of naturalistic studies on real-world practice. Our results seems to indicate the use of ECT for this clinical picture in the early stages of treatment, and not as “last resort”. Further controlled studies in larger samples are necessary

Is There a Major Role for Undetected Autism Spectrum Disorder with Childhood Trauma in a Patient with a Diagnosis of Bipolar Disorder, Self-Injuring, and Multiple Comorbidities?

This case report highlights the relevance of the consequences of trauma in a female patient with an undetected autism spectrum disorder (ASD) affected by bipolar disorder (BD) with multiple comorbidities. A 35-year-old woman with BD type II, binge eating disorder and panic disorder was admitted in the Inpatient Unit of the Psychiatric Clinic of the University of Pisa because of a recrudescence of depressive symptomatology, associated with increase of anxiety, noticeable ruminations, significant alteration in neurovegetative pattern, and serious suicide ideation. During the hospitalization, a diagnosis of ASD emerged besides a history of childhood trauma and affective dysregulation, marked impulsivity, feeling of emptiness, and self-harm behavior. The patient was assessed by the Autism-Spectrum Quotient (AQ), Ritvo Autism and Asperger Diagnostic Scale (RAADS-R), the Adult Autism Subthreshold Spectrum (AdAS Spectrum), Trauma and Loss Spectrum (TALS-SR), and Ruminative Response Scale (RRS). Total scores of 38/50 in the AQ, 146/240 in the RAADS-R, 99/160 in the AdAS Spectrum emerged, compatible with ASD, 47/116 in the TALS-SR, and 64/88 in the RRS. We discuss the implications of the trauma she underwent during her childhood, in the sense that caused a complex posttraumatic disorder, a lifelong disease favored and boosted by the rumination tendency of high functioning ASD

Neurodevelopmental Disorders, Schizophrenia Spectrum Disorders and Catatonia: The “Iron Triangle” Rediscovered in a Case Report

Catatonia is a complex neuropsychiatric syndrome, occurring in the context of different psychiatric and neurodevelopmental disorders, in neurological and medical disorders, and after substance abuse or withdrawal. The relationship between Autism Spectrum Disorder (ASD), Schizophrenia Spectrum Disorders (SSDs) and catatonia has been previously discussed, with the three disorders interpreted as different manifestations of the same underlying brain disorder (the “Iron Triangle”). We discuss in this paper the diagnostic, clinical and therapeutic implications of this complex relationship in an adolescent with ASD, who presented an acute psychotic onset with catatonia, associated with mixed mood symptoms. Second-generation antipsychotics were used to manage psychotic, behavioral and affective symptoms, with worsening of the catatonic symptoms. In this clinical condition, antipsychotics may be useful at the lowest dosages, with increases only in the acute phases, especially when benzodiazepines are ineffective. Mood stabilizers with higher GABAergic effects (such as Valproate and Gabapentin) and Lithium salts may be more useful and well tolerated, given the frequent association of depressive and manic symptoms with mixed features

Predictors of Suicidal Ideation and Preparatory Behaviors in Individuals With Bipolar Disorder: The Contribution of Chronobiological Dysrhythmicity and Its Association With Hopelessness

Objective: To examine the role of chronobiological dysrhythmicity in suicidal ideation and behaviors and its relation with hopelessness.Methods: One hundred twenty-seven patients (77 females, mean age of 47.4 +/- 12.5 years) with a major depressive episode and bipolar disorder (BD) type I or II (according to Structured Clinical Interview for DSM-5 assessment) were recruited in 2019 and assessed for depressive and manic symptoms (Beck Depression Inventory-II, Young Mania Rating Scale) and with the Biological Rhythms Interview of Assessment in Neuropsychiatry, Beck Hopelessness Scale, and Scale for Suicide Ideation. Univariate regression and mediation analyses were performed.Results: Forty-one patients (32.3%) showed clinically significant suicidal ideation and were more frequently affected by BD type I (P = .029) with mixed features (P = .022). Compared to nonsuicidal individuals, they had significantly more depressive symptoms (P = .019), higher emotional component of hopelessness (P = .037), and higher dysrhythmicity of sleep (P = .009), activities (P = .048), and social life (P = .019). Passive and active suicidal ideation and suicidal plans were best predicted by dysrhythmicity of sleep and social life. Dysrhythmicity of sleep and social life mediated the direct effect of depressive symptoms on passive and active suicidal ideation and also of active ideation on suicidal plans. The emotional component of hopelessness was related to dysrhythmicity of social life and mediated its effect on suicidal plans (P = .010).Conclusions: Chronobiological alterations directly contributed to passive and active suicidal ideation and to suicidal preparation, with a key role of dysrhythmicity of sleep, activities, and social life. Chronobiological alterations also impacted the emotional component of hopelessness, hence indirectly contributing to suicidal ideations and plans. These findings call for the systematic screening of these dysrhythmicity dimensions when considering suicidal risk in individuals with BD