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Rassegna Di Psicoterapie. Ipnosi. Medicina Psicosomatica Rassegna di Psicoterapie. Ipnosi. Medicina Psicosomatica. Psicopatologia Forense. Periodico quadrimestrale a carattere scientifico UNIVERSITÀ DEGLI STUDI DI ROMA "LA SAPIENZA " VOLUME 10 – N. 1 Gennaio – Aprile 2005 Volume 10 N° 1 - 2005 Periodico quadrimestrale a carattere scientifico di proprietà della UNIVERSITÀ DEGLI STUDI DI ROMA “LA SAPIENZA ” Comitato Consultivo: G. ABRAHAM (Ginevra) L. ANCONA (Roma), P. ARBARELLO (Roma) D. AKSTEIN (Rio de Janeiro) Insegnamento di Psicopatologia Forense T. BANDINI (Genova), (Dipartimento di Scienze Psichiatriche e M- BIONDI (Roma) Medicina Psicologica), Universitá di Roma F. BRUNO (Roma), “La Sapienza” . C. COLUCCI D’AMATO (Napoli), Direttore responsabile: V. E. COSMI (Roma), Vincenzo Mastronardi G. DE BENEDITTIS (Milano), D. DE CARO (Roma), Direzione Scientifica onoraria: F. DE FAZIO (Modena), Franco Granone e Antonio Maria M. C. DEL RE (Roma), Lapenta N.M. DI LUCA (Roma), A. ERMENTINI (Milano), Capo Redattore: U. FORNARI (Torino), Maria Tosello L. FRATI (Roma), Direttore Organizzativo: L. FRIGHI (Roma), Matteo Villanova V. GHEORGHIU (Giessen), M. A. GRAVITZ (Washington), Gli elaborati vanno inviati al Prof. F. INTRONA (Padova), Vincenzo Mastronardi Dipartimento di R. GUARINI (Roma), Scienze Psichiatriche e Medicina W. KRETSCHMER (Tübingen), Psicologica, Universitá “La Sapienza”, P.le C. LORIEDO (Roma), Aldo Moro, 5 – 00185 Roma – Fax: 06/49912268 V. MASTRONARDI (Roma), M. MORCELLINI (Roma), Comitato Redazionale: G.C. NIVOLI (Sassari), M. Calderaro, A. Bormioli, F. Donvito, G. B. PALERMO (Milwaukee), V. Ferrante, E. Foppiani, F. Marascio, A. PETIZIOL (Roma), G. Maurizio, A. Pacciolla, C. Bairati P. PINELLI (Milano), Papi, A. Pomilla, G. Saladini, G. Tirone V. RAPISARDA (Catania), L. RAVIZZA (Torino), Tutti i diritti sono riservati : Nessuna parte G. G. ROVERA (Torino), di questa pubblicazione puó essere N. RUDAS (Cagliari), riprodotta, trasmessa e memorizzata in E. TORRE (Torino), qualsiasi forma e con qualsiasi mezzo. G. UMANI RONCHI (Roma), Per quanto non espressamente richiamato H. WALLNÖFER (Vienna), valgono le norme delle Leggi sulla Stampa J. C. WATKINS (Missoula), e le norme internazionali sul Copyright. L. WOLLMAN (New York), Stampa : Tipografia Centro Copie Cervialto J. K. ZEIG (Phoenix). - Via Monte Cervialto, 17 – 00139 Roma Registrazione al Tribunale Civile di Roma n° 00325/96 (28.06.1996) Rassegna di psicoterapie. Ipnosi. Medicina Psicosomatica. Psicopatologia forense. Volume 10 N° 1 - 2005 SOMMARIO - LAVORI ORIGINALI - La gestione dell’aggressività nelle diverse fasi del disturbo bipolare Filippo Turchi, Micaela Piva, Giovanni Placidi, Gian Franco Placidi ……………………………………........pag.7 - Conversioni diagnostiche da un Sistema di classificazione ad un altro Antonino Calogero, Vincenzo Mastronardi ……………….pag.25 - Sindromi culture Bound con referente animale (Licantropia, Vampirismo, Tarantismo, “La possessione della tigre” in oriente e in africa) Claudia Petricelli …………………………………………..pag.67 - Norme di pubblicazione per gli Autori............................pag.117 Rassegna di psicoterapie. Ipnosi. Medicina Psicosomatica. Psicopatologia forense. Rassegna di psicoterapie. Ipnosi. Medicina Psicosomatica. Psicopatologia forense. 6 Volume 10 N° 1 - 2005 LA GESTIONE DELL’AGGRESSIVITÀ NELLE DIVERSE FASI DEL DISTURBO BIPOLARE Filippo Turchi, Micaela Piva, Giovanni Placidi, Gian Franco Placidi 1 Parole chiave Disturbo Bipolare, Aggressività, Impulsività, Antipsicotici Atipici Key Words Bipolar Disorder, Aggressivity, Impulsivity, Atypical Antipsychotics Riassunto Nell’ambito delle malattie mentali l’aggressività è uno dei principali motivi di ricovero e di difficoltà di gestione. Nel disturbo bipolare l’aggressività auto- diretta è più frequente della forma etero-diretta; infatti quasi il 50% dei bipolari compie un tentativo di suicidio, mentre la mortalità per suicidio è del 20%. L’aggressività e l’impulsività sono tra i principali fattori di rischio a breve termine per condotte suicidarie e potenzialmente modificabili se trattati tempestivamente. Nel disturbo bipolare le condotte suicidarie sono frequenti in corso di depressione ma anche in corso di stato misto o mania disforica. Questo studio, mediante l’analisi della più recente letteratura, si propone di chiarire il ruolo degli stabilizzatori dell’umore nel controllare il quadro clinico per la prevenzione del rischio di suicidio e il ruolo degli antipsicotici atipici, la cui azione sembra specifica nel gestire e ridurre l’aggressività. Abstract Aggressivity is one of the main reasons of admission and of difficulty in the management of mental diseases. In bipolar disorder auto-directed aggressive behaviour is most frequent than the etero-directed one; almost the 50% of bipolar disorders committed suicide attempt, but only 20% really died. Aggressivity and impulsivity are among the most powerful predictors of future suicidal acts, and potentially modifiable if adeguately treated. In bipolar disorder suicidal behaviour is particularly frequent during depression but also in mixed state or dysphoric mania. The aim of this study, by the analysis of 1 Unità di Ricerca per lo Studio e la Prevenzione delle Condotte Suicidarie Dipartimento di Scienze Neurologiche e Psichiatriche Università degli Studi di Firenze 7 Rassegna di psicoterapie. Ipnosi. Medicina Psicosomatica. Psicopatologia forense. most recent literature data, is trying to explain the role of mood stabilizers in preventing suicidal risk and the role of atypical antipsychotics in managing and reducing aggressivity. Epidemiologia e caratteristiche dell’aggressività L’aggressività nell’ambito dei disturbi mentali rappresenta spesso uno dei motivi principali di ricovero o di trattamento sanitario obbligatorio, comportando notevoli problemi di gestione anche in ambito ospedaliero. I comportamenti patologici caratterizzati da aggressività-ostilità si presentano in modo trans-nosografico rispetto ai disturbi psichiatrici. L’aggressività è un importante fattore predittivo di condotte suicidarie e comporta una minore risposta ai trattamenti legata soprattutto ad una scarsa compliance, determinando la persistenza e la cronicizzazione di un quadro come quello depressivo. L’aspetto fondamentale per poter definire il comportamento aggressivo è l’intenzione di fare del male, danneggiare gli altri o se stessi, che si manifesta verbalmente o con atti fisici che esprimono rabbia, ostilità, ira, talvolta accompagnati da paura o disperazione. La prevalenza lifetime dell’aggressività è tra il 2% e il 5% (13). Negli Stati Uniti la prevalenza lifetime degli attacchi fisici nella popolazione generale è circa del 10-15%, mentre degli omicidi è dello 0,01% per anno (26). Il suicidio, nel disturbo bipolare è più frequente rispetto alle forme di aggressività etero- diretta e di maggiore interesse per lo psichiatra per le implicazioni e le opportunità terapeutiche; viene stimato che circa l’82% di coloro che compiono un atto suicidario presenta una comorbilità psichiatrica (23) e il 60% di tutti i suicidi si verifica in soggetti affetti da disturbi dell’umore (3). Definizioni e aspetti psicopatologici dei comportamenti aggressivi Tre aspetti permettono di classificare un comportamento aggressivo; l’intento, che rappresenta la volontà di arrecare un danno in modo diretto o in diretto e 8 Volume 10 N° 1 - 2005 può essere dedotto dalle dichiarazioni verbali o dalle azioni. L’azione, sia fisica che verbale, che segue l’intenzionalità e ne rappresenta la modalità di realizzazione. La terza caratteristica che definisce un comportamento aggressivo è lo stato emotivo; se non è presente ira, rabbia o ostilità, si parla di aggressività fredda, strumentale o predatoria; altrimenti di aggressività affettiva o impulsiva. Considerando i condizionamenti dell’aspetto psicopatologico, sono due gli aspetti fondamentali dell’aggressività, il vissuto e il controllo. Nel vissuto del soggetto è presente il desiderio deliberato di danneggiare e distruggere se stessi o gli altri, associato ad ira, rabbia, ostilità, ma anche a disperazione, paura o rancore; per cui alla base di un comportamento aggressivo vi è sempre una tonalità emotiva specifica. Contribuiscono alla definizione di un comportamento aggressivo una ridotta o assente efficienza dei meccanismi di controllo inibitori. Quindi l’aggressività può essere divisa in due tipologie: auto o etero-diretta, se in relazione all’oggetto; impulsiva o premeditata, se consideriamo la modalità di controllo. L’aggressività impulsiva o affettiva, è quasi sempre non premeditata e reattiva, anche se di dimensioni sproporzionate, rispetto agli stimoli avversi; e si associa frequentemente ad una storia di abuso di alcol o sostanze. L’aggressività predatoria è premeditata, controllata e volta ad ottenere dei vantaggi; inoltre è più frequentemente associata a condotte criminali ed è meno responsiva alle terapie farmacologiche rispetto alla forma impulsiva (51). Il rapporto tra aggressività e abuso di alcol o sostanze è rilevante e ampiamente studiato in letteratura. Da un lato l’impulsività predispone al consumo di sostanze di abuso, dall’altro gli effetti disinibenti di queste sostanze, a dosi non eccessive e sedative, facilitano condotte aggressive. In tutte le possibili patologie psichiatriche, la comorbilità con l’abuso di sostanze facilita l’insorgenza di comportamenti aggressivi o violenti (52); in particolare tali comportamenti sono facilitati dall’abuso di alcol soprattutto in coloro che 9 Rassegna di psicoterapie. Ipnosi. Medicina Psicosomatica. Psicopatologia forense. hanno
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