MIXED STATES: A “NEW” NOSOGRAPHIC ENTITY

Objective: Mixed states represent a controversial topic in the current psychiatry. The definitions and the diagnostic criteria have changed over the past years. The new DSM-5 classification will have a substantial impact in several fields: epidemiology, diagnosis, treatment, research, education, and regulations. Methods: We reviewed the latest literature by using the key words “mixed states” and “agitated depression” on the PubMed. Results: Although there is a great expectation about the validity of the new DSM-5 mixed states diagnosis, little is known about its application on large population study but the formulation of less restrictive and more specific criteria for the diagnosis of mixed states represent a starting point for future researches, mainly in consideration of the fact that previous classifications consider the MS a superposition of manic and depressive symptoms, underestimating the clinical complexity and the wider phenomenologic variability of these conditions. Conclusions: Clinical trials need to address treatment effects according to the presence or absence of mixed features in consideration of the fact that replacing in the bipolar spectrum patients that traditionally are considered to be affected by unipolar depression, represent a topical research hypothesis and has a practical remarkable importance in the appropriate therapeutic choice

COMPARISON OF ASSESSMENT AND MANAGEMENT OF SUICIDAL RISK FOR ACUTE PSYCHIATRIC ASSESSMENT BETWEEN TWO STATE SPONSORED HOSPITALS IN ENGLAND AND ITALY

The risk of suicide is one of the most important risk factors looked into for acute psychiatric assessments that influences the management plan. The prevalence of suicide is on a rise across European countries; as a consequence, the different countries have created specific guidelines and policies in order to prevent suicides in the acute settings. These guidelines are based on both different cultural aspects as well as the different organization of the mental health system in the different countries. This paper wants to present the comparison between the guidelines of two European countries, England and Italy, in order to evaluate the systems, understand differences and common contact points. The different European countries could learn one from the other and a European shared point of view may be a way forward to create better understanding and preventing the risk of suicide across the population

BIPOLAR AND BORDERLINE PERSONALITY DISORDERS: A DESCRIPTIVE COMPARISON OF PSYCHOPATHOLOGICAL ASPECTS IN PATIENTS DISCHARGED FROM AN ITALIAN INPATIENT UNIT USING PANSS AND BPRS

Background: There is current scientific debate in consideration of the possibility to consider the Borderline Personality Disorder (BPD) as a mood disorder within the bipolar spectrum furthermore, authors reported about the challenging differential diagnosis of BPD and Bipolar Disorder (BD). Subjects and methods: 32 patients hospitalized in the Inpatient Psychiatric Unit in Perugia, discharged with a diagnosis of BD or BPD, were included. Factor analyses of BPRS and PANSS items were performed. Association between socio-demographic, clinical and psychopathological variables was tested using bivariate analyses. Results: Factor analysis identified 6 Factors, explaining 67.6% of the variance, interpreted as follow: 1) Euphoric Mania, 2) Psychosis, 3) Inhibited Depression, 4) Disorganization, 5) Psychosomatic features, and 6) Mixed features. Bivariate analyses identified statistically significant differences between BPD and BD according to: PANSS positive symptoms domain, BPRS total score, Euphoric Mania and Disorganization. No statistically significant differences came up on socio-demographic and clinical aspects. Conclusion: Even though the sample is small, interesting findings came out from our investigation. Our findings are in line with the current literature. Euphoric mood, is one of the aspects which best differentiated BD from BPD. Higher scores in Disorganization, BPRS and PANSS positive symptoms in BD may be related to the fact that our sample is a group of patients from an acute inpatient unit, so the impact of the symptoms severity for BD may be remarkable

THE PSYCHOSOMATIC SPECTRUM: A CLINICAL-ANALYTIC SURVEY OF THE RELATIONSHIP BETWEEN EATING DISORDERS AND MIGRAINE

Objective: To evaluate if somatic symptoms of Eating Disorders and Migraine reflect similar aspects of personality and temperament. Methods: The clinical notes of 27 migraineurs and of 26 ED outpatients were reviewed; 40 medical students of the University of Perugia were recruited as healthy controls. TCI, DMI, SCID-II and TAS-20 were used. Statistical analysis: performed by logistic regression, a cluster analysis that gave the weight for the three groups, and a logistic regression of the cluster analysis. Results: Patients showed medium scores in almost all the scales of the different tests. High scores in HA and low scores in NS characterized both migraine and ED patients. Logistic regression of the cluster analysis underscored that ED patients, migraineurs, and controls differed for HA (435.424, p≤0.0001), TAS-20 F2 (difficulty in describing feelings to others; 7.087, p=0.029), and the defense mechanism turning against object (6.702, p=0.035). Discussion: The temperamental aspects of low NS and high HA represent the core symptoms of a spectrum composed of somatizing patients who use affective and behavioral strategies that are not functional enough in affective regulation

Malignant Melanoma Treated with Topical Imiquimod: A Bespoke Treatment That Spared the Amputation

Surgical excision represents the primary treatment for malignant melanoma. On occasion, however, surgery may not be possible, and a different approach is required. Imiquimod is a Toll-like receptor 7 agonist involved in the activation of the innate immune system. We report the case of a 77-year-old female with a large, invasive, malignant melanoma of the malleolar area. Due to the size of the lesion, its location, and the patient’s general condition, neither surgery nor radiotherapy were indicated. We offered topical treatment with 5% imiquimod to be applied once/day continuously over a 3-month period, pausing only when intense inflammation on the area of application occurred. Complete clinical and histological resolution of the lesion were observed. This case adds further merit to the growing body of evidence that imiquimod can be used to successfully treat malignant melanoma in cases where no other options are suitable

BIPOLAR DISORDER: THE IMPORTANCE OF CLINICAL ASSESSMENT IN IDENTIFYING PROGNOSTIC FACTORS - AN AUDIT. Part 1: An analysis of potential prognostic factors

Background: Prognostic factors of bipolar disorder must be identified to assist in staging and treatment, and this may be done primarily during the initial psychiatric assessment. In fact, most of the prognostic factors, which determine disease outcome, could be detected from simple but often-unrecorded questions asked during the psychiatric clinic visit. Methods: We collected data from the clinical notes of 70 bipolar outpatients seen at the initial psychiatric assessment clinic about socio-demographic and clinical factors to determine whether various factors had relevance to prevalence, prognosis, or outcome. Results: The sample comprised 16 bipolar I (22.9%) and 54 bipolar II (77.1%) outpatients; a psychiatric comorbidity was noted in 26 patients (37.1%). 60.9% (42 patients) reported anxiety features and 12 patients (17.6%) were noted to have obsessivecompulsive characteristics. Percentages reported in our results are of the sample for which the data was available. Anhedonia is a depressive feature that was present in most of the population where this data was available (92.2%, 59 patients) and 81.8% (54 patients) reported suicidal thoughts during a depressive episode. 74.6% (47 patients) had a family history of bipolar disorder, depression, suicide or psychosis. 27 patients (39.7%) reported current alcohol use and 14 patients (22.6%) current illicit drug use. A comparison between 10 prognostic factors found that only the correlations between current illicit drug use/previous illicit drug use (χ2=11.471, P<0.001), current alcohol use/previous alcohol use (χ2=31.510, P<0.001) and current illicit drug use/anxiety (χ2=5.094, P=0.022) were statistically significant; the correlation between previous illicit drug use/previous alcohol use (χ2=5.071, P=0.023) and previous alcohol use/family history (χ2=4.309, P=0.037) were almost statistically significant. 17 patients (24.3%) of the 70 bipolar patients were assigned to a care coordinator; we have evaluated the possible differences between the patients with or without a care coordinator on the basis of the presence of 10 possible prognostic factors and found no statistically significant differences between these two groups of patients. Conclusions: We have identified several trends in our patients with bipolar disorder that agree with previous research. Our sample suggested that the assignation of a care coordinator is not done on a clinical basis. In our sample, some patients were found not to have information available so we suggest that a questionnaire to remind clinicians of potentially useful information would be helpful to aid in prognostication. In particular, specific features of the disease, like family history, age at onset, and features of depressive episodes may be highlighted as our sample suggests that these are often unrecorded when not known or negative

BIPOLAR DISORDER: THE IMPORTANCE OF CLINICAL ASSESSMENT IN IDENTIFYING PROGNOSTIC FACTORS - AN AUDIT. Part 2: Mixed state features and rapid cycling

Background: Rapid cycling in bipolar disorder complicates the clinical picture and worsens the long-term outcomes of bipolar disorder. Mixed states features do similarly and are known to present an increased risk to patients. Early recognition of these patterns can lead to better treatment strategies and improvement of the long-term course of the disease. Method: We collected data from the clinical notes of 70 bipolar outpatients seen at an ASPA (initial assessment) clinic about socio-demographic and clinical characteristics. Results: The sample comprised 16 bipolar I (22.9%) and 54 bipolar II (77.1%) outpatients; percentages reported in our results are of the sample for which the data was available. 71.7 % (33 patients) of the sample reported mixed states features and 32 patients (72.7%) are recorded to have more than 4 changes in mood in a year. There were no statistically significant correlations between mixed state features or rapid cycling and anhedonia, suicidal ideation, borderline symptoms, OCD symptoms, anxiety, positive psychiatric family history, current alcohol use, previous alcohol use, current illicit drug use, or previous illicit drug use. An almost significant correlation was found between mixed state features and anxiety. Assignation of a care coordinator did not seem to be associated with these prognostic factors. Conclusions: The two subgroups of mixed state features and rapid cycling patients share very common clinical characteristics: high incidence of suicidal thoughts, high levels of anxiety, and high previous substance use – but low levels of current alcohol and drug use and high levels of features of atypical depression. These features of mixed state bipolar disorder and rapid cycling bipolar disorder should be identified during psychiatric assessment to identify useful information for prognosis

TRAUMATIC EVENTS IN CHILDHOOD AND THEIR ASSOCIATION WITH PSYCHIATRIC ILLNESS IN THE ADULT

Introduction: Child maltreatment is a well-known condition that is currently considered to be associated with the development of severe psychiatric conditions. Consequently, the authors decided to review the current literature in order to give a complete scenario of the situation in the world and to give recommendations about prevention and treatment as well as research goals. Methods: An electronic search was conducted through the means of MEDLINE database in order to find the most up to date peer-reviewed papers, including only those papers published in 2015. Results: 15 papers were included and analyzed the current situation in different countries: US (n.3), Australia (n.2), Ireland (n.2), Israel (n.2), China (n.2), Indonesia (n.1), Pakistan (n.1) and Norway (n.1). Discussion: Even though sexual abuse has been studied extensively, both physical and emotional abuse and neglect appear to be more represented within the population of patients that had suffered from abuse. Psychiatric disorders (mainly personality disorders, depression and anxiety), interpersonal, social and legal outcomes are important consequences of child maltreatment. Conclusions: Interventions and strategies are needed at different levels, from prevention to treatment and further research is important in order to better understand the phenomenon

BIPOLAR DISORDER: THE IMPORTANCE OF CLINICAL ASSESSMENT IN IDENTIFYING PROGNOSTIC FACTORS - AN AUDIT. Part 1: An analysis of potential prognostic factors

Background: Prognostic factors of bipolar disorder must be identified to assist in staging and treatment, and this may be done primarily during the initial psychiatric assessment. In fact, most of the prognostic factors, which determine disease outcome, could be detected from simple but often-unrecorded questions asked during the psychiatric clinic visit. Methods: We collected data from the clinical notes of 70 bipolar outpatients seen at the initial psychiatric assessment clinic about socio-demographic and clinical factors to determine whether various factors had relevance to prevalence, prognosis, or outcome. Results: The sample comprised 16 bipolar I (22.9%) and 54 bipolar II (77.1%) outpatients; a psychiatric comorbidity was noted in 26 patients (37.1%). 60.9% (42 patients) reported anxiety features and 12 patients (17.6%) were noted to have obsessivecompulsive characteristics. Percentages reported in our results are of the sample for which the data was available. Anhedonia is a depressive feature that was present in most of the population where this data was available (92.2%, 59 patients) and 81.8% (54 patients) reported suicidal thoughts during a depressive episode. 74.6% (47 patients) had a family history of bipolar disorder, depression, suicide or psychosis. 27 patients (39.7%) reported current alcohol use and 14 patients (22.6%) current illicit drug use. A comparison between 10 prognostic factors found that only the correlations between current illicit drug use/previous illicit drug use (χ2=11.471, P<0.001), current alcohol use/previous alcohol use (χ2=31.510, P<0.001) and current illicit drug use/anxiety (χ2=5.094, P=0.022) were statistically significant; the correlation between previous illicit drug use/previous alcohol use (χ2=5.071, P=0.023) and previous alcohol use/family history (χ2=4.309, P=0.037) were almost statistically significant. 17 patients (24.3%) of the 70 bipolar patients were assigned to a care coordinator; we have evaluated the possible differences between the patients with or without a care coordinator on the basis of the presence of 10 possible prognostic factors and found no statistically significant differences between these two groups of patients. Conclusions: We have identified several trends in our patients with bipolar disorder that agree with previous research. Our sample suggested that the assignation of a care coordinator is not done on a clinical basis. In our sample, some patients were found not to have information available so we suggest that a questionnaire to remind clinicians of potentially useful information would be helpful to aid in prognostication. In particular, specific features of the disease, like family history, age at onset, and features of depressive episodes may be highlighted as our sample suggests that these are often unrecorded when not known or negative

BIPOLAR DISORDER: THE IMPORTANCE OF CLINICAL ASSESSMENT IN IDENTIFYING PROGNOSTIC FACTORS - AN AUDIT. Part 3: A comparison between Italian and English mental health services and a survey of bipolar disorder

Background: Most of the prognostic factors of bipolar disorder, which determine disease course and outcome, could be detected from simple but often-unrecorded questions asked during the psychiatric clinic assessments. In previous parts of this research, we analysed various prognostic factors and focused on mixed states and rapid cycling subsets. We now compare our sample in England with a small sample from Italy to demonstrate the utility of focused prognostic questioning and of international comparison. Methods: We collected data from the clinical notes of 70 English bipolar and 8 Italian bipolar outpatients seen at the initial psychiatric assessment clinic about socio-demographic and clinical factors to determine whether various factors had relevance to prevalence, prognosis, or outcome. Results:The sample comprised 16 bipolar I (22.9%) and 54 bipolar II (77.1%) English outpatients and 7 bipolar I (87.5%) and 1 bipolar II (12.5%) Italian outpatients. Differences between the groups are seen mainly in terms of age of onset, duration of both depressive and hypomanic episodes, presence of psychiatric family history, incidence of mixed state features and rapid cycling, presence of elated mood in response to past antidepressant treatment, and misuse of illicit drugs and alcohol. Conclusions: In order to promote improved mental health primary care, mental health systems in all countries should develop standardized epidemiological tools that are shared between countries. We recommend the use of a questionnaire that reminds clinicians of potentially prognostic information and suggest that this might identify important components of a potential standardized diagnostic and prognostic tool